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http://www.archive.org/details/treatiseonprinci1916edwa 


A  TREATISE 


PRINCIPLES  AND  PRACTICE 
OF  MEDICINE 


BY 

ARTHUR  R.  EDWARDS,   A.M.,  M.D. 

PROFESSOH  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDICINE  AND  OF  CLINICAL  MEDICINE  AND    DEAN 

OF  THE  FACULTY  IN  THE  NORTHWESTERN  UNIVERSITY    MEDICAL    SCHOOL,   CHICAGO; 

ATTENDING    PHYSICIAN  TO  MICHAEL  REESE  HOSPITAL,    ETC. 


THIRD  EDITION,  THOROUGHLY  REVISED,  AND  REWRITTEN 


ILLUSTRATED   WITH    80    ENGRAVINGS   AND   23    PLATES 


LEA   &   FEBIGER 

PHILADELPHIA   AND    NEW   YORK 
19  16 


Entered  according  to  the  Act  of  Congress,  in  the  year  1916,  by 

LEA   &  FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PEEFACE  TO  THE  THIRD  EDITION. 


The  demand  for  a  new  edition  of  a  work  in  so  highly  developed  a 
field  of  medical  literature  is  both  a  commendation  and  a  summons 
to  improvement.  The  author  has  spared  no  effort  in  complying.  The 
real  advances  throughout  this  enormous  and  active  domain  have  been 
incorporated,  and  the  whole  work  has  moreover  been  virtually  re- 
written to  secure  increased  brevity  and  clearness.  The  result  is 
indicated  by  the  fact  that  a  vastly  greater  amount  of  information  is 
furnished  in  a  space  decreased  by  some  two  hundred  pages. 

A  few  of  the  additions  and  changes  may  be  mentioned.  Particu- 
lar attention  has  been  given  to  therapeutic  details  in  accordance 
with  the  recent  awakening  of  the  profession  to  the  importance  of  logical 
treatment;  numerous  new  preparations,  and  modified  names  and 
dosages,  particularly  for  children,  are  explicitly  specified.  There  are 
practically  new  chapters  on  ictero-anemia,  the  ductless  glands,  x-ray 
findings,  erythremia,  sepsis  (infection,  toxemia,  bacteriemias),  high 
calory-feeding  in  typhoid  with  a  table  of  food  values,  sporotrichosis, 
blastomycosis,  trichinosis,  hook-worm  disease,  pellagra,  gas  poisoning, 
the  arrhythmias  and  other  cardiac  neuroses,  tropical  splenomegaly  and 
various  other  tropical  affections.  Due  consideration  has  been  given  to 
the  meningitis  serum  of  Flexner  and  Jobling,  Strong's  work  on  amebic 
dysentery,  Brill's  disease,  anaphylaxis,  paratyphoid,  blood  cultures  in 
typhoid  and  other  bacteriemias,  the  "carriers  of  infection,"  the  recent 
epidemics  of  meningitis  and  poliomyelitis,  vaccines,  serotherapy,  the 
spirochete  as  the  cause  of  syphilis  and  the  recent  status  of  tuberculin  in 
its  diagnostic  and  therapeutic  application.  The  diagnostics  and  thera- 
peusis  of  cardiac  failure,  hypertension,  diabetes,  gastric  and  duodenal 
ulcer,  constipation,  drug  addictions,  neuralgias,  etc.,  have  been  elabo- 
rated fully.  New  plates  are  introduced,  illustrating  the  diphtheria 
bacillus  and  its  cultural  appearance,  the  Spirochetse  pallida  and  refringens, 
and  .T-ray  plates  in  gastric  subjects. 

The  chapters  on  tuberculosis  and  syphilis  are  designedl}^  amplified, 
as  these  diseases  touch  every  organ,  enter  every  specialty,  and  attain 
as  great  sociological  as  medical  importance;    indeed,  an  understanding 


iv  PREFACE  TO   THE  THIRD  EDITION 

of  these  maladies  is  almost  an  understanding  of  medicine.  The  Was- 
sermann  and  luetin  tests,  congenital  lues,  and  new  matter  on  mercury 
and  salvarsan  are  treated  with  much  detail,  because  of  their  colossal 
importance.  Attention  has  been  given  to  numerous  criticisms  and  many 
minor  alterations  have  been  made  in  the  interest  of  logic,  clarity  and 
conciseness. 

So  wide  is  the  range  of  Modern  Practice  that  an  author  who  would 
cover  it  in  a  single  volume,  and  a  reader  who  would  grasp  it  intelli- 
gently, must  approach  their  respective  tasks  with  the  aid  of  thorough 
system.  An  effort  has  been  made  to  deal  with  the  subject  in  this 
manner,  from  its  main  divisions,  which  follow  the  most  rational  classi- 
fication, down  to  the  subordinate  paragraphs.  Careful  use  has  been 
made  of  types  of  various  prominence  to  facilitate  the  finding  of  a  topic 
and  the  appreciation  of  its  importance.  With  the  vast  mass  of  material, 
an  attempt  has  been  made  to  so  arrange  the  facts  that  the  reader  may 
grasp  the  process  of  reasoning.  Causative  pathology  has  been  blended 
with  the  consecutive  clinical  features  of  disease,  reasons  have  been 
given  for  facts,  exceptions  have  been  subordinated  to  what  is  usually 
found  at  the  bedside,  and  the  allurements  of  typical  clinical  pictures  and 
dogmatic  generalizations  have  been  avoided  because  they  hold  neither 
in  practice  nor  at  the  postmortem  table. 

The  author  also  conceives  that  a  book  on  Practice  should  be  well 
directed,  which  implies  that  it  should  deal  adequately  with  scientific 
theories  and  principles,  but  that  it  should  recognize  that  the  final 
object  of  its  existence  is  the  applicatioii  of  knowledge  to  the  cure  or 
alleviation  of  disease.  Accordingly,  an  unusual  amount  of  space  has 
been  devoted  to  treatment,  to  the  detailed  consideration  of  drugs  and 
to  numerous  formulae  and  prescriptions  ready  for  the  student  to  use 
or  improve  upon.  The  physiological  action  of  drugs  has  been  dwelt 
upon  carefully  because,  in  the  writer's  experience,  the  symptoms  of 
disease  may  be  confounded  with  those  of  the  remedies  exhibited  for 
its  cure.  The  index  embraces  the  chief  references  to  the  remedies  and 
the  formulae  for  their  exhibition,  and_the  table  of  contents  sketches  the 
general  scheme  of  arrangement. 

The  reader  will  also  find  a  large  number  of  tables  giving  the  differ- 
ential diagnosis  of  diseases  likely  to  be  confused,  and  in  many  instances, 
of  entire  subjects,  such  as  those  of  the  liver,  brain  and  kidney,  the 
chief  eruptive  diseases  and  those  of  the  typhoid  group.  They  are  prac- 
tical, though  necessarily  schematic.  Nowadays  the  border-lines  of 
surgery  and  medicine  overlap,  and  the  practitioner,  internist  and  sur- 
geon must  be  familiar  with  the  province  of  each  other.    For  this  reason, 


PREFACE  TO   THE  THIRD   EDITION  v 

as  far  as  the  scope  of  the  treatise  admits,  surgical  indications  and  results 
are  introduced. 

Names  and  dates  are  employed  to  give  credit,  where  it  is  possible, 
to  the  great  workers  in  the  history  of  ^Medicine. 

The  writer  wishes  to  acknowledge  the  extremely  careful  attention 
bestowed  by  the  Publishers  upon  every  literary  and  typographical 
detail,  and  the  assistance  of  Dr.  Milton  :\Iandel  in  the  proof  reading. 

A.  R.  E. 

Chicago,   1916. 


CONTENTS. 


SECTION   I. 


The  Specific  Infections. 

Bacterial  Diseases 
Septic  Infections 
Typhoid  Fever   . 
Erysipelas 
Pneumonia    . 
Diphtheria    . 
Cerebrospinal  Fever 
Acute  Poliomyelitis 
Influenza  (La  Grippe) 
Pertussis  (Whooping-cough) 
Cholera  Asiatica 
The  Plague   .      . 
Dysentery 

Shiga's  Bacillary  Form  of  Dysentery 

Amebic  Dysentery 

Indeterminate  Dysenteries 
Malta  Fever 
Anthrax  .... 

External  Anthrax 

Internal  Anthrax 
Glanders 

Tetanus  .... 
Gonorrheal  Infection 
Tuberculosis 

Tuberculosis  Miliaris  Acuta 

Tuberculous  Meningitis    . 

Tuberculosis  of  the  Lungs  (Phthisis,  Consumption) 

Tuberculosis  of  the  Lymph  Glands  . 

Tuberculosis  of  the  Serous  Membranes 

Tuberculosis  of  the  Brain  and  Meninges     . 

Tuberculosis  of  the  Eye 

Tuberculosis  of  the  Alimentary  Tract    . 

Tuberculosis  of  the  Genito-urinary  Tract    . 

Tuberculosis  of  the  Upper  Respiratory  Tract 

Tuberculosis  of  the  Heart  and  Vessels 

Tuberculosis  of  the  Bones  and  Joints 

Tuberculosis  of  the  Skin  . 

Treatment  of  Tuberculosis 

Leprosy 

Non-bacterial  Fungus  Infections    . 
Actinomycosis 


viii  COXTEXTS 

Xon-bacterial  Fungus  Infections — 

Nocardiosis " 196 

Sporotrichosis " 196 

Oidiomycosis 196 

Mj-cetoma .197 

Aspergillosis 197 

Protozoan  Infections 197 

Syphilis  (Pox,  Variola  Magna,  Lues  Venerea) 197 

Acquired  S\T3hilis 198 

Skin 201 

Lymph  Glands 203 

Gastro-intestinal  Tract *  .      .      .  203 

Spleen 205 

Liver 205 

Kidneys 207 

Circulation ...  207 

Respiratory  Tract 209 

Nervous  System  .      .            210 

Eye  and  Ear 214 

Genitalia    . 216 

Bones,  Joints  and  Muscles 217 

Mammae 218 

Diagnosis  of  Syphilis 219 

Congenital  Sj'philis 221 

Treatment  of  SyphiUs                                           224 

Malaria 229 

Recurrent  Fever 243 

Kala-azar ' 245 

Trypanosomiasis 246 

Other  Protozoa 247 

Amebiasis 247 

Yaws,  or  Frambesia 247 

Trichomonas 247 

Lamblia 247 

Coccidia 247 

Infections  of  Doubtful  Etiologj' 247 

Smallpox,  Variola,  Vaccination 247 

Chicken-pox  (Varicella) 259 

Scarlet  Fever  (Scarlatina)        260 

Measles  (:vIorbilli,  Rubeola) 270 

RubeUa- 275 

Typhus  Fever 276 

Epidemic  Parotitis  (Mumps) 279 

Acute  Articular  Rheumatism  (Rheumatic  Fever) 281 

Dengue 289 

.YeUow  Fever 291 

Hydrophobia  (Lyssa;  Rabies) 294 

Febricula       .      '      .      .     ' 298 

Glandular  Fever 298 

Miliary  Fever 299 

Weil's  Disease  (Acute  Febrile  Jaundice)        299 

Milk  Sickness 300 

Rocky  Mountain  Fever 300 

Foot-and-mouth  Disease 301 


CONTENTS 


IX 


Infections  of  Doubtful  Etiology — 
Rat-bite  Disease 

Psittacosis 

Metazoan  Infections 

Diseases  Caused  by  Cestodes 

Tenia  Solium    . 

Tenia  Saginata  (Mediocanellata) 

Other  Tenise  Occurring  in  Man  . 

Tenia  Echinococcus  (Echinococcus  Diseases) 

Echinococcus  of  the  Lung 

Diseases  Caused  by  Nematodes 

Ascaris  Lumbricoides 

Oxyuris  Vermicularis  (Seat-worm,  Pin-  or  Thread 

Trichina  (Trichinella)  Spiralis;  Trichinosis 

Ankylostoma  (Uncinaria)        .... 

Filaria 

Dracunculus  (Filaria)  Medinensis     . 

Trichocephalus,  Dispar  or  Whip-worm 

Strongyloides  Intestinalis       .... 
Diseases  Caused  by  Trematodes  (Distomiasis) 


worm) 


SECTION   II. 


Diseases  of  the  Circulation. 


Diseases  of  the  Heart  Muscle    . 
Introductory  Physiology 
Dilatation  of  the  Heart 
Hypertrophy  of  the  Heart 
Atrophy  of  the  Heart    . 
Fatty  Heart        .... 
Acute  Myocarditis  . 

Acute  Circumscri-pt  Myocarditis 
Fragmentation  of  the  Heart  Muscle 
Chronic  Myocarditis   (Chronic  Fibrous  or  Interstitial  Myocarditis 

fibrosis  Cordis) 

Rupture  of  the  Heart    .      .      . 

Angina  Pectoris 

Tumors  of  the  Heart 

Cardiac  Thrombosis — Thrombosis  Cordis 
Neuroses  of  the  Heart  . 

Palpitation  of  the  Heart 
Arrhythmia 
Tachycardia 
Bradycardia 
Diseases  of  the  Endocardium     . 
Endocarditis       .... 
Acute  Endocarditis 

Malignant  (Ulcerative  or  Septic)  Endocarditis 
Acute  Verrucose  or  Benign  Endocarditis  . 
Chronic  Endocarditis,  Chronic  Valvular  Disease 
Aortic  Insufficiency  (Corrigan's  Disease) 
Aortic  Stenosis 


Myo- 


CONTENTS 


Diseases  of  the  Endocardium — Chronic  Endocarditis — 
Mitral  Insufficiency  . 
Mitral  Stenosis 
Pulmonary  Insufficiency 
Pulmonar}^  Stenosis  . 
Tricuspid  Insufficiency 
Tricuspid  Stenosis 
Combined  Valvular  Lesions 
General  Symptoms  of  Valvular  Disease  and  Decompensation 
Prognosis  of  Valvular  Disease 
Treatment  of  Valvular  Disease   . 

Congenital  Heart  Disease 

Pulmonary  Stenosis 

Defects  of  the  Interauricular  Septum 
Defects  of  the  Interventricular  Septum 
Patency  of  the  Ductus  Botalli 
Persistent  Isthmus  Aortse       .... 
Aortic  Atresia  or  Stenosis       .... 
Tricuspid  Stenosis  or  Atresia 
Transposition  of  the  Arteries  and  Veins 

Valvular  Anomalies 

Anomalies  in  Location  and  Development 
Diseases  of  the  Pericardium 

■  Pericarditis 

Fibrinous  (Plastic)  Pericarditis 
Pericarditis  with  Effusion 
Adhesive  Pericarditis  . 
Pneumopericardium       ... 
Hydropericardium  (Hydrops  Pericardii) 
Hemopericardium    . 
Diseases  of  the  Arteries 

Arteriosclerosis  .... 

Aneurysm 

Abdominal  Anem-ysm 
Acute  Aortitis  and  Arteritis 
Rupture  of  the  Aorta    . 


357 
359 
362 
362 
363 
365 
365 
366 
370 
371 
378 
378 
379 
379 
379 
379 
380 
380 
380 
380 
380 
381 
381 
382 
382 
389 
391 
391 
392 
392 
392 
400 
408 
410 
410 


SECTION  III. 

Diseases  of  the  Respiratory  Tract. 


Diseases  of  the  Nose 411 

Acute  Rhinitis,  Coryza '.      .      .  411 

Hay  Fever 412 

Chronic  Rhinitis .      .' 413 

The  Hypertrophic  Form 413 

The  Atrophic  Form 413 

Rhinitis  Fibrinosa 413 

Epistaxis 414 

Diseases  of  the  Larynx 414 

Acute  Catarrhal  Laryngitis 414 

Chronic  Catarrhal  Laryngitis 416 

Edema  of  the  Larynx 417 


CONTENTS 


XI 


Diseases  of  the  Larynx — 

Perichondritis  Laryngis 

Ulcerations  and  Neoplasms  of  the  Larynx 
Diseases  of  the  Trachea  and  Bronchi  . 

Acute  Bronchitis 

Chronic  Bronchitis 

Fibrinous  Bronchitis     .... 
Bronchial  Dilatation,  Bronchiectasis 
Tracheal  and  Bronchial  Stenosis 

Tracheal  Stenosis 

Bronchial  Stenosis 
Bronchial  Asthma    . 
Diseases  of  the  Lung   .    . 
Emphysema 
Bronchopneumonia 
Indiu-ative  Pneumonia,  Liing  Cirrhosis,  Fibroid  Phthisis 
Pneumokoniosis 
Atelectasis     . 
Abscess  of  the  Lung 
Gangrene  of  the  Lung 
Tumors  of  the  Lung 

Carcinoma  . 

Sarcoma  and  Lymphosarcoma 

Other  Tumors  of  the  Lung     . 
Circulatory  Affections  of  the  Lung 

Active  Congestion 

Passive  Congestion;  Hypostasis 

Infarct;  Embolism 

Edema  of  the  Lungs 

Hemoptysis 
Diseases  of  the  Pleura 
Pleurisy   .    •  . 
Pneumothorax 
Hydrothorax 
Hemothorax 
Chylothorax 
Pleural  Tumors 
Diseases  of  the  Mediastinum 
Mediastinal  Tumors 
Mediastinitis 
Mediastinal  Hemorrhage 
Interstitial  Emphysema 


417 
418 
418 
418 
421 
423 
423 
426 
426 
426 
427 
430 
430 
434 
438 
440 
441 
442 
444 
446 
446 
448 
448 
448 
448 
448 
449 
450 
450 
453 
453 
468 
472 
473 
473 
474 
474 
474 
475 
'476 
476 


SECTION   IV. 

Diseases  of  the  Digestive  Tract. 


Diseases  of  the  Mouth    . 
Catarrhal  Stomatitis 
Stomatitis  Ulcerosa 
Aphthous  Stomatitis 
Parasitic  Stomatitis 
Gangrenous  Stomatitis 


477 
477 
477 
478 
479 
479 


xu  CONTENTS 

Diseases  of  the  Tongue 480 

Eczema 480 

Leukoplakia 480 

Acute  Glossitis 480 

Glossitis  Desiccans 480 

Diseases  of  the  Salivary  Glands 481 

Ptyalism,  Salivation,  Hypersecretion,  Sialorrhea 481 

Xerostomia 481 

Parotitis 481 

Angina  Ludovici 482 

Sialodochitis  Fibrinosa • 482 

Sialolithiasis 482 

Diseases  of  the  Pharynx 483 

Acute  Pharyngitis 483 

Chronic  Pharyngitis      .      .      .     ■ 483 

Phlegmonous  Pharyngitis 484 

Retropharyngeal  Abscess 484 

Pharyngeal  Ulceration 484 

Diseases  of  the  Tonsils 485 

Acute  Follicular  or  Lacunar  Tonsillitis 485 

Suppurative  Tonsillitis 487 

Chronic  Tonsillitis 488 

Diseases  of  the  Esophagus 489 

Inflammation,  Necrosis,  LUceration 489 

Esophagitis 489 

Necrosis 490 

Ulceration 490 

Stenosis  or  Stricture  of  Esophagus  490 

Dilatation,  Diverticulum 492 

Cancer  of  the  Esophagus 494 

Perforation;  Rupture;  Hemorrhage  of  the  Esophagus 495 

Motor  and  Sensory  Disturbances  of  the  Esophagus  .     • .  495 

Diseases  of  the  Stomach 496 

Acute  Gastritis  (Acute  Catarrh,  Acute  Dyspepsia) 496 

Simple  Gastritis 496 

Gastritis  Toxica  (Venenata) 497 

Phlegmonous  Gastritis 497 

Diphtheritic  Gastritis 498 

Parasitic  Gastritis 498 

Chronic  Gastritis 498 

Achylia  Gastrica 503 

Dilatation  of  the  Stomach;  Motor  Insufficiency 504 

Acute  Dilatation 504 

Chronic  Dilatation  and  Motor  Insufficiency 504 

Changes  in  the  Form,  Size  and  Location  of  the  Stomach 508 

Ulcer  of  the  Stomach  and  Duodeniim 509 

Cancer  of  the  Stomach 519 

Hematemesis 526 

Neuroses  of  the  Stomach 527 

Secretory  Neuroses 528 

Hyperchlorhydria 528 

Gastrosuccorrhea  (Hypersecretion;  Continuous  Secretion)  529 

Hyposecretion 530 

Motor  Neuroses  of  the  Stomach 531 


CONTENTS 


Xlll 


Diseases  of  the  Stomach — Motor  Neuroses — 

Irritative  Types 

Depressive  Motor  Neuroses  (Lessened  Motility) 

Sensory  Neuroses  of  the  Stomach 
Hyperesthesia       ... 

Gastralgia 

Disturbances  in  the  Sense  of  Hunjrer  and  Appetite 

Mixed  Neuroses  of  the  Stomach 

Diseases  of  ythe  Intestines 

Acute  Enteritis  .     " 

Chronic  Enteritis 

Enteritis  (Cohtis)  Mucosa  or  Membranacea 

Diphtheritic,  Croupous  and  Phlegmonous  Enteritis 

Intestinal  Ulceration 

Intestinal  Disorders  in  Infants 

Appendicitis 

Intestinal  Obstruction  . 

Intussusception  (Invagination) 

Strangulation    . 

Volvulus  and  Knots 

Strictures     . 

Tumors 

Foreign  Bodies 

Dynamic  Ileus 
Intestinal  Tumors    . 
Enteroptosis 
Dilatation  of  the  Colon 
Intestinal  Hemorrhage 

Piles 

Diarrhea        .      .     ».      . 
Constipation 
Intestinal  Diverticula   . 
Nervous-Affections  of  the  Bowel 

Neuroses  of  Motility  . 

Neuroses  of  Sensation 

Neuroses  of  Secretion 
Affections  of  the  Mesentery 

Inflammation    .... 

Hemorrhage      .... 

Diseases  of  the  Mesenteric  Vessels 

Affections  of  the  Chyle  Vessels 

Mesenteric  Tumors 
Diseases  of  the  Liver 

Acute  Yellow  Atrophy 
Portal  Cirrhosis 
Biliary  Cirrhosis 
Abscess  of  the  Liver 

Solitary  or  Tropical  Abscess 
Tumors  of  the  Livdt 
Echinococcus  Cysts  of  the  Liver 

Multilocular  or  Alveolar  Echinococcus 

Fatty  Liver 

Amyloid  Liver 

Anomalies  of  Form  and  Location  of  the  Liver 


XIV  CONTENTS 

Diseases  of  the  Liver — Anomalies  of  Form  and  Location- 
Wandering  Liver 584 

Corset  Liver 584 

Affections  of  the  Bloodvessels  of  the  Liver 585 

Active  Hyperemia  of  the  Liver 585 

Passive  Hyperemia  of  the  Liver 585 

Pylethrombosis — Pylephlebitis 586 

Affections  of  the  Hepatic  Artery  and  Vein 588 

Diseases  of  the  Gall-bladder  and  Bile  Vessels 588 

Icterus 588 

Cholelithiasis 591 

Cholecystitis 597 

Cholangitis,  Catarrhal  Icterus,  Congenital  Occlusion 598 

Suppurative  Cholangitis 598 

'  Acute  Catarrhal  Jaundice 598 

Chronic  Catarrhal  Cholangitis 599 

Congenital  Occlusion  of  the  Bile  Ducts 599 

Tumors  of  the  Gall-bladder  and  Bile  Vessels 599 

Cancer  of  the  Gall-bladder 599 

Tumors  of  the  Extra-hepatic  Bile  Ducts 600 

Diseases  of  the  Pancreas 601 

Acute  Pancreatitis;  Fat  Necrosis 601 

Chronic  Pancreatitis 603 

Pancreatic  Apoplexy 603 

Lithiasis 604 

Pancreatic  Cysts 604 

Tumors  of  the  Pancreas 605 

Diseases  of  the  Peritoneum 607 

Acute  Diffuse  Peritonitis 607 

Chronic  Diffuse  Peritonitis 610 

Localized  Peritonitis 611 

Suppurative  Forms 611 

Subphrenic  Abscess  and  Pyopneumothorax  Subphrenicus  .      .      .  611 

Suppuration  in  the  Lesser  Peritoneum .612 

Pelvic  Abscess •     .  612 

Adhesive  or  Indurative  Forms    . .      .      .  612 

Chronic  Hemorrhagic  Peritonitis 612 

Carcinoma  of  the  Peritoneum 613 

Ascites 613 

Chylous  and  Adipose  Ascites 617 


SECTION  V. 

Diseases  of  the  Kidney. 

Acute  Nephritis 619 

Chronic  Nephritis 624 

Chronic  Parenchymatous  Nephritis ' 624 

Chronic  Interstitial  Nephritis 627 

Treatment  of  Chronic  Nephritis 633 

Passive  Congestion.     Embolism  638 

Passive  Congestion        638 

Embolism 639 


CONTENTS  Y,, 

Amyloid  Degeneration  of  the  Kidney 

Malformations  of  the  Kidney .'      _' ^^ 

Malformations  and  Structural  Anomalies  of  the  Kidney rao 

Movable  Kidney ^*^ 

Anomalies  of  Renal  Secretion ^^^ 

Albuminuria 

Hematuria 

Hemoglobinuria       .  

Pyuria      .      . ^48 

Chyluria        .      .  ^^^ 

Lipuria  ...::;: ^^9 

Phosphaturia      .      .  ^^^ 

Lithuria  .      .      .     •  ^^0 

Oxaluria  ...  ^^^ 

Indicanuria 

Alkaptonuria 

Hydrochinon       •....''.'' 5^ 

Hematoporphyrinuria J^^ 

Pyelitis.     Pyelonephritis.     Suppurative  Nephritis  a^o. 

Pyelitis    .      .  ^^^ 

Suppurative  Nephritis r^4 

Perinephric  Abscess 

Hydronephrosis ••••-.. 

Renal  Calculus  (Nephrohthiasis)    .      . ^„ 

Tumors  of  the  Kidney  ^^' 

Cancer .'      '      '      ' 

Sarcoma 

Hypernephroma       .... 

Other  Tumors     ■..■..]..,] ^^ 

Cystic  Degeneration ] ^^ 

Renal  Parasites    .      .  

Echinococcus  Cysts       .  „„ 

665 


SECTION  VI. 
Diseases  of  the  Blood. 

Chlorosis ^ 

Pernicious  Anemia     .  

fi72 

Secondary  Anemia     . 

•^  678 

Acute  PosthemoiThagic  Anemia •      •      .      . 

Chronic  Secondary  Anemia „„„ 

Leukemia '      ' "'^ 

Acute  Lymphatic  Leukemia 

Chronic  Lymphatic  Leukemia •      .  682 

Myeloid  Leukemia  .... 

Pseudoleukemia •      .     683 

Erythremia     .      .  ^^' 

The  Hemorrhagic  Diseases 

Purpura  .... 

'  ,                    69'> 

Symptomatic  Purpura ^„^ 

Purpura  Simplex ••••.••  - 

Purpura  (or  Peliosis)  Rheumatica    .......  qqo 


XVI  CONTENTS 

The  Hemorrhagic  Diseases — Purpura — 

Pui'pura  Hemorrhagica 693 

Hemorrhagic  Diseases  of  the  Newborn 694 

Sj'phihs  Hemorrhagica  Neonatorum 694 

Winckel's  Disease        694 

Morbus  Alaculosus  Neonatorum 694 

Scurw 695 

Infantile  Scur\^' — Barlow's  Disease 697 

Hemophiha • 698 


SECTION   VH. 
Diseases  of  the  Ductless  Glands. 

Diseases  of  the  Suprarenal  Glands '.      .  701 

Addison's  Disease 701 

Other  Affections  of  the  Suprarenal  Glands 704 

Diseases  of  the  Spleen 705 

Acute  Splenic  Tumor 705 

Chi'onic  Splenic  Tumor 705 

Embolism  and  Abscess 705 

Perisplenitis ' 706 

Amj-loid  Spleen 706 

Rupture  of  the  Spleen  .  706 

Movable  or  Floating  Spleen 706 

Primarj'  Splenomegaly 707 

Diseases  of  the  ThjToid  Gland 707 

Goitre 707 

Exophthalmic  Goitre  (Hyperth;yToidism) 709 

Myxedema 712 

Cretinism 712 

Myxedema  of  Adults 713 

Cachexia  Thyreopriva  or  Operative  Myxedema 714 

Treatment  of  IVIyxedema,  Cretinism  and  Cachexia  Thyreopriva        .      .      .  714 

Diseases  of  the  Parathyroid  Glands 715 

Tetany 715 

Diseases  of  the  Thj-mus  Gland 718 

Lymphatism  (Status  Lymphaticus) 719 

Diseases  of  the  Hypophysis 719 

Acromegah' '.      .      .  720 

Infantihsm 722 


SECTION  vni, 

CONSTITUTIOXAL    DISEASES. 

Diabetes  Mellitus  725 

Diabetes  Insipidus 737 

Gout 738 

Rickets 742 

Obesity 746 

Adiposis  Dolorosa  or  Dercum's  Disease 747 


CONTENTS  xvii 


SECTION  IX. 
Diseases  of  the  Nervous  System. 
Diseases  of  the  Brain      .... 


749 


Cerebral  Localization ■               y^g 

The  Motor  Cortex y^o 

The  Cortex  of  the  Parietal  Lobes 753 

The  Cortex  of  the  Occipital  Lobes 753 

The  Cortex  of  the  Temporal  Lobes 753 

The  Frontal  Cortex  and  Aphasia 754 

Motor  Aphasia 754 

Sensory  Aphasia         7gg 

Auditory  Aphasia 7^^ 

Visual  Aphasia 7cq 

Centrum  Ovale 7ce 

The  Internal  Capsule 7gQ 


Anterior  Limb 


756 


Knee 7^7 

Posterior  Limb 7g7 

The  Corpus  Striatum 7^0 

The  Optic  Thalamus 7rg 

The  Corpora  Quadrigemina 7go 

The  Crus  (Cerebral  Peduncle) 759 

The  Pons y/>Q 

The  Cerebellum 7^-. 

Circulatory  Diseases  of  the  Brain 753 

Anemia  of  the  Brain 7Q3 

Hyperemia  of  the  Brain    .  , 7q3 

Edema  of  the  Brain 7g4 

Cerebral  Hemorrhage 7gc 

Cerebral  Embolism      . 77^ 

Cerebral  Thrombosis 770 

Intracranial  Aneurysms 700 

Sinus  Thrombosis 703 

Infantile  Cerebral  Paralysis 7gQ 

The  Hemiplegic  Form 7gg 

The  Double  Hemiplegic  or  Diplegic  Form 787 

Brain  Tumors '  709 

Inflammation  of  the  Brain 797 

Encephalitis 707 

Abscess  of  the  Brain 799 

Dementia  Paralytica gQ2 

Chronic  Bulbar  Paralysis gQg 

Asthenic  Bulbar  Paralysis.     Myasthenia  Gravis 810 

Apoplectiform  Bulbar  Paralysis §11 

Progressive  Nuclear  Ophthalmoplegia   .            811 

Hydrocephalus gi. 

Chronic  External  Hydrocephalus 812 

Chronic  Congenital  Internal  Hydrocephalus 812 

Acquired  Chronic  Hydrocephalus 813 

Diseases  of  the  Cerebral  Meninges '  §14 

Pachymeningitis gj4 


x\-iii  CONTENTS 

Diseases  of  the  Cerebral  Meninges — 

Meningeal  Hemorrhage 816 

Acute  Suppurative  Leptomeningitis 816 

Serous  Meningitis 818 

Chi'onic  Leptomeningitis 818 

Diseases  of  the  Spinal  Cord 819 

General  Anatomical,  Physiological  and  Symptomatic  Considerations      .      .  819 

Diseases  of  the  Spinal  Meninges 829 

Hemorrhage 829 

Pachymeningitis 829 

Tumors  of  the  Spinal  Cord  and  its  Membranes 830 

Tumors  of  the  Membranes .....  830 

Tumors  in  the  Cord  Substance 831 

Cii-culatory  Disturbances.    Hemorrhage.     Trauma  of  the  Cord  ....  833 

Anemia  of  the  Spinal  Cord 833 

Embolism  and  Thrombosis  (Myelomalacia) 833 

Hemorrhage  (Hematomj-eha) 833 

Caisson  or  Divers'  Paralysis 834 

Brown-Sequard's  Paralysis 835 

Inflammation  of  the  Cord 836 

Acute  Myelitis 837 

Acute  ^Multiple  Disseminated  MyeUtis 841 

Chronic  IMyeUtis 841 

Subacute  and  Chi-onic  Poliomyelitis 841 

Landry's  Paralysis 842 

^Multiple  Sclerosis 843 

SjTingomj'eha 846 

System  Diseases 849 

Sj'stem  Diseases  of  the  Sensorj^  Tract 849 

Tabes  Dorsahs,  Locomotor  Ataxia  « 849 

System  Diseases  of  the  Motor  Tract 857 

Spastic  Spinal  Paraplegia 857 

Amyotrophic  Lateral  Sclerosis 858 

Progi'essive  Spinal  Muscular  Atrophy 860 

Neural  Muscular  Atrophy 862 

Muscular  Dystrophy 862 

Pseudohypertrophic  ]\Iuscular  Paralysis 862 

Infantile  Atrophic  Form,  with  or  without  Facial  Involvement  863 

The  Juvenile  Form  of  Erb 864 

Combined  System  Diseases 864 

Hereditary  Ataxia,  Friedreich's  Ataxia 865 

Ataxic  Paraplegia 866 

Other  Combined  Sj-stem  Diseases 866 

Diseases  of  the  Peripheral  Nerves 867 

Mononeuritis 867 

IMultiple  Neuritis 869 

Neuroma 872 

Diseases  of  the  Cranial  Nerves 873 

Olfactory  Nerve .873 

Optic  Nerve 873 

The  Retina 873 

Optic  Nerve 873 

Chiasm 873 

Optic  Tract 874 


CONTENTS  xix 

Diseases  of  the  Cranial  Nerves — Optic  Nerve 

Optic  Centre 

Functional  and  Toxic  Blindness 075 

Ocular  Paralysis;  Third,  Foui-th  and  Sixth  Nerves       .'      ' 375 

Paralysis  of  the  Third  Nerve -876 

Internal  Oculomotor  Palsy •      .      . 

Recurrent  Palsy ;  ... 

Paralysis  of  the  Fourth  (Trochlear)  Nerve       ....".'  877 

Paralysis  of  the  Sixth  Nerve o^y 

Combined  Eye  Paralysis g^- 

Progressive  Nuclear  Ophthabnoplegia   .      .      .      .      '  '   .      '           '  §79 

Sympathetic  Paralysis      .     • '      •.     •      •      • 

Ocular  Muscular  Spasms ggQ 

Fifth  Nerve  (Trigeminus;  Trifacial  Nerve)  ■■....  s,d>Q 

Paralysis 881 

Masticatory  Spasm gg2 

Progressive  Facial  Hemiatrophy .... 

Facial  Hemihypertrophy gg^ 

Seventh  or  Facial  Nerve ' goo 

Peripheral  Facial  Paralysis \      \ ggg 

Facial  or  Mimetic  Spasm  (Tic  Convulsif)   .      .      .      .      .  .  887 

The  Eighth  or  Auditory  Nerve ggy 

.    ^      Meniere's  Disease,  Auditory  Vertigo  (Vertigo  ab  aure  lajsa)       .  888 

Ninth  or  Glossopharyngeal  Nerve ggn 

Tenth  or  Vagus  Nerve gq^ 

Pharyngeal  Branches ■      -      .      . 

Paralysis .890 

Laryngeal  Branches ... 

Anesthesia  and  Hyperesthesia  of  the  Larynx       .      ..."  892 

Laryngeal  Spasm '      '     ggg 

Pulmonary  Branches .... 

Cardiac  Branches oq - 

Gastric  Branches .... 

Eleventh  or  Spinal  Accessory  Nerve  (External  Portion)     .      '  894 

Paralysis 895 

Accessory  Spasm,  Spasmodic  Torticollis  or  Wryneck        .      .  895 

Twelfth  Nerve 

Spasm 

Diseases  of  the  Spinal  Nerves 
The  Phrenic  Nerve 

Paralysis 

Phrenic  Spasm _ 

The  Posterior  Thoracic  Nerve 

The  Suprascapular  Nerve 

The  Musculospiral  Nerve .     •      •      •      • 

The  Median  Nerve 

The  Ulnar  Nerve     ....... 

Combined  Paralysis  of  the  Arm  Nerves 

Brachial  Neuritis 

The  Nerves  of  the  Trunk 

The  Nerves  of  the  Lower  Extremities 

The  Lumbar  Plexus     ; 

Anterior  Crural  Nerve 

Obturator  Nerve    ... 


896 

896 

897 

897 

897 

897 

898 

898 

898 

899 

899 

900 

900 

901 

901 

901 

901 

901 


XX  COXTEXTS 

Diseases  of  the  Spinal  Xerves — The  Xerves  cf  the  Lower  Extremities — 

Superior  Gluteal  Xerve 902 

The  Sacral  Plexus        .      .    ' 902 

Great  Sciatic  Xerve 902 

Caudal  Lesions 903 

Sciatic  Xeuritis 903 

The  Xeuroses 905 

Hysteria 905 

Xeurasthenia 912 

The  "Traumatic  Xeuroses" 918 

Epilepsy 919 

Infantile  Convulsions 926 

Chorea  and  Choreiform  Affections 926 

Occupation  or  Fatigue  Xeuroses;  Writer's  Cramp 932 

^Myotonia  (Thomsen's  Disease) 933 

Parah'sis  Agitans 934 

Periodic  Family  Paralysis 936 

Migraine 937 

Xeuralgia 939 

Vasomotor  and  Trophic  Xeuroses 944 

Erythromelalgia 944 

Acroparesthesia 944 

Spontaneous  Symmetrical  Gangrene 945 

Acute  Angioneurotic  Edema 945 

Chronic  Hereditary  Trophedema 946 

Hydrops  -Ai-ticulorum  Intermittens 946 

Scleroderma 946 

Ainhum 947 


SECTIOX   X. 
Diseases  of  the  Locomotor  System. 

Diseases  of  the  Muscles        949 

:^Iyositis 949 

^Myositis  Ossificans 950 

Muscular  Rheumatism  (Myalgia) 950 

Amyotonia  Congenita 951 

Diseases  of  the  Joints 951 

Arthritis  Deformans  and  Chronic  Rheumatism 951 

Diseases  of  the  Bones 956 

Osteomalacia 956 

Achondroplasia 956 

Fragihtas  Ossium 957 

Oxj'cephah- 957 


SECTIOX  XL 

IXTOXICATIOXS.       SrXSTROKE. 

Alcoholism 959 

Acute  Alcohohsm 959 


CONTENTS  xxi 

Alcoholism — 

Chronic  Alcoholism 960 

Delirium  Tremens 961 

Opium  Poisoning 963 

Acute  Poisoning 963 

Chronic  Morphinism .  ' 963 

Lead  Poisoning 965 

Acute  Poisoning 966 

Chi'onic  Poisoning 966 

Arsenical  Poisoning 968 

Chronic  Poisoning 968 

Food  Poisoning 969 

Meat  Poisoning 969 

Poisoning  by  Milk 970 

Poisoning  by  Fish    .      .      .      .     - 970 

Grain  Poisoning 970 

Ergotism 970 

Lathyrism 971 

Potato  Poisoning 971 

Pellagra 971 

Beriberi 972 

Illuminating-gas  Poisoning 974 

Sunstroke 975 

Index ' ,      .  979 


SECTION  I. 

THE  SPECIFIC  INFECTIONS. 


BACTERIAL  DISEASES. 


SEPTIC  INFECTIONS. 


Synonyms. — Sapremia,  septicemia  (sepsis),  pyemia,  septicopyemia. 

Definition. — To  understand  sepsis  is  to  understand  all  infections. 
Sepsis  is  no  longer  a  purely  surgical  or  obstetrical  term;  today  it  is  more 
important  in  medicine  than  surgery.  Intoxications  are  the  result  of  the 
absorption  of  substances  elaborated  by  microorganisms.  Infections 
are  always  due  to  microorganisms,  which  enter  the  body  and  multiply 
there.  Tetanus  is  an  infection,  yet  it  is  non-contagious.  Contagion  refers 
to  infection  by  direct  contact,  as  in  scarlatina,  or  by  indirect  means, 
as  water  infected  by  typhoid  dejecta.  Sapremia  is  the  absorption 
of  putrescent  substances,  but  not  of  the  germs  which  develop  them. 
Toxemia,  a  broader  term,  includes  intoxication  and  sapremia;  toxins 
in  the  hlood  are  largely  the  result  of  bacterial  metabolism.  Prob- 
ably all  pathogenic  bacteria  produce  toxins;  the  latter  are  divisible 
into  intracellular  toxins,  found  in  the  bodies  of  microorganisms — the 
case  in  most  toxemias — and  the  extracellular  toxins,  thrown  free  into  the 
circulation.  Septicemia  (sepsis)  is  the  presence  in  the  blood  of  micro- 
organisms (bacteriemia)^-usually  pyogenic — without  hematogenous  sup- 
puration or  metastasis.  Pyemia  is  infection,  caused  by  microorganisms, 
which  leads  to  hematogenous  suppuration  or  metastasis.  Septicopyemia 
is  septicemia  (bacteriemia)  plus  pyemia  (metastatic  suppuration). 

General  Groups. — 1.  Some  infections — such  as  carbuncles,  puerperal 
parametritis,  diphtheria  and  tetanus — are  local  so  far  as  the  causal 
microbe  is  concerned,  and  their  symptoms  are  due  to  absorbed  toxins 
(toxinemia,  toxemia).  Local  reactive  inflammation  seeks  to  protect 
the  body  against  generalization  of  the  microbes,  by  means  of  (i)  mechani- 
cal measures,  as  pouring  out  of  the  leukocytes,  deposition  of  fibrin  or 
development  of  connective  tissue;  (ii)  phagocytosis;  and  (iii)  bacteri- 
cidal and  antitoxic  action  of  the  lymph  and  blood  serum. 

2.  Other  infections — such  as  carbuncles,  puerperal  sepsis,  anthrax, 
and  gonorrhea — at  first  local,  may  become  general  when  their  germs  enter 
the  blood  {hacteriemia  or  septicemia).  Some  infections,  especially  typhoid 
and  pneumonia,  once  considered  local,  are  always  general. 

.3.  Still  other  infections,  often  resulting  from  the  same  microorganisms, 
cause    metastatic    suppuration    {pyemia).      Among    these    are    multiple 
2 


18  BACTERIAL  DISEASES 

abscesses  from  carbuncles,  puerperal  fever,  typhoid  osteomyelitis,  pneu- 
mococcic  endocarditis,  and  gonorrheal  arthritis.  It  is  frequently  clinically 
difficult  to  preserve  these  types  which  so  often  blend;  what  is  seemingly 
toxemia  may  prove  bacteriemia  if  blood  cultures  are  made;  apparently 
pure  bacteriemia  may  prove  pyemia  at  necropsy;  all  three  grades  may 
occur  successively;  the  primary  infection — e.  g.,  with  scarlatina,  tuber- 
culosis, and  diphtheria — whether  local  or  general,  may  be  complicated 
by  a  later  secondary  or  a  simultaneous  mixed  infection,  especially  by 
the  streptococcus;  again  the  symptoms  vary,  first  with  the  variety  of 
microbe  and  its  virulence;  second,  with  its  localization  (in  the  throat, 
lung,  pelvis,  etc.);  and  third,  with  the  physiological  resistance  or  sus- 
ceptibility of  the  patient.  Subjects  of  malignancy,  cardiac,  vascular, 
nephritic,  cirrhotic  and  other  diseases,  readily  succumb  to  an  ultimate 
sepsis  to  which  the  name  terminal  infection  is  applied.  For  these  reasons 
we  will  discuss  septic  infections  as  a  whole,  and  indicate  such  special" 
etiological  and  clinical  variations  as  seem  necessary. 

Etiology  and  History  of  Septicopyemia. — Of  the  numerous  causal  organ- 
isms, the  most  common  are  the  pyogenic  cocci,  the  pneumococcus  and  colon 
bacillus;  less  frequent  are  the  gonococcus,  anthrax  bacillus,  t^'phoid  or 
diphtheria  bacillus,  Friedlander's  pneumobacillus,  meningococcus.  Bacillus 
pyocyaneus,  B.  influenzse,  B.  phlegmones  emphysematosse,  B.  aerogenes 
encapsulatus,  and  least  often,  the  Micrococcus  tetragenus,  the  blasto- 
mycetes,  the  spirilli  and  bacilli  of  Vincent,  the  Bacillus  fusiformis,  and 
the  proteus  group.  Wunderlich  (1847)  spoke  of  spontaneous  pyemia, 
and  Leube  (1878)  of  cryptogenetic  (occult)  septicopyemia,  yet  careful 
clinical  and  necropsy  investigations  reveal  the  atrium  of  infection  in  94 
per  cent,  of  cases;  (1)  skin  lesions,  such  as  furuncles,  felons,  navel  in- 
fection in  infants,  and  invisible,  as  well  as  visible  wounds  (staphyl- 
ococcus); (2)  throat  (streptococcus),  as  in  tonsillitis,  scarlatina  or  diph- 
theria; (3)  Jiose  (not  frequent  in  sepsis,  though  in  meningitis  the  atrium 
for  the  meningococcus  and  pneumococcus);  (4)  ear  (pneumococcus  and 
streptococcus);  (5)  lungs  (pneumococcus);  (6)  intestines  and  bile  tracts, 
gall-stone  infection,  appendicitis,  dysenteric  ulcers  (colon  bacillus, 
typhoid  bacillus);  (7)  urinary  tract  (pyelitis  from  colon  bacillus;  vesical 
and  urethral  infections,  chiefly  by  the  staphylococcus,  far  less  by  the 
streptococcus  and  gonococcus);  and  (8)  mgina  and  vterus  (chiefly 
streptococcus),  causing  puerperal  infection. 

Puerperal  fever,  primary  wound  fever  and  severe  late  pyemic  infection 
were  known  to  Hippocrates. 

Boerhaave  (1720)  declared  that  secondary  abscesses  were  due  to 
pus  in  wounds.  John  Hunter  (1774)  associated  purulent  phlebitis  and 
pyemia.  D'Arcet  (1842)  drew  a  sharp  distinction  between  toxemia 
and  pyemia.  In  1846  Virchow  discovered  that  the  "pus  in  the  A'eins" 
was  softened  thrombi  and  that  the  "pus  in  the  blood''  was  merely  leuko- 
cytosis; he  used  the  terms  septicemia  and  pyemia  in  their  modern 
construction.  Following  his  work,  the  subject  was  clarified  by 
bacteriology. 

General  Pathology  and  Symptomatology. — {A)  Gexeeal  Toxemic 
Symptoms. — 1.  Fever. — The  virulence  of  the  germ  and  its  toxin  (rather 


SEPTIC  INFECTIONS  19 

than  its  variety)  governs  the  intensity  of  the  toxemic  symjJtoms.  Fever  is 
associated  with  cellular  reactions  which  form  specific  antibodies  (anti- 
toxins, lysins,  opsonins,  and  agglutinins).  It  is  difficult  to  state  how  far 
fever  is  benign  and  how  far  injurious.  By  toxemic  disturbance  of  the 
cerebral  centres  regulating  temperature  equilibrium,  more  heat  is 
produced  and  less  eliminated.  Fever  is  usually  the  first  clinical  symptom 
and  in  general  the  fever  tends  to  be  remittent  or  intermittent;  (a) 
streptococcus  infections  usually  produce  irregular  intermittent  fever  with 
moderate  variations;  (h)  the  staphylococcus  and  pneumococcus  produce 
remittent  or  _  continuous  fever;  (c)  the  colon  bacillus  and  gonococcus 
cause  intermittent  fever  with  great  variations.  Fever  may  be  absent 
in  very  severe  forms,  especially  before  death,  when  the  cells' of  the  body 
are  overwhelmed  by  an  excessive  production  of  toxins. 

2.  Chills  occur  in  septicemic  and  especially  in  pyemic  forms  and  are 
usually  irregular.  They  mark  the  discharge  of  bacteria  or  toxins  into  the 
circulation. 

3.  Nervous  toxemia  may  appear  as  unrest,  delirium,  stupor,  dry  tongue, 
and  the  status  typhosus,  or  it  may  resemble  meningitis.  The  s'ensorium 
may  be  clear. 

4.  Vasomotor  and  cardiac  weakness  may  be  present  with  increased, 
irregular  or  hopping  pulse;  the  cardiovascular  system  may  suffer  the 
same  damage  as  in  typhoid  or  pneumonia  toxemia. 

5.  Increased  respiration,  from  augmented  gaseous  exchange,  and 
bronchitis  may  be  noted. 

6.  Albuminuria  and  acute  nephritis  are  common  from  microbic  or 
toxemic  injury. 

7.  Septic  diarrhea,  in  which  the  dark,  perhaps  bloody,  movements 
number  six  to  ten  daily,  may  be  observed.  Tympanites  is  frequent  from 
the  toxins  lowering  the  tone  of  the  intestinal  muscle. 

8.  Acute  splenic  tumor  is  present. 

9.  Anatomicalhj  we  find  cloudy  swelling  and  fatty  degeneration  of  the 
heart,_  liver  and  kidneys;  a  vascular,  soft,  moderately  swollen  spleen, 
with  indistinct  markings  and  wrinkled  capsule;  acute  nephritis;  hemor- 
rhages into  the  skin,  retina,  and  mucous  and  serous  membranes,  with  or 
without  bacteria;  lung  edema,  and,  where  there  is  marked  anemia, 
there  IS  fatty  heart,  increased  iron  deposit  in  the  liver,  hemorrhages 
by  injury  to  the  vessel  walls  or  necrosis  in  the  parenchymatous  organs 
or  lymph  glands. 

{B)  Blood  Findings.— 1.  Bacteriemia  is  found  in  50  per  cent,  of 
cases  clinically,  and  in  95  per  cent,  at  autopsy;  10  to  40  c.c.  of  blood  are 
removed  antiseptically  from  the  median  cephalic  vein  by  an  aspirating 
needle  and  mixed  freely  with  bouillon.  The  importance  of  blood  cultures, 
made  daily,  in  severe  or  doubtful  cases,  cannot  be  overestimated.  Some 
circulating  bacteria  are  killed  by  the  blood.  In  most  streptococcic  and 
staphylococcic  infections,  these  organisms  are  found  in  the  blood. 

2.  Polymorphonuclear  leukocytosis  and  iodophilia  are  very  common, 
though  not  invariable,  particularly  in  sepsis  due  to  pyogenic  organisms' 
The  lymphocytes  are  generally  decreased,  e.  g.,  in  contrast  to  the  tvphoid 
formula  (page  32).      However,  Cabot  and  others  describe,  in  wound 


20  BACTERIAL  DISEASES  ' 

sepsis,  boils  and  widespread  streptococcic  adenitis,  an  extreme  lympho- 
cytosis, resembling  acute  leukemia. 

3.  Anemia  is  usual,  and  may  resemble  the  pernicious  form. 

(C)  Metastases. — They  are  apparent  clinically,  or  first  found  at 
necropsy.  Thrombophlehitis  develops  at  the  seat  of  primary  infection, 
and  disintegrated  thrombi,  containing  bacteria,  escape  into  the  venous 
circulation.  They  lodge  in  the  lungs  or,  passing  them,  reach  the  left 
heart,  and  arterial  system.  Purulent  lymphangitis  may,  in  the  same 
way,  cause  metastatic  suppuration.  If  "end  arteries"  are  plugged, 
infarcts  result;  if  the  arteries  are  not  terminal,  small  suppurative  foci 
develop,  especially  where  the  circulation  is  slow,  as  in  the  liver,  kidney 
and  spleen.  Not  all  infarcts  suppurate,  either  because  the  germs  are 
less  virulent,  or  the  embolic  material  is  free  of  microbes.  (1)  Lung 
localization  may  cause  multiple  or  single  abscesses,  and  often  sero- 
fibrinous or  purulent  pleurisy.  (2)  Cardiac  metastasis  develops  in  21 
(even  63)  per  cent,  of  the  metastatic  group;  endocarditis  is  localized 
chiefly  on  the  mitral  (62  per  cent.)  and  aortic  (22  per  cent.)  valves;  it  is 
attended  by  a  heart  murmur  in  only  60  per  cent.,  and  often  by  pericar- 
ditis; the  heart  muscle  is  sometimes  the  seat  of  abscesses.  (3)  Cerebral 
metastasis  may  cause  meningitis ,  brain  abscess  or  softening  (encephalo- 
malacia  with  aphasia  and  hemiplegia).  (4)  Renal  localization  may  incite 
nephritis  or  suppurating  infarcts,  with  albuminuria,  cylindruria,  pyuria 
and  bacteriuria.  (5)  Splenic  localization  usually  results  in  enlargement, 
frequently  in  pain,  and  rarely  in  perisplenic  friction.  (6)  Localization 
in  the  bones  may  cause  early  fugitive  bone  pain,  or  later,  fixed  osteomye- 
litic  tenderness  over  one  or  more  bones,  with  inflammatory  signs;  in 
the  joints  (as  in  the  postfebrile  arthritides)  it  may  cause  simple  pain, 
or  serous  or  purulent  synovitis;  in  the  muscles  it  may  produce  abscesses, 
purulent  edema,  or  Wagner's  polymyositis.  (7)  In  the  sl'in  ecchymoses 
develop  in  50  per  cent,  of  fatal  cases,  usually  late,  often  symmetrical, 
and  sometimes  on  the  nose,  fingers,  toes  or  ears.  Ecchymoses  may  be 
peculiarly  significant  of  sepsis  in  the  absence  of  other  symptoms.  Pustules 
and  vesicles  are  less  frequent;  herpes  occasionally  develops,  particularly 
in  genito-urinary  colon  infections.  Scarlatiniform,  morbilliform,  roseo- 
lous  or  urticarial  eruptions  are  only  toxemic.  (8)  In  33  per  cent,  retinal 
ecchymoses  occur,  first  described  by  Litten  as  round,  irregular  spots  or  in 
streaks,  with  small  white  centres  and  appearing  late  or  just  before  death. 
Least  frequent  is  panophthalmitis,  of  which  33  per  cent,  is  due  to  ulcera- 
tive endocarditis.  (9)  The  peritoneum  is  chiefly  involved  in  puerperal 
forms.  (10)  The  slightly  enlarged  liver  is  more  often  due  to  toxic  paren- 
chymatous degeneration  and  cardiac  weakness  than  to  abscess,  which 
occurs  in  only  15  per  cent,  of  cases  of  septicopyemia.  Intestinal 
infarction  is  rare.  In  one  type  icterus  is  associated  with  meningeal 
symptoms. 

Some  metastases  develop,  maybe  years  later  than  the  original  infection, 
as  typhoid  osteomyelitis.  This  bacterial  latency  is  also  noted  in  diphtheria 
in  which  virulent  bacilli  persist  possibly  for  months  in  the  throat; 
in  tuberculosis  where  apparently  healthy  lymph  glands  may  contain 
tubercle  bacilli  and  perhaps  also  in  diseases  which  recur,  as  erysipelas 


SEPTIC  INFECTIONS  21 

and  articular  rheumatism.  Recurrence  may  also  be  due  to  fastness  or 
mutation  of  the  infecting  organism,  resulting  from  enduring  subinfection. 

Special  Symptomatology. — This  may  be  considered  etiologically  or 
topographically.     Only  the  leading  characteristics  are  presented. 

(A)  Etiological. — 1.  Streptococcic  infection,  the  most  frequent  primary 
and  secondary  septic  infection,  constitutes  66  per  cent,  of  all  forms,  the 
coccus  entering  the  blood  in  33  per  cent,  of  all  fatal  diseases.  Its  atrium 
is  most  often  the  throat  and  the  female  genitalia;  it  enters  the  veins 
in  puerperal  pyemia  more  often  than  the  lymphatics  (erysipelas  and 
puerperal  sepsis);  it  more  often  produces  septicemia  (65  per  cent.) 
than  pyemia  (35  per  cent.);  the  lungs  are  usually  unaffected;  endo- 
carditis occurs  in  7  per  cent.;  and  its  course  is  chiefly  acute,  sometimes 
subacute   (ulcerative  endocarditis).^ 

2.  Staphylococcic  infection  usually  enters  by  the  skin;  the  furuncle  is 
the  typical  primary  lesion.  On  the  eyelids,  nose  or  lips,  this  dangerous 
infection  may  reach  the  facial  vein,  then  the  ophthalmic  vein  and  cavern- 
ous sinus.  Furuncle  of  the  neck  may  reach  the  transverse  sinus.  In- 
fections of  the  skin  are  the  most  frequent  cause  of  osteomyelitis.  Menin- 
gitis is  known  to  have  followed  a  felon.  The  coccus  passes  the  throat 
with  difficulty,  but  then  with  increased  malignancy.  It  travels  by  the 
veins  or  lymphatics;  it  produces  metastasis  in  95  per  cent,  and  endo- 
carditis in  6  per  cent,  of  cases.  Abscesses  of  the  lung  and  kidneys  and 
pustular  skin  eruptions  are  very  frequent;  the  coccus  is  found  very 
often  in  the  blood  and  urine.  Staphylococcic  infection  is  usually 
acute. 

3.  Pneumococcic  Infections. — In  all  cases  of  pneumonia  (q.  v.)  the 
pneumococcus  appears  in  the  blood  (pneumococcemia).  In  actual 
sepsis  following  pneumonia,  it  enters  the  blood  through  the  pulmonary 
veins.  Infection  through  the  ear  or  bile  tracts  is  less  frequent,  but  in 
the  latter  type,  is  particularly  lethal;  metastases  occur  in  25  per  cent, 
and  endocarditis  in  6  per  cent.  The  pneumococcus  alone  may  produce 
pus  in  the  joints,  skin,  thyroid  and  serous  membranes.  Netter  states 
that  pneumococcic  sepsis  is  less  severe  than  other  types,  but  it  is  often 
malignant.  It  may  be  associated  with  the  pyogenic  cocci.  It  is  yet 
unknown  why  lung  infections  so  frequently  cause  brain  metastases. 

4.  Colon  sepsis,  which  is  less  frequent,  may  follow  wounds,  suppu- 
ration in  cholelithiasis,  cystitis,  pyelitis,  or  intestinal  obstruction.  Endo- 
carditis is  exceptional,  and  sepsis  (78  per  cent.)  is  more  common  than 
metastasis  (22  per  cent.).  Infection  was  hematogenous  in  the  majority 
of  Rovsing's  285  cases  of  colon  infections  of  the  urinary  organs;  the 
trouble  began  as  acute  nephritis  or  pyelitis  in  180  cases,  and  fever,  hema- 
turia and  later,  pyuria  were  common. 

,     5.   Gonococcic  infection  is  rather  more  benign  than  the  other  types. 
There  may  be  the  more  common  gonorrheal  arthritis  or  gonorrheal 

1  Schottmueller  differentiates  three  strains  of  streptococci  by  cultures  on  blood-agar: 
(i)  S.  pathogenes  sen  erysipelatos;  fine  colonies,  with  round,  clear,  hemolytic  areola,  (ii)  S. 
mitior  seu  viridans;  very  fine  green  colonies,  (iii)  S.  mucosus,  possibly  identical  with  the 
pneumococcus;  the  green  colonies  after  twent5'-four  hours  present  a  glistening,  mucoid 
appearance.  (The  S.  saprophyticus  (anhsemolyticus)  produces  no  change  in  blood-agar 
plates.) 


22  BACTERIAL  DISEASES 

endocarditis,  pericarditis  and  pleuritis.     Thayer  found  the  gonococcus 
in  the  blood  (v.  Gonorrheal  Infection). 

Other  forms  are  less  frequent,  as  typhoid  suppuration  in  the  pleura, 
bones,  meninges,  etc.,  sepsis  from  the  pneumobacillus,  meningococcus, 
etc.  Pyocyaneus  sepsis  is  attended  by  rapid  pulse,  vomiting,  diarrhea, 
and  a  hemorrhagic  diathesis. 

(jB)  Topographical.^ — The  clinical  varieties  of  sepsis  are  legion  and 
might  be  extended  to  the  chronic  infections  as  the  syphilitic  spirochete 
sepsis,  to  the  zoonoses,  malaria,  trypanosomiasis  or  certain  intoxications 
.  as  meat  poisoning.  (1)  Ulcerative  endocarditis;  (2)  cholangitic  sepsis; 
(3)  septic  sore  throat;  and  (4)  otogenous  sepsis  (v.  Sinus  Thrombosis, 
Meningitis,  Brain  Abscess)  will  be  considered  elsewhere.  The  two 
following  localizations  are  of  importance  to  the  practitioner  and 
internalist : 

(5)  Osteomyelitis  is  either  a  solitary  metastasis  or  part  of  a  generalized 
sepsis.  Even  when  a  single  bone  is  involved,  the  blood  usually  contains 
the  causal  microorganism.  It  is  due  to  the  staphylococcus  chiefly;  then  to 
mixed  infection  with  the  streptococcus,  which  is  found  in  all  fatal  cases, 
or  with  the  pneumococcus;  and  but  rarely  to  the  typhoid  organism. 
In  most  typhoid  and  pneumonia  autopsies,  the  causal  bacteria  are  present 
in  the  bone-marrow.  Acute  osteomyelitis  is  most  frequent  in  the  growing 
bones  of  children.  Trauma  is  a  promoting  element  and  the  onset  occurs 
with  chill,  fever,  vomiting,  diarrhea,  headache,  and  bone  pain.  It  is 
usually  first  seen  and  often  mistaken  by  the  practitioner.  The  rare  chronic 
cases,  which  last  one  year  or  even  thirty,  may  simulate  sarcoma  or  syphilis. 

(6)  Puerperal  fever  is  caused  chiefly  by  the  streptococcus  (95  per 
cent.).  Its  varieties  are  (a)  toxemia  or  sapremia,  caused  by  toxins  or 
putrid  decomposition  products  respectively.  Even  in  cases  apparently 
of  this  group,  bacteriemia  may  be  found  (colon  bacillus,  saprophytes 
or  streptococcus).  The  rare  puerperal  tetanus  is  wholly  toxemic,  (b) 
Lymphangitic  form:  lymphangitis,  from  infected  vaginal  or  cervical 
wounds,  may  cause  (i)  moderate,  benign,  localized  parametritis,  (ii)  Gen- 
eral septicemia,  from  vaginal  or  cervical  wounds,  infection  following  the 
lymph  vessels  through  the  pelvic  cellular  tissue  to  the  general  circulation. 
The  symptoms  appear  within  a  day  or  so  after  delivery.  Death  may 
result  in  two  to  fourteen  days,  or  encapsulation  and  massive  cellulitis 
may  develop,  (iii)  Lymphangitic  peritonitis  is  more  frequent  (20  per 
cent,  of  fatal  cases).  It  begins  three  or  four  days  after  delivery  and  is 
usually  generalized  and  suppurative.  Infection  may  travel  directly  to 
the  peritoneum  or,  more  often,  by  retrograde  lymphatic  routes  (Vir- 
chow's  "erysipelas  grave  internum  puerperale").  It  is  more  common  in 
labor  at  term  than  in  abortion.  The  symptoms  are  chill,  fever,  tense 
pulse,  vomiting,  abdominal  pain  and  distention,  and  often  effusion  and 
diarrhea.  In  many  apparently  purely  peritonitic  cases  bacteriemia  is 
found.  Early  death  is  the  rule,  commonly  in  five  to  six  days,  but  en- 
capsulation is  possible,  (c)  The  thromhophlehitic  (pyemic)  type  occurs 
in  50  per  cent,  of  fatal  cases.  It  commonly  begins  in  ulcerative  or  ichorous 
endometritis,  in  contradistinction  to  the  lymphangitic  form  of  vagino- 
cervical  origin.     Infective  thrombophlebitis  travels  (i)  from  the  upper 


SEPTIC  INFECTIONS  23 

veins  by  way  of  the  spermatic  veins,  to  the  cava  and  left  renal  vein; 
the  phlebitis  may  actually  extend  into  the  vena  cava;  (ii)  from  the 
lower  plexus,  by  way  of  the  uterine  veins  into  the  hypogastric  veins, 
and  thence  to  the  inferior  cava.  Bilateral  venous  thrombosis  is  common 
(45  per  cent.).  Metastases  are  common  in  the  lungs,  kidneys,  joints, 
muscles,  and  spleen.  Ulcerative  endocarditis,  meningitis  and  peritonitis 
may  be  present.  The  course  may  be  stormy  from  predominating  toxemia 
or  slower  with  metastases.  The  fever  is  irregular,  the  pulse  rapid,  the 
chills  severe,  the  anemia  marked,  and  streptococcemia  is  present  in  over 
90  per  cent. 

Diagnosis.— The  direct  diagnosis  rests  upon  the  detection  of  an  atrium, 
the  symptoms  of  toxemia  and  metastatic  suppuration  and  the  blood 
cultures.  The  differentiation  from  typhoid,  malaria,  and  miliary  tuber- 
culosis is  fully  considered  on  pages  46  and  47.  Solitary  local  or  visceral 
syrnptoms,  as  osteomyelitis,  arthritis,  endocarditis,  etc.,  may  cause  con- 
fusion if  not  viewed  in  their  broad  relations  to  a  possible  sepsis. 

Prognosis.— The  prognosis  depends  upon  the  organism,  its  mnilence 
and_  dissemination,  the  patient's  physiological  resistance  (whence  the 
obviously  poor  outlook  in  terminal  infections),  and  finally  on  the  surgical 
accessibility  of  the  primary  lesion  or  metastatic  foci.  Only  17  per  cent, 
of  Lenhartz's  cases  with  bacteriemia  recovered,  yet  recoveries  are  recorded 
m  cases  of  gonococcemia  and  streptococcemia.  A  stormy  onset  and  chills 
are  ommous.  A  case  of  Lenhartz  with  empyema,  lung  abscess,  pan- 
ophthalmitis, diffuse  venous  thrombosis  and  multiple  osteomyelitis 
recovered.  Puerperal  infections,  with  the  large  wound  surface  and 
frequent  hemorrhages,  are  severe,  the  mortality  of  all  forms  being  55 
per  cent.,  and  of  severe  forms  65  per  cetit.  (Curschmann) .  The  strepto- 
coccus has  been  regarded  with  particular  dread;  however,  Bertelsmann 
states  that  the  prognosis  is  twice  as  favorable  as  in  staphylococcic  in- 
vasion. 

Treatment.— Surgical  prophylaxis,  even  in  apparently  insignificant 
wounds  and  obstetrical  asepsis  is  important,  especially  in  subjects 
reduced  by  general  diseases.  Treatment  of  existing  sepsis  consists 
in  giving  the_  largest  possible  amount  of  food  which  can  be  digested; 
m  free  administration  of  salt  solution  by  rectum  or  transfusion,  to  flush 
the  toxins  through  the  kidneys;  and  in  the  free  use  of  alcohol  The  treat- 
ment of  hypostasis,  diarrhea,  vomiting  and  chills  is  symptomatic.  The 
temperature  is  seldom  influenced  by  drugs  safely.  The  internal  use  of 
germicides  is  justly  abandoned.  We  have  not  observed  the  slightest 
benefit  from  Crede's  silver  ointment.  Crede's  collargol  has  been  used 
with  benefit,  intravenously,  in  doses  of  one  to  two  and  a  half  drams. 
Nuclein  and  5j-ij  of  fresh  brewers'  yeast  are  also  advised.  Surgical 
intervention  is  indicated  whenever  definite  accessible  foci  are  localized. 

Vaccine  and  Serum  Therapy.— Nature  heals  and  the  progress  to  re- 
covery is  usual,  if  infection  is  not  too  rapidly  fatal.  The  so-called  im- 
munity principles  reside  in  the  phagocytes  and  soluble,  probably  protein 
bodies,  preformed  in  the  body  and  increasing  under  the  stimulus  of 
mfection.  The  various  portals  of  entrance  of  the  infective  agent  into 
the  body  are  detailed  above;  whereas  the  surfaces  of  the  body  are 


24  .  BACTERIAL  DISEASES 

inhabited  by  myriads  of  bacteria,  they  resist  infection  usually,  the 
epithelium  being  protective,  the  hydrochloric  acid  of  the  stomach, 
the  overgrowth  of  the  infective  virus  by  the  normal  flora  of  the  intestine 
and  the  acid  reaction  of  the  vagina  combating  localization,  etc.  Gaining 
access  to  the  body,  the  microorganisms  produce  toxins,  which  in  turn 
excite  the  production  of  antitoxins.  The  antitoxin  is,  then,  a  reaction 
product  of  the  organism  against  the  toxin.  Immunity  is  active  when  the 
body,  in  response  to  infectious  germs  (antigens),  protects  by  producing 
its  own  antibodies;  it  is  yassive  when  protection  is  achieved,  e.  g.,  by  the 
use  of  antidiphtheric  serum  in  which  the  antibodies  formed  in  the  blood- 
serum  of  another  animal  are  employed.  The  immunity  or  protective 
forces  of  the  body  are  the  bacteriolysins  which  destroy  the  bacteria,  the 
agglutinins  which  clump  the  virus,  the  antitoxins  which  neutralize  the 
toxin  and  the  opsonins  which  so  alter  the  bacteria  that  they  fall  an 
easy  prey  to  the  phagocytes. 

Guided  by  the  opsonic  index,  bacteria,  dead  or  alive,  may  be  injected 
to  stimulate  the  lagging  reactive  powers  of  the  body;  the  bacteria  are 
the  antigen.  Vaccine  therapy  is  indicated,  theoretically,  only  in  subacute 
and  chronic  infections;  in  acute  general  infections,  particularly  of  the 
fulminating  type,  vaccines  are  contra-indicated,  since  they  expose  the 
patient  to  greater  danger,  by  imposing  the  negative  phase  (in  which  the 
opsonic  index  is  lowered).  In  septicemia,  pyemia  and  grave  sapremia, 
vaccines  should  be  avoided  or  employed  only  with  the  utmost  caution. 
In  surface  infections,  in  furunculosis,  in  lingering  infections  from  mild 
types  of  parasites,  and  in  infections  with  slow  invasion,  vaccines  sometimes 
may  be  useful.  The  average  interval  of  inoculation  is  five  to  ten  days. 
The  range  of  dosage  is  100  to  1000  millions  in  staphylococcic  infections; 
5  to  200,  in  streptococcic;  10  to  200  in  pneumococcic;  5  to  500  in  gono- 
coccic;  and  10  to  200  in  colon  infections.  Vaccines  should  be  autogenous. 
In  commercial  stock  vaccines  dangers  linger  beyond  those  inherent 
in  vaccine  therapy  in  general;  the  uncertainty  of  the  source  of  these 
cultures,  of  their  age,  potency,  dosage  and  purity  are  most  important. 

Antistreptococcic  and  other  sera  are  most  uncertain. 


X 


TYPHOID  FEVER. 


The  name  {typhos,  stupor)  refers  to  the  clouded  mentality,  and  dates 
from  Hippocrates.  Bright,  Louis  and  others  recognized  that  ulceration 
of  the  bowels  occurred  in  certain  continuous  fevers,  but  typhoid  was  first 
described  as  a  disease  separate  from  tvphus  bv  Gerhard  and  Pennock 
(1837). 

Definition. — Typhoid  fever  is  a  general  injection,  characterized — 

1.  EtiologicaUy  by  the  Bacillus  typhosus. 

2.  Anatomically  by  h^'perplasia  and  ulceration  of  the  lymphatic 
structures  of  the  intestine,  hyperplasia  of  the  spleen  and  mesenteric 
glands,  and  by  parenchymatous  degeneration  in  other  organs. 

3.  Clinically  by  a  characteristic  fever,  roseolous  eruption,  enlarge- 
ment of  the  spleen,  slow  pulse,  a  peculiar  serum  reaction,  typhoid 
bacillemia,    and   often   by   intestinal   symptoms. 


TYPHOID  FEVER  25 

Etiology. — The  typhoid  bacillus  was  first  detected  by  Eberth  and  Koch 
(1880),  and  first  cultivated  by  Graffky  (1884). 

1.  Characters. — It  has  thick,  rounded  ends,  is  three  times  as  long 
as  wide,  in  length  is  one-third  the  diameter  of  a  red  blood  corpuscle,  and 
its  numbers  are  usually  proportionate  to  the  degree  of  infection.  It  is 
polymorphous,  sometimes  thread-like,  contains  no  spores,  is  flagellated 
and  actively  motile.  It  is  a  facultative  anaerobe  growing  on  various 
media,  especially  on  agar,  gelatin  and,  characteristically,  on  potato. 
It  does  not  produce  acid,  indol,  ferment  lactose  or  coagulate  milk. 
It  stains  with  aniline  dyes  but  not  by  Gram's  method;  it  produces  an 
endotoxin  only  by  the  disintegration  of  the  bacillus  itself. 

Typical  lesions  have  been  produced  in  chimpanzees  and  goats. 

Its  tenacity  of  life  is  great,  the  germ  persisting  for  years  in  bone  lesions 
and  from  three  weeks  to  three  months  after  death.  It  resists  drying 
for  months  but  in  water  seldom  lives  longer  than  three  weeks  and  its 
multiplication  is  prevented  by  saprophytes.  The  germ  may  live  for 
months  in  ice,  sour  milk,  feces  or  in  the  upper  layers  of  the  soil.  It  may 
survive  a  year  in  soiled  clothes,  which  explains  contagion  in  washer- 
women.   It  is  killed  in  a  few  hours  by  direct  sunlight. 

2.  Location. — It  is  found  in  the  typhoid  idcers,  the  lymphatics  of 
the  mesentery,  the  spleen,  the  feces,  blood,  gall-bladder,  urine,  roseolse, 
less  frequently  in  the  lungs,  esophagus  and  mouth,  and  in  various  second- 
ary foci,  as  in  pleurisy,  pneumonia  (sputum),  endocarditis,  meningitis, 
parotitis,  osteomyelitis  and  abscesses.  It  has  been  isolated  from  the 
blood  of  the  fetus  in  maternal  typhoid  infections. 

3.  Entrance. — Its  chief  and  probably  sole  atrium  is  the  digestive 
tract,  the  infection  being  carried  in  water,  milk,  butter,  ice,  vegetables 
or  oysters.  Water  or  milk  infection  is  the  usual  explanation  for 
"explosive"  epidemics.  As  shown  in  the  Spanish-American  and  Boer 
wars,  dried  feces  containing  the  bacilli  may  be  carried  by  sand,  flies, 
cockroaches  and  other  insects. 

4.  Exit. — The  germ  leaves  the  body  chiefly  in  the  feces  and  urine, 
which  are  dangerous  far  into  convalescence;  they  are  the  chief  means 
of  dissemination,  the  disease  being  less  often  conveyed  directly  from  one 
individual  to  another,  although  direct  infection  occurs  in  hospitals  and 
camps.  Lentz  found  that  after  a  typhoid  attack  4  per  cent,  of  persons 
become  "chronic  carriers  of  typhoid  bacilli,"  the  microbes  remaining 
in  their  dejecta  for  one,  fifteen  or  even  fifty-four  years.  Soper  describes 
a  cook  who,  though  perfectly  well  herself,  was  a  "  bacillen-trager"  and 
caused  26  cases  of  typhoid  fever  in  five  years,  and  54  typhoid  infections 
are  attributed  to  a  dairy  hand.  The  bacilli-carriers  are  twofold:  the 
primary,  who  carry  bacilli  in  the  blood  or  stools,  but  resist  infection 
or  reaction  and  the  secondary  carriers,  who  have  suffered  infection — 
the  more  common  class. 

Alimentary  infection  is  the  most  common,  occurring  by  water  in  71 
per  cent,  of  typhoid  infections,  by  milk  in  17  per  cent.,  by  flies  in  4  per 
cent,  and  by  clothes,  dust,  etc.,  in  8  per  cent,  (direct  contact,  3  per  cent.), 
in  35,674  cases  (Schiider).  Kayser  holds  that  mflk  causes  27  per  cent., 
water  15  per  cent.,  and  typhoid-carriers  10  per  cent. 


26  BACTERIAL  DISEASES 

Predisposing  Etiology. — 1.  Reduced  Physiological  Resistance. — 
Reduced  resistance,  as  from  overwork,  mental  depression,  decreased 
hydrochloric  acid  formation  or  dilated  stomach,  is  a  frequent  predisposing 
cause;  yet  typhoid  very  often  occurs  in  the  robust.  It  is  claimed  that  the 
weak  or  emaciated  are  immune — e.  g.,  those  with  syphilis,  tuberculosis, 
cancer,  endocarditis  or  anemia.  Most  cases  occur  in  time  of  war  among  the 
poorer  classes,  or  among  recent  residents  in  typhoid  localities  (Trousseau) . 

2.  Season. — For  unknown  reasons  most  infections  develop  in  the  late 
summer  and  fall  ("autumnal  fever")- 

3.  Age. — The  years  from  fifteen  to  twenty-five  include  56  per  cent, 
of  cases;  a  few  cases  occur  in  the  first  year  of  life.  Their  number 
increases  from  the  first  to  the  fifth  year.  Between  the  fifth  and  fifteenth 
years  as  many  are  aft'ected  as  after  thirty-five.  The  disease  is  relatively 
rare  after  fifty. 

4.  Geogkaphical  Distribution. — Although  it  is  the  most  common 
continued  fever  in  temperate  climates,  it  is  a  world-wide  disease  and 
sustains  a  most  intimate  relation  to  the  water  supply,  the  disposal  of 
sewage,  the  density  of  population  and  personal  hygiene. 

Immunity. — Immunity  bears  no  relation  to  the  severity  of  the  disease; 
usually  conferred  after  one  attack,  it  is  not  life-long  nor  as  frequent 
as,  e.  g.,  in  scarlatina.  In  the  Hamburg  epidemic  (1887)  2.4  per  cent, 
of  the  cases  were  second  attacks.  Second  attacks  may  equal  or  exceed 
the  original  in  severity. 

Symptoms. — The  general  clinical  picture  offers  more  variability  than 
any  other  infection.  Typhoid  is  not  an  intestinal  disease,  hut  a  general 
injection,  with  hacillemia.     Its  forms  are: 

1.  The  typical  enteric,  frequently  with  diarrhea,  tympany,  hemor- 
rhage and  perforation. 

2.  The  septicemic,  without  any  or  with  very  slight  intestinal  lesions; 
the  Widal  reaction  and  bacillemia  are  present. 

3.  Other  localizations  than  enteric,  e.  g.,  in  the  lung,  bone,  etc. 

4.  Mixed  infections — malaria,  streptococcus,  colon  bacillus,  etc. 

5.  Paratyphoid,  with  close  clinical  resemblance  to  typhoid  but  with 
organisms  differing  culturally  and  otherwise  (p.  47). 

The  incubation  lasts  two  or  three  weeks,  with  symptoms  more  vague 
than  in  other  infections,  e.  g.,  depression,  pains  in  the  head,  back  or 
limbs,  disturbed  sleep,  chilliness,  anorexia,  epigastric  oppression,  con- 
stipation or  diarrhea.  The  incubation  was  three  days  in  a  girl  who 
drank  a  typhoid  culture  with  suicidal  intent. 

The  first  week  corresponds  anatomically  to  the  intestinal  catarrh 
and  the  beginning  of  medullary  infiltration  of  Peyer's  plaques.  The 
disease  dates  from  the  fever,  which  each  evening  is  from  1°  to  1.5° 
higher  than  on  the  previous  day,  until  a  temperature  of  103°  to  104° 
is  reached.  The  pulse  is  full,  dicrotic  and  rapid,  but  slow  in  proportion 
to  the  fever.  The  tongue  is  coated  white.  Thirst,  anorexia,  dry  cough, 
enlarged  spleen,  eruption  of  rose  spots  and  typhoid  bacillemia  are  found. 
The  abdomen  shows  slight  distention  and  pain  or  tenderness  over  the 
ileocecal  region  or  epigastrium.  Headache,  constipation,  and  apathy 
are  usually  present. 


TYPHOID  FEVER  27 

The  second  week  corresponds  to  the  end  of  medullary  infiltration  and 
the  beginning  of  eschar  formation.  The  fever  is  higher  and  usually 
continuous;  the  moriiing  remission  is  less.  The  pulse  is  full,  faster  and 
less  dicrotic.  The  Widal  test  appears.  The  tongue  is  dry  and  glazed, 
as  are  also  the  lips,  pharynx  and  mouth,  <to  which  the  mucus  adheres. 
The  face  is  apathetic,  its  lines  obliterated,  the  mouth  half-open  and  the 
upper  lip  retracted,  showing  sordes.  The  voice  is  weak.  The  bron- 
chitis increases,  and  the  urine  is  febrile.  Meteorism  appears  and 
yellow  pea-soup  dejecta,  involuntary  in  severe  cases.  Roseolse  de- 
velop during  this  week.  Nervous  symptoms  increase  with  higher  fever; 
delirium  follows;  the  patient  becomes  less  querulous;  and  euphoria 
from  narcosis  by  the  toxins  is  the  rule,  while  pain  suggests  complications. 
The  toxemia  is  due  to  endotoxins  liberated  from  typhoid  bacilli,  killed 
by  the  tissues.  The  patient  may  begin  to  recover  through  the  opsonins, 
bacteriolysins  and  agglutinins,  overcoming  the  toxins,  or  may  die  at 
this  stage  from  hemorrhage,  nervous  toxemia,  etc. 

The  third  weeh  is  the  stage  of  ulceration.  The  fever  gradually  declines 
with  marked  morning  remissions  and  unaccountable  "S'ariations.  The 
pulse  is  smaller  and  faster  (100  to  120),  and  loses  its  dicrotism.  The 
tongue  clears  and  the  roseolse  are  replaced  by  miliaria  from  sweating. 
Diarrhea  may  be  seen  for  the  first  time  in  this  week.  ^^Tien  the  fever 
falls  the  emaciated  patient  complains  of  hunger,  weakness  and  pain. 
Death  may  occur  in  the  typhoid  state  from  heart  weakness,  pulmonary 
inflammation,  paralysis  of  the  nerve  centres,  hemorrhage  or  per- 
foration. 

The  fourth  week  (cicatrization)  usually  marks  convalescence,  as  the 
average  t^'phoid  runs  three  to  six  weeks;  in  severe  cases  the  symptoms 
of  the  third  week  may  continue.  Convalescence  may  be  uneventful, 
or  marred  by  slight  fever,  rapid  pulse,  weakness,  etc. 

Symptoms  in  Detail. — To  avoid  repetition,  and  to  explain  anatomi- 
cally the  clinical  symptoms,  the  typhoid  pathology  will  be  incorporated 
under  the  appropriate  organs,  and  complications  and  sequels  classified 
with  the  usual  typhoid  manifestations. 

1.  Fever. — Fever  is  a  cardinal  symptom  of  t^'phoid;  it  is  toxemic, 
the  toxins  so  affecting  the  heat  centre  (in  the  corpus  striatum),  that  heat 
production  is  increased  and  its  elimination  decreased.  It  is  subacute, 
averages  three  or  four  weeks  in  duration,  usually  comes  on  without  a 
chill,  and  resolves  by  h'sis.  Wunderlich  diagnosticated  typhoid  from  the 
fever  chart  alone.  In  the  first  week,  corresponding  to  the  catarrh  and 
medullary  infiltration,  the  evening  temperature  is  0.6°  to  1°  more  than  in 
the  morning,  and  the  ascension  is  ladder-like.  In  the  second  iceek,  cor- 
responding to  the  end  of  infiltration  and  to  the  formation  of  the  slough, 
the  fever  is  continuous  from  one-half  to  three  tceeks.  In  the  third  week 
(ulceration)  the  fever  is  remittent  (the  amphibolic  stage  or  stadium 
hecticum).  The  fourth  iceek  (cicatrization)  is  the  stage  of  "steep  curves," 
lasting  from  three  to  eight  days.  When  a  sudden  drop  occurs,  recurrences 
and  relapses  are  not  infrequent. 

Convalescence. — At  first  the  typical  curve  is  subnormal,  with  a  later 
gradual  rise  to  normal. 


28 


BACTERIAL  DISEASES 


Afyjncal  Fever  Course. — As  to  onset,  two  variations  may  be  observed. 
(1)  There  is  a  sudden  explosive  onset  in  10  per  cent,  of  typhoids.  The 
writer  saw  a  sudden  rise  to  106°  on  the  second  day.  (2)  When  there  is  an 
initial  chill  every  other  disease  should  first  be  excluded,  yet  Osier  observed 
chills  in  22  per  cent,  of  his  cases  (a)  at  the  onset,  especially  in  children, 
and  in  light  forms;  (6)  throughout  the  course,  and  accompanied  by 
sweats,  the  sudoral  type;  (c)  in  complications — pneumonia,  otitis  media; 
{d)  after  antipyretics,  tubbing,  or  (e)  in  defervescence  from  secondary 
sepsis. 

In  the  second  week  especially  high  temperature  suggests  complications; 
if  the  fever  becomes  very  high,  the  course  is  apt  to  be  severe.  In  a  fatal 
case,  the  writer  observed  fever  ranging  from  106°  to  108°  for  one  week. 
Sometimes  a  pseudocollapse  may  occur,  particularly  in  subjects  between 
twenty-five  and  thirty  years  of  age.     In  the  third  or  fourth  iveek  the 


PULSE 

1     U;i}9     6 

12 

iS 

24 

SO 

ss 

12 

^/^ 

V\/v\j 

y  A 1 

130 

a/ 

r    ^ 

m 

120 

/ 

n 

\ 

100 

/ 

/  V 

V 

aI 

90 

/ 

V     x/ 

i 

Aj 

80 

/\'V 

K 

r-f 

wY^"^ 

.'\ 

70 

NORMAL 

1 

M/l     .              A     AAA^1-~^I 

1   'VWIV          1 

Fig.   1. — Typical  typhoid-fever  curve.     The  heavj^  line  marks  the  temperatuie  curve,  and 
the  broken  line  the  pulse  curve. 

fever  exceptionally  may  decline  by  crisis;  a  brusque  defervescence 
occurs  in  29  per  cent,  of  cases  (Jaccoud). 

The  fever  may  be  intermittent  or  remittent  throughout  the  disease, 
especially  in  children,  the  aged  and  in  severe  cases;  protracted  irregu- 
larity may  suggest  miliary  tuberculosis  or  sepsis. 

In  the  typus  inversus,  seen  chiefly  in  children  and  the  aged,  the  morning 
temperature  is  higher  than  the  evening  record.  Afebrile  typhoid  is 
exceptional.  Modification  of  temperature  may  be  caused  by  excitement, 
entrance  to  the  hospital,  relapse,  hemorrhage,  abortion,  peritonitis 
and  other  complications. 

2.  The  Splenic  Tumor  is  a  cardinal  symptom,  occurring  early  and 
persisting  in  exacerbations  and  relapses.  In  importance  and  size,  it 
ranks  third  to  the  splenic  enlargement  of  malaria  and  sepsis.  Its  cause 
is  the  bacillus  or  its  toxin  which  produces  splenic  hyperemia  and  hyper- 
plasia— changes  analogous  to  those  in  the  intestinal  lymph  structures — 
and  endothelial  proliferation  in  the  splenic  vessels  (Mallory).     In  the 


TYPHOID  FEVER 


29 


first  week  the  spleen  is  hyperemic  and  swollen  to  twice  its  normal  size. 
Its  markings  are  injlistinct.  In  the  second  week  it  is  darker  and  more 
pulpy.  By  the  fourth  week  it  usually  has  disappeared,  but  as  long  as 
splenic  tumor  persists  the  disease  persists. 

Frequency. — (a)  Anatomically  the  splenic  tumor  is  present  in  98.4 
per  cent,  of  the  cases.  Its  rare  absence  is  explained  by  capsular  thicken- 
ing or  induration  or  infarction  of  the  organ.  (6)  Clinically,  it  is  present 
in  75  to  90  per  cent.  The  percentage  varies  with  the  skill  and  the  method 
of  examination  (the  sign  being  often  absent  in  children,  in  adults  older 
than  forty-five  years,  or  after  hemorrhage).  It  should  be  palpated 
with  the  patient  in  the  right  diagonal  position;  the  examiner  should 
sit  on  the  right  side  of  the  patient  palpating  with  the  right  hand  pressing 
evenly  on  the  abdomen,  and  the  left  hand  hooked  beneath  and  lifting 
up  the  loAver  left  ribs.  If  the  palpating  fingers  are  not  pressed  too  deeply 
into  the  splenic  region,  the  spleen  is  almost  invariably  detected.  Tympany 


UAY 

1 

2 

3 

4 

5 

G 

8 

9 

10 

11 

12 

la 

11 

15 

1611; 

13 

19 

20 

21  22i23 

24 

25   2 

0   27 

28 

29 

30 

31 

32 

TEMP. 

lOi 

103 

i 

n 

1 

/         1 

1 

A 

1 

l\ 

A 

1 

Wi 

1 

Aa 

A 

li 

/ 

'  1 

\/ 

' 

\ 

'    K 

U 

Y 

k 

1  r 

\   A 

aI 

V 

\ 

Tn 

A 

f\ 

li 

A 

1 

101 

N| 

A 

[ 

J\ 

/ 

nri 

I 

v 

w 

1 

IfV 

1 

V 

y 

M 

j 

100 

tf 

V\ 

1 

K 

v 

h 

1 

1 

'JO 

- 

1 

98              1 

_ 

Fig.  2. — Typhoid  fever,   irregular  fever  curve  throughout  the  course. 


may  obscure  the  splenic  tumor.  Percussion  of  the  spleen  gives  utterly 
unreliable  results.  The  author  has  twice  seen  the  spleen  ruptured  by 
rough  palpation.  Rare  complications  are  abscess,  infarct  and  spontaneous 
rupture  (38  instances,  Bryan,   1909). 

3.  Skin. — (a)  Rose  spots  (roseola  typhosa,  tdche  rosee  lenticulaire 
of  Louis)  constitute  the  third  cardinal  symptom.  The\'  are  round  spots, 
varying  in  size  from  a  pin-head  to  a  lentil  (lenticular),  rose-colored, 
slightly  elevated,  purely  hj'peremic  and  therefore  disappearing  on  pressure 
and  reappearing  on  its  release.  Pustulation  is  rare  (5  cases,  Eggleston), 
as  also  are  fusion,  vesiculation  and  hemorrhage — the  term  petechia  being 
inappropriate.  They  usually  appear  from  the  seventh  to  the  tenth  day. 
They  occur  in  crops,  during  two  weeks,  each  crop  lasting  from  three  to 
five  days.  Occasionally  they  outlive  the  fever.  They  appear  on  the 
lower  chest  and  abdomen,  though  sometimes  twenty-four  hours  earlier 
on  the  back,  because  of  its  warmth.    They  rarelv  occur  on  the  neck  or 


30  BACTERIAL  DISEASES 

face,  and  are  more  frequent  on  the  proximal  parts  of  the  extremities 
than  on  the  distal.  (If  many  spots  appear  here,  they  are  probably 
not  roseolse.)  They  number  five  to  ten,  or  even  thirty.  They  are  more 
abundant  in  women,  less  so  in  children  and  the  aged,  and  seldom  so 
numerous  as  to  resemble  measles  closely.  Eichhorst  found  them  con- 
stantly in  2044  cases.  Osier  in  93  and  Murchison  in  33  per  cent.  Typhoid 
bacilli  in  the  roseolse  (in  100  per  cent.)  may  establish  a  doubtful  diagnosis, 
but  rarely  an  early  one;  in  miliary  tuberculosis,  meningitis  and  pneu- 
monia, roseolse  are  very  rarely  encountered. 

(h)  Other  Cutaneous  Manifestations. — The  typhoid  odor  is  musty 
or  semicadaveric.  Furunculosis  is  the  most  common  cutaneous  compli- 
cation. Miliaria  are  frequent,  though  less  than  in  sepsis;  usually  appear- 
ing in  the  third  or  fourth  week,  they  indicate  convalescence.  The  author 
has  observed  herpes  only  ten  times  in  upward  of  2000  cases;  it  is  far 
less  frequent  than  in  pneumonia,  malaria,  typhus,  meningitis  and  in- 
fluenza. Decubitus  occurs  in  1  per  cent.,  mostly  in  severe  and  hospital 
cases.  (See  Therapy.)  Noma  is  a  rare  complication.  In  204  cases  of 
gangrene  collected  by  Keen,  50  per  cent,  occurred  in  the  leg  and  25  per  cent, 
in  the  face,  neck  and  trunk.  Sweats  and  chills  occur  in  the  "  typhus  sudo- 
ralis,"  especially  in  the  latter  half  of  the  fever  course,  described  in  Naples 
by  Borelli  and  in  Paris  by  Jaccoud.  Edema  is  due  most  frequently  to 
phlebitis,  sometimes  to  anemia,  and  rarely  to  nephritis.  The  skin  some- 
times shows  atrophic  strise  cutis  distensse  like  those  of  pregnancy.  Other 
cutaneous  manifestations  are:  Urticaria;  desquamation  (in  7  per  cent.); 
erythema,  even  of  the  nodose  or  exudative  forms;  morbilliform  rashes; 
purpura;  pelioma  typhosum  or  the  tache  bleudtre — pale  blue  spots, 
measuring  4  to  10  millimeters — due  to  pediculosis  and  therefore  seen 
in  parts  nearest  the  pubic  or  axillary  hair  (Piednagel,  1837);  erysipelas 
or  phlegmon;  and  alopecia  after  the  typhoid  attack,  rarely  followed  by 
permanent  baldness. 

4.  Circulation. — (a)  The  slow  pulse  is  the  fourth  cardinal  sym/ptom. 
It  is  lower  than  the  fever  would  justify,  especially  in  men  under  forty 
years,  e.  g.,  pulse  90  with  the  fever  103°.  Its  slowness  is  due  to  an 
inhibitory  action  of  the  toxins  on  the  medulla  or  the  heart.  The  pulse 
may  range  from  50  to  60,  with  the  fever  above  103°  and  the  respirations 
above  40.  Slowness  is  of  good  import.  Dicrotism,  evidenced  by  a 
double  shock,  occurs  in  80  per  cent,  of  cases,  which,  with  slowness, 
suggests  typhoid.  It  is  usual  in  adults,  but  is  absent  in  children  and 
often  in  adults  at  the  fastigium  in  very  severe  cases.  Since  it  indicates 
lack  of  arterial  tone,  it  is  also  absent  in  arteriosclerosis,  or  in  vasomotor 
paralysis.  The  systolic  blood-pressure  is  115  to  125  mm.  A  fast  pulse 
early  in  the  typhoid  course  is  a  poor  prognostic,  especially  in  men 
(heart  or  lung  inflammation,  perforative  peritonitis,  hemorrhage  and 
severe  intoxication).  It  may  also  run  up  on  visiting  days,  in  women, 
children,  emaciated  and  nervous  individuals,  or  in  the  stage  of  great 
temperature  variations.  Irregularity  or  crossing  of  the  pulse  and  tem- 
perature curves  is  ominous.  Early  in  convalescence,  when  there  is 
subnormal  temperature,  the  pulse  is  usually  normal  in  rate  or  slow, 
from  depressed  conductivity  or  myocarditis.     Later  it  is  usually  above 


TYPHOID  FEVER 


31 


normal,  especially  after  getting  out  of  bed,  or  after  a  bowel  movement. 
On  the  whole,  brs^dj'^cardia  in  convalescence  is  more  common  than 
tachycardia. 

(6)  Heart  Muscle. — Parenchymatous  degeneration,  evidenced  by  albu- 
minous granules,  nuclear  swelling  and  pigmentation,  makes  the  heart 
flabby,  soft,  pale  and  even  waxy.  Fatty  and  hyaline  degeneration, 
vacuole  formation,  periarteritis,  endarteritis  and  segmentary  myocarditis 
are  the  usual  findings  in  fatal  cases.  Interstitial  myocarditis,  like  that  of 
diphtheria  or  scarlatina,  occurs  in  over  50  per  cent,  of  typhoid  cases. 
Its  clinical  signs  appear  at  the  end  of  the  second  week,  lasting  into  the 
fourth  week,  or  develop  first  in  convalescence.  The  symptoms  are 
gradual  dilatation  of  the  left  ventricle,  weak  tones  (especially  the  first 
tone  at  the  apex),  accentuation  of  the  second  pulmonic,  a  systolic  bcuit, 
and  a  fast,  irregular  pulse.  Tachycardia,  without  myocarditis,  may 
result  from  the  toxins  acting  on  the  medulla  oblongata.  It  usually 
regresses  completely,  and  chronic  myocarditis  rarely  develops. 

Dilatation  of  the  right  heart  may  be  observed  in  severe  cases.  Less 
frequent  are  the  following  complications:  Cardiac  thrombosis  and 
embolism;  pericarditis,  once  in  1000  typhoid  autopsies,  mostly  fibrinous 


Fig.  3. — Pulse  tracing  in  typhoid,  showing  dicrotism. 


and  in  complicating  sepsis;  and  endocarditis,  once  in  1000,  mostly 
mural  over  myocarditic  patches,  sometimes  due  to  Eberth's  bacillus. 
Collapse,  with  its  usual  signs,  may  cause  death  from  heart  degeneration, 
or  from  toxic  vasomotor  paralysis  (as  in  diphtheria  or  pneumonia) ;  myo- 
carditis is  the  most  frequent  cause,  while  pulmonary  embolism,  uremia, 
cerebral  hemorrhage,  etc.,  are  far  less  common.  Sometimes  no  clear 
cause  is  discovered  at  autopsy.  Sudden  death  is  recorded  in  80  instances 
(Dieulaf oy) .  Collapse  develops  most  often  during  convalescence  and 
mostly  in  strong  men  (80  per  cent,  of  Dewevre's  140  cases)  (see 
Prognosis). 

(c)  Vessels. — Phlebitis  typhosa  occurs  in  1  per  cent,  of  cases,  being 
marantic,  or  infective  due  to  Eberth's  bacillus  or  pus  cocci,  when  pain 
and  fever  are  present;  it  occurs  chiefly  in  males  and  is  usually  left-sided, 
since  the  left  iliac  vein  has  a  slower  current,  being  crossed  by  the  right 
iliac  artery.  The  symptoms  are  pain,  coldness,  edema  and  sometimes 
a  tender,  palpable  cord,  manipulation  of  which  may  precipitate  embolism. 
Thrombosis  usually  occurs  in  the  saphenous  vein  where  it  empties  into 
the  femoral,  sometimes  in  the  popliteal  vein,  and  rarely  in  the  arms. 
It  may  extend  from  the  leg  to  the  cava,  when  the  other  leg  may  be 


32  BACTERIAL   DISEASES 

involved.  There  is  some  danger  of  detachment,  pulmonary  embolism, 
and  sudden  death;  but  relative  recovery  is  usual  after  two  or  three 
months.  L.  A.  Connor  believes  that  thrombophlebitis  develops  in  10 
to  15  per  cent,  of  t^'phoids  and  causes  embolism  (33  per  cent.),  post- 
typhoid chills,  and  "tender  toes"  (usually  considered  as  a  plantar  neuritis). 
Arteritis  typhosa,  most  often  femoral,  is  rare,  W.  W.  Keen  collecting 
only  44  cases,  and  it  is  specific,  caused  by  the  typhoid  bacillus.  Sponta- 
neous gangrene  was  noted  in  44  typhoid  patients,  among  180  cases  of 
gangrene  in  youth  after  various  infections  (Barraud,  1904).  Arterio- 
sclerosis may  be  initiated  by  tA'phoid. 

(d)  The  Blood. — The  red  blood  cells  average  4,000,000.  Anemia  is  most 
frequent  during  the  third  week  or  in  relapses.  An  apparent  increase 
of  the  red  disks  may  result  from  loss  of  fluids,  as  from  diarrhea.  The 
hemoglobin  decreases  slightly  in  excess  of  the  oligocythemia.  The  leuko- 
cytes decrease  from  8000  to  1700,  averaging  5000  per  cubic  millimeter. 
Leukopenia  is  more  common  in  typhoid  than  in  any  other  febrile  condition 
and  helps  to  differentiate  it  from  pneumonia,  sepsis,  meningitis,  etc. 
Severe  infections  always  exhibit  a  low  count;  the  converse  is  not  true. 
The  polymorphonuclear  neutrophiles  are  absolutely  and  relatively 
decreased  to  below  60  or  50  per  cent.,  while  they  are  increased  in  most 
other  infections.  The  large  mononuclear  and  transitional  forms  are 
relatively  increased.  The  eosinophiles  are  greatly  decreased;  their 
return  is  a  good  prognostic.  Leukocytosis  occurs  only  in  complicating 
inflammations. 

Typhoid  is  a  primary  hacillemia  or  septicemia  (Frankel  and  Simmonds, 
1885).  The  bacilli  reach  the  blood  from  the  lymphopoietic  organs,  and 
from  the  blood  reach  the  feces  secondarily  by  way  of  the  bile  or  by 
ulceration  of  Peyer's  patches.  A  positive  blood  culture  is  the  safest  and 
surest  means  of  diagnosis  in  the  first  week  of  typhoid.  Cultures,  repeated 
day  after  day,  are  positive  in  100  per  cent,  in  the  first  week,  in  71  per  cent, 
in  the  second,  and  in  36  per  cent,  in  the  third  week.  Convalescence 
is  rapidly  established  as  soon  as  the  bacillemia  ceases. 

The  Gruber-Widal  Test. — ^The  agglutination  and  immobilization  of 
typhoid  bacilli  occur  when  they  are  brought  in  contact  with  a  typhoid 
serum.  The  agglutinins  are  produced  by  the  tissues  reacting  to  the 
bacilli.  Gruber  pointed  out  the  value  of  the  test  in  proving  the  existence 
of  a  previous  typhoid,  while  ^Yidal  applied  the  laboratory  facts  at  the 
bedside. 

Technique. — A  bouillon  culture,  not  more  than  eighteen  hours  old, 
is  used,  taking  forty  parts  of  the  bouillon  and  one  of  the  blood  (dilution 
of  1  to  40),  since  the  test  is  quantitative  rather  than  qualitative.  The 
test  may  be  made  macroscopically  in  the  test-tube,  or  on  the  microscopic 
slide,  where  immobilization,  clumping  and  agglutination  of  the  bacilli 
may  be  observed,  sometimes  in  a  very  short  time — an  hour  is  the  usual 
time-limit  for  the  test.  Ficker  employs  dead  cultures  with  equally 
accurate  results,  and  this  method  is  more  convenient  and  safe  than  the 
use  of  living  bacilli   (Plate  I). 

Significance. — The  reaction  may  be  found  thirty  years  after  a  typhoid 
attack.     It  is  sometimes  absent  in  typhoid,  particularly  in  severe  cases, 


PLATE  I 


Bouillon  Culture  of  Typhoid  Bacilli  before  the  Addition  of  Diluted 
Typhoid  Serum.     X  SOO.     (After  Cabot.)     Serum  diagnosis. 


The  Same,  Five  Minutes  after  the  Addition  of  Typhoid  Serum 

(dilution  1  to  10),  shoxA'ing  Typical  Clump  Reaction. 

X  400.     (Cabot.) 


TYPHOID  FEVER  33 

and  it  often  develops  late,  e.  g.,  not  until  the  seventeenth  or  sixty-seventh 
day.  Cabot  found  the  reaction  in  97  per  cent,  of  5978  typhoid  cases. 
In  Osier's  series  it  appeared  in  93  per  cent,  before  the  eighth  day.  When 
it  appears  in  the  first  week,  it  is  due  to  a  "silently  developing"  infection 
(Widal),  i.  e.,  the  typhoid  is  more  advanced  than  we  appreciate.  The 
test  is  most  significant  when  it  is  absent  early  and  develops  later.  Typhoid 
bacillemia  decreases  as  the  Widal  develops.  The  Widal  reaction  is 
specific;  its  occasional  occurrence  in  icterus  is  probably  due  to  a  previous 
attack  of  typhoid.  Some  maintain  that  the  reaction  is  not  one  of  infec- 
tion, but  one  of  immunity,  agglutination  becoming  most  marked  toward 
the  end  of  the  disease.^ 

5.  Nervous  Symptoms. — Typhoid  was  once  called  "nervous  fever" 
{jebris  nervosa,  nervenfieher) .  The  nervous  system  may  be  conspicuously 
involved  even  in  the  incubation  stage. 

(a)  Headache. — Toxemic  headache  is  almost  invariable,  being  most 
often  frontal  or  occipital,  constricting  or  throbbing.  It  disappears 
in  the  second  week,  but  if  it  lasts  or  develops  late,  it  may  indicate 
meningitis.  Insomnia  may  be  both  early  and  lasting.  The  early  ex- 
citation passes  into  the  later  depressive  euphoria  of  the  typhoid  state. 

(6)  The  typhoid  state  begins  in  the  second  week  {v.  s.)  with  apathy 
and  delirium,  which  is  usually  mild.  The  patient  may  attempt  to  get 
out  of  bed,  and,  in  alcoholics,  delirium  tremens  may  be  simulated  or 
actually  develop.  In  mild  cases  delirium  lasts  into  the  third  week.  In 
irritable  subjects  or  in  overwhelming  intoxication,  we  may  have  photo- 
phobia, stupor,  coma,  loud  breathing  with  an  open  mouth,  involuntaries, 
waving  of  the  hands  {fioccitation) ,  leaping  of  the  tendons  {suhsultus 
tendinum),  picking  of  the  bedclothes  (carphologia) ,  trismus,  contractures, 
grinding  of  the  teeth  and  rigid  neck,  which  symptoms  are  due  to  toxemia. 
In  coma-vigil  the  patient  is  semicomatose  subjectively,  but  the  open, 
unseeing  eyes  give  a  "watchful"  appearance.  Anatomically  a  "wet- 
brain"  is  found.  Convulsions  (0.2  per  cent.)  may  develop  in  children, 
in  severe  intoxication,  or  from  cerebral  complications  as  meningitis, 
encephalitis,  embolism,  etc. 

(c)  Nervous  Complications. — The  author  has  seen  five  typhoids  taken 
to  the  detention  hospital  in  the  third  week  under  a  diagnosis  of  mania. 
Psychoses  are  due  to  the  exhausting  inanition  of  protracted  toxemia, 
or  sometimes  an  hereditary  predisposition.  They  are  generally  post- 
febrile and  of  the  depressive  variety  such  as  melancholia;  alienists  assert 
that  one-third  to  one-fifth  do  not  recover.  Two-thirds  of  juvenile  cases 
recover  (Edsall) .    Typhoid  may  cure  a  previous  insanity. 

Meningitis  occurs  in  0.5  per  cent,  of  cases,  generally  as  a  late  complica- 
tion. Meningitis  may  be  due  to  the  pneumococcus,  pyogenic  cocci, 
tubercle  bacillus  (4  cases  recorded)  or  Eberth's  bacillus,  which  has  been 
found  on  lumbar  puncture  in  over  twenty-six  cases  (Cole),  of  which 
half  were  serous  and  half  suppurative.  Typhoid  meningitis  may  develop 
without  typhoid  lesions  in  the  bowel  (Henry).    In  a  patient  recovering 

'  Chantemesse  reports   an  ophthalmoreaction,   similar    to    the    tuberculin    reaction    of 
Calmette.     Gay  has   devised  a  skin   test;  and   a  hemolytic   test  is  suggested,  similar  in 
principle  to  the  Wassermann  test. 
3 


34  BACTERIAL  DISEASES 

from  typhoid  and  exhibiting  no  meningeal  symptoms,  bacihi  were  found 
in  the  cerebrospinal  fluid  (Stiihmer).  ^Meningitis  must  not  be  con- 
founded with  pseudomeningitis  or  "meningismus,"  in  which  toxemia 
produces  irritative  meningeal  symptoms  as  described  under  tj^hoid 
state  (y.  s.).     The  writer  observed  hemorrhagic  pachymeningitis. 

In  the  brain,  edema,  degenerated  and  pigmented  ganglionic  cells,  and 
nuclear  multiplication  are  the  most  common  findings  at  the  autopsy. 
Hemorrhage,  embolism,  arterial  and  sinus  thrombosis,  and  abscess 
(sepsis)  are  rare  pathological  complications.  Aphasia,  monoplegia, 
hemiplegia  and  paralysis  of  the  cerebral  nerves  are  rare  clinical  compli- 
cations. The  author  twice  noted  hemiplegia  developing  suddenly  in 
convalescence,  probably  embolic  from  detached  heart-clots,  the  patients 
being  allowed  to  leave  the  bed  too  soon.  Forty  cases  of  hemiplegia 
in  typhoid  are  on  record. 

In  the  cord,  myelitis,  multiple  sclerosis,  infantile  paralysis  and 
Landry's  paralysis  are  rare  complications.  The  knee-jerks  are  some- 
times increased,  especially  in  emaciated  subjects,  and  ankle-clonus  may 
appear. 

Neuroses  may  complicate  convalescence,  such  as  chorea,  hysteria, 
neurasthenia,  Basedow's  disease,  tetany,  paralysis  agitans,  etc. 

Neuritis  in  the  single  or  multiple  form  (g.  v.)  may  follow  typhoid. 
It  constitutes  the  "  tender  toes"  of  Hanford  and  always  results  in  recovery 
(see  Phlebitis,  p.  32). 

6.  DiGESTH'E  Tract. — The  upper  lip  is  retracted  and  bleeds  easily. 
Sordes  of  dried  saliva,  food  and  epithelium  are  observed  on  the  teeth  and 
gums.  Though  the  tongue  shows  nothing  characteristic,  early  it  is  white 
on  the  dorsum,  moist,  flabby,  and  therefore  indented  by  the  teeth  and  its 
edges  are  red.  It  may  be  moist  throughout  the  disease.  The  coating 
is  explained  partly  by  the  milk  diet  and  lack  of  mastication.  In  the  second 
week  it  becomes  dry  (from  the  fever,  lack  of  saliva  and  mouth-breathing), 
small  and  fissured;  it  bleeds,  and  a  brown  coating  replaces  the  white. 
In  the  third  week  or  later,  a  triangular  patch  clears  at  its  tip.  Typhoid 
bacilli  are  said  to  occur  in  the  mouth  in  50  per  cent,  of  cases.  Acute 
glossitis  is  a  severe,  yet  rare  complication. 

The  throat  is  swollen,  granular  and  eroded.  Angina  may  usher  in  the 
disease  and  lead  to  a  wrong  diagnosis;  usually  of  the  ordinary  tj-pe,  it 
may  be  due  to  the  typhoid  bacillus.  The  phlegmonous  type  is  very 
dangerous.  Letulle  observed  yellowish  or  pinkish-gray  ulcers  on  the 
uvula  or  anterior  pillars  in  one  out  of  every  three  cases. 

Parotitic,  occurring  in  1  per  cent,  of  cases,  became  less  frequent  since 
special  care  of  the  mouth  has  lessened  infection  ascending  Steno's  duct. 
It  is  usually  one-sided,  is  due  to  the  typhoid  bacillus  or  pyogenic  cocci, 
and  is  usually  seen  on  the  fifteenth  day.  The  prognosis  is  poor,  especially 
when  due  to  metastasis.  Two  personal  cases,  caused  by  the  typhoid 
bacillus,  recovered.  Ulceration  of  the  esophagus  is  very  rare;  the 
cicatrized  ulcer  may  produce  later  stenosis  (12  cases,  J.  E.  Thompson, 
1904)." 

In  the  stomach  specific  typhoid  lesions  are  rarely  observed;  hema- 
temesis  may  occur.     Early  and  severe  epigastric  pain  rather  contra- 


TYPHOID  FEVER  35 

indicates  typhoid.  Incipient  nausea  and  vomiting  occur  mostly  in  nervous 
women  or  children;  at  the  height  of  the  disease  they  suggest  meningitis, 
overfeeding  or  perforation,  and  in  convalescence  dietetic  errors.  Anorexia 
is  observed  during  the  onset  and  fastigium;  great  hunger  denotes  con- 
valescence. 

Specific  changes  in  the  intestines:  (a)  Hyperemia,  catarrh  and  beginning 
medullary  infiltration  in  the  lymphoid  structures  during  the  first  week, 
most  changes  being  observed  in  the  lower  ileum,  whence  the  name 
ileotyphoid.  (b)  Medullary  infiltration  or  hyperplasia,  during  the  second 
week,  occurring  first  in  Peyer's  patches  and  then  in  the  follicles.  The 
patches  are  oval  and  parallel  with  the  long  axis  of  the  gut;  they  lie  oppo- 
site to  the  mesenteric  attachment,  are  3  to  5  millimeters  high,  and  are 
at  first  red,  then  paler  from  compression  of  the  bloodvessels.  The  solitary 
follicles,  even  to  the  sigmoid  flexure  (colotyphoid),  may  be  principally 
enlarged.  These  changes  are  not  distinctive  of  t^^^hoid,  but  are  more 
significant  in  adults  than  in  children,  in  whom  they  are  frequent  in 
digestive  diseases,  the  exanthemata  and  diphtheria.  The  lymphoid 
swelling  is  explained  by  proliferation  of  the  endothelial  cells  of  the 
vessels  to  act  as  phagocytes;  when  they  degenerate,  fibrinous  thrombi 
develop  (Mallory).  Medullary  infiltration  need  not  advance  to  ulcera- 
tion; regression  may  occur,  and  the  lymphatic  structures  then  assume  a 
"shaven  beard"  appearance,  (c)  Ulceration  occurs  in  the  third  week 
from  anemic  necrosis,  slough  formation  and  exfoliation  of  small  particles. 
The  tjTDhoid  ulcers  are  usually  seen  without  opening  the  gut.  They 
have  an  irregular  oval  outline,  sharp,  steep,  often  undermined  edges, 
with  a  red  floor  generally  composed  of  the  muscular  coat.  The  lower 
ileum  is  most  affected  and  in  extreme  cases  may  present  almost  no 
normal  surface.  The  solitary  follicles,  both  in  the  large  and  small  gut, 
ulcerate  at  their  apices.  As  to  localization  of  the  typhoid  ulcer,  Baer 
states  that  it  may  occur  in  any  part  of  the  digestive  tract  (v.  s.  mouth). 
The  pharynx  is  affected  in  2  per  cent,  of  the  cases,  the  esophagus  in  4  per 
cent.,  the  stomach  in  2  per  cent.;  97  per  cent,  of  the  ulcers  develop  in  the 
small  intestine,  89  per  cent,  in  the  ileum,  2  per  cent,  in  the  appendix,  and 
33  per  cent,  in  the  large  intestine,  (d)  Cicatrization  occurs  by  granulation 
tissue  and  growth  inward  of  the  epithelium.  The  cicatrix  is  depressed, 
slightly  pigmented  and  does  not  narrow  the  intestinal  lumen.  Slight 
bowel  lesions  are  usually  present  in  most  cases  reported  "without  in- 
testinal lesions." 

The  mesenteric  glands  are  swollen  in  the  second  week,  contain  typhoid 
bacilli  and  are  altered  like  the  intestinal  lymphatics.  The  swollen  glands 
usually  regress,  but  may  soften,  sometimes  causing  peritonitis  or  simula- 
ting perforation.  Six  cases  of  suppuration  are  recorded;  Le  Conte 
reports  a  recovery  after  operation. 

No  parallelism  exists  between  the  frequency,  constancy  or  severity 
of  the  clinical  symptoms,  and  the  degree  of  anatomical  involvement, 
e.  g.,  in  ambulant  cases  there  may  be  perforation  or  hemorrhage,  or  lethal 
cases  may  occur  with  little  intestinal  change. 

Meteor  ism  is  less  common  than  usually  described.  It  occurs  mostly 
in  the  duodenum  or  jejunum  above  the  ulceration,  but  sometimes  involves 


36  BACTERIAL  DISEASES 

the  colon.  If  much  tympany  develops  the  prognosis  is  poor,  since  meteor- 
ism  is  due  to  toxemic  -paresis  of  the  intestinal  musculature  rather  than 
to  local  ulceration;  tympanites  develops  in  four-fifths  of  the  fatal  cases. 
The  heart  and  lungs  may  be  crowded  upward.  It  may  occur  with  hemor- 
rhage or  perforation. 

Abdominal  tenderness  and  paiti  occur  in  half  the  cases;  they  are  due 
to:  (a)  Local  bowel  conditions,  as  gas,  constipation,  inflammation  in  the 
ileocecal  region,  or  perforative  and  peritonitic  complications;  (h)  to 
splenic  or  hepatic  tumefaction;  (c)  distended  bladder;  (d)  muscle 
changes  or  cutaneous  hyperesthesia,  so  frequently  observed  in  fever  of 
any  variety;  (e)  pleurisy  or  phlebitis,  etc.;  (J)  typhoid  axj-pendicitis 
may  simulate  ordinary  appendicitis  which  is  differentiated  only  by 
the  blood  count,  seroreaction  or  clinical  evolution  (the  fever,  rose 
spots,  etc.,  preceding  local  pain  and  tenderness).  Gurgling  has  no 
diagnostic  value  in  typhoid.     A  thickened  ileum  may  be  palpated. 

The  stools  are  not  pathognomonic  save  that  the  Bacillus  typhosus, 
present  in  30  per  cent,  of  cases,  reaches  the  bowel  by  the  bile  or  through 
the  ulcers.  The  dejecta  are  thin,  offensive,  pea-soup-like  and  alkaline. 
Because  the  feces  are  poor  in  mucus,  two  layers  form  on  standing,  an 
upper,  cloudy,  and  a  lower,  yellowish-gray,  granular  and  flocculent  layer. 
The  stools  contain  red  corpuscles  and  triple  phosphates,  the  latter  more 
abundantly  than  in  any  other  disease.  Shreds  or  sloughs  may  also  be 
found. 

Diarrhea  in  the  febrile  stage  occurs  in  25  per  cent,  of  cases.  Three 
to  six  stools  daily  are  the  average;  if  this  is  exceeded,  the  type  of  the 
disease  is  severe;  prodromal  diarrhea  rarely  occurs.  Diarrhea  is  a  measure 
of  the  degree  of  toxemia  or  of  colonic  involvement,  and  is  not  a  result  of 
ulceration  of  the  small  intestine. 

Hemorrhage  is  seen  in  5  per  cent,  of  cases.  It  usually  occurs  after  the 
first  two  weeks,  and  is  less  frequent  in  relapses  and  in  children  (1  per 
cent.).  Ulceration  into  the  muscularis  is  its  chief  cause.  Oozing,  from 
simple  hyperemia  and  bleeding  in  the  hemorrhagic  forms  are  exceptional. 
Bleeding  is  more  common  in  ambulatory  and  delirious  patients.  There 
are  no  symptoms  if  the  hemorrhage  is  small  (occult  hemorrhage);  if  it 
be  large,  acute  anemia  develops,  with  collapse,  evidenced  by  a  fast  pulse, 
lowered  temperature  and  pallid  skin.  The  intellect  often  clears,  the 
spleen  becomes  smaller  and  fresh  blood,  or,  later,  hlacl\  tar-lil'e  movements 
are  voided  (manifest  hemorrhage).  The  abdomen  is  often  distended. 
There  may  be  dulness  on  percussion  from  blood  retained  in  the  bowel, 
if  the  peristalsis  is  weak  and  the  hemorrhage  is  very  profuse.  In  two 
rapidly  fatal  cases  one  and  two  pints  of  blood  were  vomited.  Confusion 
with  bleeding  piles  and  bismuth  stools  is  possible.  The  average  number 
of  hemorrhages  is  four. 

Some  patients  improve  at  once  after  hemorrhage,  as  was  remarked 
by  Graves  and  Trousseau;  yet  30  to  50  per  cent.  die.  Large  blood  clots 
are  ominous,  indicating  erosion  of  a  large  artery.  Hemorrhage  may  cause 
death  within  an  hour  (Trousseau,  Leymaire). 

Perforation  occurs  mostly  at  the  time  of  eschar  formation,  at  the 
end  of  the  second  or  in  the  third  week;  but  it  may  also  occur  later — 


TYPHOID  FEVER 


37 


in  the  third  to  fifth  week  (Leube).  Scott  found  that  92  per  cent,  occurred 
between  the  second  and  fifth  weeks.  It  develops  in  10  per  cent,  of  fatal 
cases  and  in  3  per  cent,  of  all  cases,  but  it  very  rarely  occurs  in  children 
under  five  years;  after  this  year  perforation  is  half  as  frequent  as  in  adults. 
Scott's  figures,  in  9713  cases,  show  perforation  in  one-third  of  all  fatal 
cases.  Perforation  is  usually  low  in  the  ileum,  81  per  cent.;  or  in  the 
colon  or  sigmoid,  12  per  cent. ;  in  the  appendix,  3  per  cent. ;  in  Meckel's 
diverticulum,  2.4  per  cent.;  in  the  jejunum,  1.2  per  cent.;  according 
to  Fitz's  figures.  In  83  per  cent,  but  one  perforation  is  found;  several 
may  occur,  twenty-five  being  observed  in  one  patient.  It  is  promoted 
primarily  by  deep  ulceration,  and  secondarily  by  movement,  straining, 
coughing,  constipation  or  tympanites;  in  75  per  cent,  of  cases  perforation 
occurs  in  severe  infections.  Three  tj^es  are  encountered:  (1)  Least 
frequently,  undiscovered  latent  perforation;  the  typhoid  state  masks 
the  perforation,  which  affords  an  unpleasant  postmortem  surprise.    (2) 


PU-SE 

TEMP. 

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110 

102 

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2ND  WEEK 

FOUR  COPIOUS 

1     HEMORRHAGE 

STOOLS  WITHOUT 
S                        TRACES  OF  BLOOD 

Fig.  4. — Tj-phoid-fever  curve,  with  fall  of  temperature  (solid  line)  after  hemorrhage  and 
rise  of  pulse  (broken  line).    Note  crossing  of  curves  at  A. 


More  frequently,  cases  with  gradual  onset,  and  ambiguous  symptoms. 
(3)  Most  frequently,  cases  with  sudden  symptoms  and  more  or  less  clear 
diagnosis.  The  symptoms  of  perforation  are:  (a)  Pain  due  to  the  per- 
foration itself  (in  75  per  cent.),  usually  localized  in  the  hj^ogastrium 
or  right  lower  quadrant  of  the  abdomen  and  followed  later  by  the  pains 
of  peritonitis.  In  70  per  cent,  the  pain  is  sudden  and  severe;  in  20 
per  cent.,  gradual  in  onset;  and  in  10  per  cent.,  absent.  (6)  Tenderness 
on  palpation  (75  per  cent.),  evidenced  by  the  board-like  rigidity  of  the 
abdominal  muscles,  (c)  Limitation  of  the  respiratory  movements  of  the 
abdomen,  due  to  pain  and  tenderness,  {d)  Vomiting  of  gastric  contents 
or  fecal  matter,  (e)  Intestinal  obstruction.  (/)  Abdominal  distention, 
appearing  possibly  for  the  first  time — in  which  event  its  significance  is 
enhanced — or  increasing,  if  already  present;  nevertheless  the  abdomen 
may  be  flat;  in  one  typhoid  patient,  seen  first  in  a  dying  condition, 
the  scaphoid  abdomen  contained  three  pints  of  pus.     Abdominal  dis- 


38  BACTERIAL  DISEASES 

tention  crowds  upward  the  diaphragm,  heart  and  lungs,  and  causes 
hurried  breathing,  (g)  Disappearance  of  the  hepatic  flatness  by  reason 
of  free  gas  in  the  peritoneum.  This  is  more  significant  if  the  abdomen 
was  not  previously  distended.  Perihepatic  adhesions  prevent  oblitera- 
tion of  the  liver  dulness;  a  gas-distended  colon  may  overlie  the  liver, 
and  in  some  cases  the  colon  normally  overlaps  the  liver.  W.  W.  Herrick 
suggests  the  detection  of  pneumoperitoneum  by  introducing  a  blunt 
needle  attached  to  a  wash  bottle,  (h)  Other  occasional  abdominal 
findings  are  fiatness  in  the  flanks,  caused  by  fluid;  the  Beatty-B right 
friction-rub;  absence  of  peristalsis,  rectal  or  vesical  pain  or  tenderness. 
(i)  Marked  leukocytosis  is  found  in  but  half  the  cases  and  special  emphasis 
on  its  absence  is  most  misleading,  (j)  Sudden  fall  of  temperature,  rapid 
rise  in  pulse-rate  and  other  signs  of  shock  may  occur  at  the  time  of  per- 
foration, though  less  frequently  than  the  usual  descriptions  indicate. 
The  writer  has  seen  the  pulse-rate  remain  normal.  Dieulafoy's  case, 
successfully  operated  upon  for  perforation,  resulted  fatally  from  two 
later  perforations.  The  sudden  clearing  of  the  patient's  intellect  may 
deceive  the  inexperienced  physician.  In  the  advancing  generalized 
peritonitis,  the  fever,  if  it  has  fallen,  rises;  the  pulse  becomes  rapid, 
small  and  thready;  the  skin  clammy  and  dusky,  and  the  features  pinched 
(facies  Hippocratica) .  Hiccough  is  common.  The  peritonitis  rarely 
remains  local;  in  six  of  the  author's  cases,  the  local  abscess  ruptured 
later.  Ninety-eight  per  cent,  of  unoperated  perforations  die.  Hemor- 
rhage and  perforation  may  occur  in  association  or  in  succession. 

Peritonitis  occurs,  frequently  in  ambulatory  cases,  from  rupture  of 
the  bowel,  gall-bladder,  spleen  or  lymph  glands;  occasionally  from 
post- typhoid  appendicitis;  or  without  rupture  of  any  organ  or  tissue 
(in  2  per  cent,  of  fatal  cases). 

The  liver  in  the  early  stages  is  anatomically  hyperemic,  large  and 
firm;  later  its  lobular  markings  become  indistinct  from  cloudy  swelling 
and  fatty  change.  The  organ  is  softer,  and  Wagner's  lymphomata 
and  some  focal  necrosis  occur.  Clinically,  some  tenderness  is  not 
unusual  and  at  times  may  lead  to  an  incorrect  diagnosis  of  liver  abscess 
or  cholecystitis. 

Icterus  is  very  rare  (0.5  per  cent.),  and  its  absence  is  of  diagnostic 
value.  Icterus  may  occur  from  duodenal  catarrh,  gall-stones,  cholecys- 
titis or  abscess.  The  author  has  seen  icterus  but  once  in  typhoid  fever. 
Single  liver  abscess  is  rare,  as  are  suppurative  pylephlebitis  and  sup- 
purative cholangitis.  Thirty  cases  of  liver  abscess  are  on  record  (von 
Eberts,  1911)  and  six  instances  of  abscess  with  pure  typhoid  cultures 
(Venema).  Suppuration  generally  follows  mild  infections;  icterus  is 
present  in  15  per  cent.,  and  in  50  per  cent,  the  abscess  is  seated  in  the 
right  lobe. 

Typhoid  favors  the  formation  of  gall-stones,  which  may  develop  months, 
years  or  decades  later. 

Cholecystitis  has  been  reported  by  Chiari  and  others;  thirty-nine  per- 
forations are  on  record,  among  154  cases  (Thomas,  1907).  Tenderness, 
pain,  muscular  rigidity  and  enlarged  gall-bladder  are  found  in  most 
cases.    Typhoid  bacilli  from  hematogenous  infection  are  found  in  the 


TYPHOID  FEVER  39 

gall-bladder,  free  or  in  its  walls,  in  nearly  all  autopsies,  although  seldom 
having  produced  symptoms. 

7.  The  Respiratory  Tract. — This  is  the  seat  of  frequent  and  mani- 
fold symptoms  and  complications. 

(tt)  The  Nose. — Epistaxis  occurs  in  20  per  cent,  of  cases,  usually 
early  and  in  young  subjects;  it  is  often  profuse,  sometimes  dangerous, 
but  rarely  lethal.  Croup  and  diphtheria  are  rare.  The  author  has  seen 
but  two  cases  begin  with  profuse  coryza. 

(6)  The  Larynx. — Ulceration  of  the  swollen  hyperplastic  lymph 
follicles  (like  the  intestinal  changes),  occurs  in  the  posterior  wall,  followed 
often  by  edema  glottidis.  These  "bed-sores"  are  found  in  12  per  cent, 
of  lethal  cases.  Perichondritis  and  necrosis  are  attended  by  pain,  aphonia, 
stenosis,  mediastinitis,  cervical  cellulitis  and  diffuse  emphysema,  indi- 
cating tracheotomy;  the  author  has  seen  but  three  cases.  Dupuy 
collected  255  cases  of  perichondritis  and  submucous  laryngitis,  and 
believes  they  explain  3  to  10  per  cent,  of  typhoid  fatalities.  Without 
operation  the  mortality  is  98  per  cent. 

(c)  Air  Tubes. — A  dry  catarrh  of  the  trachea  and  bronchi  is  very 
frequent.  Rales,  retrosternal  rawness  and  pain  are  present  in  the  bron- 
chitis of  typhoid.  Bronchiolitis  is  regular  and  specific.  It  is  found 
especially  in  the  lower  lobes.  Coughing  in  early  t}'phoid  is  of  value  in 
differentiation  from  simple  intestinal  catarrh.  The  outlook  is  less  favor- 
able when  severe  and  early  coughing  occurs. 

(d)  Lungs. —  Hypostasis,  from  a  dorsal  decubitus  and  weak  heart, 
is  often  relieved  by  change  of  posture.  It  is  very  common  in  weak 
adults  and  in  severe  infections.  The  percussion  note  is  tympanitic  or 
dull;  the  fremitus  is  increased  if  the  patient  is  not  too  stupid  to  talk,  or 
decreased  from  stagnation  of  secretion;  the  breathing,  especially  the 
expiration,  is  distant  or  sometimes  bronchial.  Rales,  moist,  crepitant 
and  subcrepitant,  are  heard. 

Lobar  pneumonia  may,  in  rare  instances,  dominate  the  early  clinical 
picture  (pneumotyphoid)  and  is  of  two  types:  The  more  frequent 
type,  (a)  in  which  at  the  height  of  the  disease,  the  pneumonia  is  a  true 
complication,  due  to  the  pneumococcus  or  sometimes  to  the  colon  bacillus 
and  streptococcus.  The  pneumonic  symptoms  are  atypical,  as  in  most 
secondary  pneumonias,  often  without  chill,  with  a  slower  course,  and 
often  ending  by  lysis  or,  less  often,  w4th  such  complications  as  abscess 
or  gangrene.  More  than  one-half  of  these  cases  die.  The  less  frequent 
second  type  (b)  is  due  to  Eberth's  bacillus.  The  course  is  that  of  an 
initial  pneumonia,  which  does  not  end  tj^pically,  but  shows  later  a 
typhoid  temperature,  rose  spots,  Widal  reaction,  etc.  These  cases  are 
confusing  in  their  incipiency,  and  the  typhoid  is  apt  to  be  overlooked. 
Lobidar  pnenmo7iia,  from  inhalation,  pus  cocci  or  Eberth's  bacillus,  is  a 
complication.  Abscess  follows  pneumonia  or  sepsis;  it  occurs  in  0.7 
per  cent,  of  fatal  cases.  Lnfarct  occurs  in  6  per  cent,  of  typhoid  fatalities, 
thrombi  from  the  leg  reaching  the  lungs  by  way  of  the  right  heart  and 
accompanied  by  hemoptysis,  chill,  temperature,  pain,  etc.  Gangrene 
(1  per  cent,  of  typhoid  autopsies)  is  usually  metapneumonic,  but  may 
be  caused  by  perichondritis  or  aspiration  of  food. 


40  BACTERIAL  DISEASES 

(e)  Pleura. — Serofihrinous  'pleurisy  (1.6  per  cent.)  is  rare  unless  the 
lungs  are  diseased.  Postmortem  statistics  show  it  in  6  per  cent.  Empyema 
(0.2  per  cent.)  is  due  oftenest  to  Eberth's  bacillus.  In  1903,  55  cases 
of  pleurisy  were  collected  in  which  the  typhoid  bacillus  was  found. 

(/)  Tuberculosis. — Acute  caseous  pneumonia,  subacute  tuberculous  peri- 
bronchitis with  a  few  bacilli,  fever  and  aggravation  of  the  bronchial 
symptoms,  or  occasionally  miliary  tuberculosis,  may  occur.  The  sooner 
tuberculosis  begins  after  typhoid  the  more  unfavorable  is  its  course. 

8.  Genito-urinary  Tract. — (a)  The  urine  is  febrile,  i.  e.,  decreased, 
acid,  concentrated,  with  a  high  specific  gravity,  but  the  amount  of  urine 
depends  upon  the  amount  of  water  ingested.  Water  is  retained  in  the 
tissues  in  protracted  fevers.  Typhoid  bacilli  are  present  in  30  per  cent, 
of  cases  and  may  give  the  urine  a  glistening  appearance.  Bacilluria  is 
hematogenous  and  occurs  in  severe  infections ;  it  is  favored  by  retention 
and  albuminuria;  the  bacilli  multiply  in  urine  of  low  acidity  and  usually 
disappear  spontaneously,  but  may  persist  months  or  years;  cystitis  is  due 
to  other  organisms  (Connell).  In  convalescence,  the  urine  is  increased, 
is  neutral  in  reaction,  and  has  a  lower  specific  gravity,  (fe)  Serum 
albumin,  globulin  and  rarely  peptone  are  found  in  jebrile  albuminuria. 
Serum  albumin  is  found  in  50  per  cent,  of  the  cases;  cylindruria  is  ap- 
proximately half  as  frequent.  The  prognosis  is  three  times  as  unfavorable 
when  albumin  is  found.  Albuminuria  appears  from  the  seventh  to  the 
tenth  day,  and  its  average  duration  is  twelve  days.  It  corresponds 
anatomically  to  parenchymatous  and  fatty  degeneration  of  the  kidneys. 
(c)  Nephritis  in  typhoid  is  of  the  acute  parenchymatous  type.  It  is 
often  hemorrhagic,  and  occurs  usually  in  the  first  three  weeks  but  oc- 
casionally in  convalescence.  It  is  found  in  1  per  cent,  of  cases,  mostly 
in  men,  rarely  in  children.  Nephritis  indicates  a  severe  infection,  from 
which  50  per  cent,  of  the  cases  die.  Uremia  and  suppression  of  urine 
are  rare.  If  not  fatal,  nephritis  usually  regresses  entirely  and  rarely 
becomes  chronic.  Early  marked  renal  symptoms  constitute  the  nephro- 
typhoid  of  French  writers.  Miliary  typhoid  abscesses  in  the  kidney 
may  keep  up  the  bacilluria.  id)  The  urine  of  typhoid  exhibits  the  diazo 
reaction  of  Ehrlich,  due  to  incomplete  oxidation  of  the  proteid  metabolism 
of  the  aromatic  sulphates.  The  author  found  it  in  98  per  cent,  of  his  cases. 
It  occurs  in  the  early  stages  of  the  disease,  at  the  acme  and  during  re- 
lapses. It  closely  parallels  the  bacillemia.  It  is  a  valuable  sign,  though 
not  of  differential  value.  Its  absence  somewhat  contra-indicates  a 
florid  typhoid,  (e)  Cystitis  and  pyelitis  occur,  due  chiefly  to  pus  organisms 
or  colon  bacilli.  Simple  retention  of  urine  is  common  in  the  typhoid 
state.  Hemoglobinuria  is  rare.  Typhoid  bacilli  may  form  the  nuclei 
of  renal  stones.  (/)  The  genitalia  are  more  often  implicated  in  women 
than  in  men.  Menstruation  often  appears  early  at  the  onset  of  typhoid 
and  is  suppressed  in  60  per  cent,  of  the  cases.  Hematocele,  endometritis, 
vaginal  erosions,  ulcers,  inflammation,  gangrene  and  mastitis  are  rare 
complications.  Pregnancy  is  of  grave  import^  especially  in  its  later 
stages.  At  the  acme  of  the  fever,  abortion  and  premature  delivery 
intervene  in  65  per  cent.  The  maternal  mortality  is  increased  twofold 
at  least.    Blumer  and  Dobbin  report  puerperal  infection  from  the  typhoid 


TYPHOID  FEVER  41 

bacillus.  Orchitis  usually  develops  late  or  in  convalescence,  with  chills 
and  fever.  Velpeau  described  the  first  instance.  J.  G.  Beardsley  collected 
102  cases,  chiefly  due  to  the  typhoid  bacillus.  The  patient  generally 
recovers  in  two  weeks.  It  is  frequently  associated  with  urethritis. 
Emissions  are  common  in  convalescence. 

Adrenal  Function. — According  to  Sergent,  adrenal  insufficiency  may 
ensue  in  typhoid  or  other  infections;  peritonitis  and  hemorrhage  may 
be  simulated  at  the  height  of  the  disease,  and  anemia,  prostration  and 
psychasthenia  may  be  evident  in  convalescence,  exhibiting  prostration, 
lowered  temperature,  the  white  dermographic  line,  low  arterial  tension 
and  collapse,  and  relieved  by  adrenal  therapy. 

9.  Special  Senses. — Ocular  muscle  paralysis  (neuritis)  and  inflam- 
mation are  very  uncommon.  In  convalescence,  mydriasis  and  paralysis 
of  accommodation  often  result  from  exhaustion.  Uhtoft,  in  253  cases 
of  optic  neuritis,  found  17  cases  following  typhoid.  Involvement  of  the 
ear  includes  functional  toxemic  disturbance  of  hearing,  abscess  and 
otitis  media  (2  per  cent.).  Mastoid  disease  and  meningitis  are  very 
exceptional. 

10.  Muscles,  Thyroid  Gland  and  Bones. — The  muscles  ana- 
tomically are  dry,  of  a  smoked-meat  appearance,  and  may  be  the  seat 
of  hemorrhage,  rupture,  granulofatty  or  waxy  degeneration,  and  abscess, 
due  to  Eberth's  bacilli  and  pus  cocci.  Myositis  may  explain  some 
instances  of  muscular  tenderness  with  cramps. 

In  the  thyroid  gland  a  strumitis  typhosa,  with  suppuration  or  re- 
gression, is  due  to  the  typhoid  bacillus.    Recovery  is  the  rule. 

Bone  disease  is  more  frequent  than  the  237  cases  of  Keen  indicate. 
Periostitis  is  the  more  common.  These  post-typhoid  complications  are 
due  to  the  typhoid  bacillus  (75  per  cent.),  or  pus  cocci  (25  per  cent.). 
They  attack  the  tibia  (38  per  cent.),  the  ribs  (13  per  cent.),  femur, 
ulna,  temporal  bones,  etc.,  occur  chiefly  in  young  individuals  and  are 
characterized  by  indolence  and  recurrence.  Osteomyelitis  may  resemble 
syphilitic  or  tuberculous  osteopathies.  Typhoid  bacilli  have  been  found 
fourteen  years  after  typhoid  in  osteomyelitic  fistulee;  this  typhoid 
septicopyemia  is  a  striking  instance  of  bacterial  latency.  Arthritis 
may  be  typhoid,  gonorrheal  or  septic.  Keen  noted  eighty-four  cases. 
It  may  be  poly-  or  mono-articular,  serous  or  purulent.  The  hip  is  most 
frequently  affected.  The  "typhoid  spine"  of  Gibney,  of  which  Elkin 
and  Halfpenny  collected  94  cases  (1914),  is  characterized  by  pain,  often 
referred  to  the  belly,  tenderness  and  stiffness  in  the  back;  these  seem 
to  be  root  symptoms.    It  is  clearly  an  embolic  spondylitis. 

Anomalous  Courses. — 1.  Malignant. — The  malignant  or  hyperpyretic 
form  is  rare.  It  is  severe  even  in  the  earliest  stages.  The  temperature 
rises  rapidly  and  there  may  be  hyperpyrexia.  The  pulse  is  weak  and 
rapid.  Meteorism,  diarrhea  and  .albuminuria  are  present,  and  death 
usually  follows  the  deep  intoxication. 

2.  The  slow  severe  form  lasts  four  weeks  to  four  months.  The 
fever  is  often  remittent  with  frequent  exacerbations.  Defervescence 
may  occur  or  death  intervene,  marasmus  alone  being  found  at  autopsy. 
The  severe  types  of  typhoid  have  decreased  during  the  last  two  decades. 


42  BACTERIAL  DISEASES 

3.  Typhus  Abortiyus. —  Typhus  levissimus,  typhoidefte,  exliibits  a 
short,  mild-course  temperature  with  a  short  initial  stage,  or  often  a  crisis, 
lasting  one  to  three  weeks.  Bronchitis  is  frequent,  splenic  enlargement 
is  constant  and  meteorism,  diarrhea,  roseolse,  hemorrhage  and  per- 
foration are  rare.    Relapses  are  more  frequent. 

4.  Typhus  AjkiBULATORius. —  Typhus  amhulaforius  (latent  or  walking 
typhoidj  occurs  especially  in  men,  who  often  endure  it  by  the  help  of 
alcohol.  There  are  two  types:  (a)  the  lighter  and  atypical,  and  (h)  the 
usual  course,  Yery  often  ending  in  hemorrhage,  perforation,  etc.  The 
temperature  often  is  not  high,  but  is  usually  less  at  night  than  during  the 
diurnal  actiYity.  The  pulse  is  faster  because  of  exertion.  The  spleen 
is  often  enlarged  and  the  roseolse  are  frequent. 

5.  Typhus  Afebrilis. — ^The  afebrile  form  is  most  often  encountered 
in  family  practice.  It  may  be  ambulatory  and  is  diagnosticated  by  the 
pulse,  spleen,  roseolse,  Widal  test,  etc.  Atypical  cases  haYC  increased 
in  recent  years. 

6.  Hemorrhagic. — ^The  hemorrhagic  form  is  characterized  by  nasal, 
subcutaneous  and  intestinal  hemorrhages — the  blood  dissolution,  of  the 
older  T^Titers.  It  occurs  especially  in  children  and  alcoholics  (0.1  per 
cent,  of  typhoid  cases).  The  prognosis  is  usually  bad.  The  four  cases 
which  the  author  has  seen  occurred  in  1900,  in  St.  Luke's  Hospital, 
where  a  seYere  house  epidemic  prevailed. 

7.  A  iscERAL  Forms. — The  so-called  visceral  forms  may  cause  confusion. 
They  include  the  gastric  or  bilious  types,  nervous  fever,  meningotyphoid, 
cerebrotyphoid  (mania,  psychoses),  larj-ngo-,  tonsillo-,  nephro-,  and 
pneumotyphoid . 

8.  Ix  CHiLDREX  the  course  is  shorter  and  milder.  The  younger  the 
patient,  the  less  is  the  fever.  Epistaxis  is  less  common.  The  pulse  is 
faster  than  in  adults,  though  after  the  twelfth  year  it  is  equally  slow. 
Roseolae  occur  as  often  m  children  as  in  adults,  and  in  some  cases  are 
abundant  and  confluent  (between  the  fifth  and  tenth  years).  Bed-sores 
are  very  rare,  but  noma  is  more  frequent  than  in  adults.  The  nervous 
system  is  generally  less  involved  in  children,  though  if  the  infection  is 
severe,  convulsions,  irregular  pupils,  rigidity  of  the  neck,  etc.,  may 
occur  (see  Typhoid  State).  Neuralgias  and  psychoses  are  rare.  The 
frequency  of  aphasia  has  not  yet  been  explained.  Atelectasis,  hypostasis 
and  lobular  pneumonia  are  more  frequent.  Children  exhibit  less  meteor- 
ism, hemorrhage  (1  per  cent.)  and  perforation.  There  are  fewer  ana- 
tomical changes.  Splenic  enlargement  is  palpable  in  50  per  cent.  Initial 
vomiting,  pain  and  perhaps  diarrhea,  are  more  frequent.  Albuminuria 
and  nephritis  are  relatively  rare.  In  infants:  Griffith  and  Ostheimer 
assembled  32.5  cases  in  infants,  of  which  139  occurred  under  one  year, 
187  in  the  second,  and  68  between  two  and  two  and  one-half  years. 
The  mortality  under  one  year  (v.  i.)  was  73  per  cent.,  and  of  the  entire 
group,  50  per  cent.  Typhoid  is  rare  in  the  first  two  years  of  life,  and 
is  sometimes  overlooked,  being  very  atypical.  The  course  is  short. 
Bronchitis,  splenic  tumor  and  roseolse  are  infrequent.  If  the  disease  is 
severe,  a  very  high  temperature,  meningeal  symptoms,  and  initial 
vomiting  occur,  and  also  a  50  per  cent,  mortality  caused  by  toxemia, 
pneumonia,  perforation  or  ulceration  of  the  larynx. 


TYPHOID  FEVER 


43 


9.  In  the  Aged. — Typhoid  is  infrequent  after  the  fortieth  year. 
The  fever  is  lower,  atypical  and  often  absent.  The  pulse  is  faster, 
irregular  and  without  dicrotism.  There  is  greater  lung  congestion, 
owing  to  weakness  of  the  right  heart,  and  lung  complications  are  more 
frequent.  The  nervous  symptoms  are  dominant,  often  occurring  with 
great  depression.  Roseolse  are  fewer  and  bed-sores  are  more  frequent. 
The  spleen  is  less  often  enlarged  because  of  old  infarcts,  induration  and  a 
thicker  capsule.  Tympany  and  hemorrhage  occur  more  often.  Con- 
valescence is  naturally  slower.  In  1903,  the  author  had  under  his  care, 
in  ^Vesley  Hospital,  a  woman,  aged  fifty-seven  and  her  mother,  aged 
seventy-two,  both  with  typhoid,  ending  in  recovery. 

Relapses  and  Exacerbations. — Relapses  and  exacerbations  differ  in 
degree  only.  Their  explanation  is  probably  involved  in  the  immunity 
problem,  an  exhaustion  of  the  antibacterial  forces  of  the  body.  .  In  the 
relapse,  the  temperature  falls  to  normal  or  nearly  normal,  for  five  days 
on  the  average,  and  then  fever  and  other  signs  of  typhoid  reappear. 
It  occurs  in  9  per  cent,  and  varies  with  the  epidemic,  sometimes  occur- 


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IIGH  FEVER       REMISSION 


EXACERBATION     LYSIS 


Fig.  5. — Showing  remission,  exacerbation,  lysis,  and  relapse. 

ring  in  as  much  as  35  per  cent.  Relapse  is  more  likely  to  occur  (a)  in 
light  or  moderately  severe  cases  (75  per  cent.)  than  in  severe  ones  (25 
per  cent.) ;  (6)  when  the  splenic  tumor  does  not  disappear  (but  the  spleen 
may  have  been  enlarged  from  some  previous  disease,  as  malaria);  (c) 
when  the  temperature  in  convalescence  does  not  become  subnormal; 
{d)  when  the  pulse  is  variable  and  rapid;  and  ie)  more  commonly  in 
young  than  in  old  subjects. 

The  fever  runs  the  same  course  as  in  the  first  attack,  and  averages 
ten  days.  The  pulse  is  faster  and  less  dicrotic.  There  are  less  roseolse, 
nervous  and  respiratory  symptoms,  hemorrhage  (4  per  cent.)  and  per- 
foration (0.7  per  cent.),  whence,  as  a  rule,  the  prognosis  is  relatively 
good.  There  are  seldom  more  than  two  relapses — three  or  four  being 
very  rare.  The  author  has  seen  five  relapses,  covering,  with  the  original 
attack,  as  many  months.  They  may  be  afebrile,  with  a  return  of  the 
roseolse,  spleen,  etc.  Relapses  should  not  be  confused  with  Biermer's 
"after  fever,"  due  to  inanition  or  possibly,  sepsis.  Recrudescence  .is 
renewal  of  the  fever  after  it  has  lessened,  but  not  entirely  subsided,  and 
in  50  per  cent,  is  followed  by  more  severe  symptoms. 


44  BACTERIAL  DISEASES 

Convalescence. — CoiiA'alescence  requires  two  or  three  weeks  and  is 
not  certainly  established  until  subnormal  temperature  is  observed.  The 
pulse  tends  to  run  high  on  exertion  or  excitement.  Anemia,  emaciation, 
phlebitis,  tuberculosis,  psychoses,  bone,  muscle  and  other  complications 
may  intervene.  If  the  appetite  is  poor  in  convalescence,  complications 
are  to  be  expected. 

Diagnosis. — General  Rules. — 1.  Observe  long  and  carefully.  Say 
that  a  diagnosis  is  impossible  in  the  first  few  days. 

2.  No  single  sign  is  absolutely  diagnostic,  except  bacilli  in  the  blood 
and  the  Widal  reaction. 

3.  Diagnosticate  from  positive  findings  and  careful  exclusion. 

4.  The  typhoid  state  only  indicates  toxemia,  not  typhoid. 

5.  In  doubtful  cases  remember  the  great  statistical  frequency  of 
typhoid.. 

6.  Remember  its  manifold  forms,  e.  g.,  pneumotyphoid,  etc. 

7.  Be  on  the  safe  side  in  light,  ambulatory  or  abortive  cases  as  to  the 
diagnosis  and  treatment. 

The  Cardinal  Signs  are:  (a)  Bacillemia  is  found  in  practically  all 
early  cases. 

(6)  The  serotest  is  successful  in  97  per  cent,  of  cases;  its  absence 
does  not  exclude  typhoid. 

(c)  The  eruption  has  a  diagnostic  value  in  its  location,  occurrence 
in  crops,  time  of  appearance  and  short  duration. 

(d)  The  slow  and  dicrotic  pulse  is  suggestive. 

(e)  The  fever  curve  shows  a  gradual,  step-like  onset,  continuous 
fastigium,  steep  curves  in  the  breaking  stage  and  subnormal  register 
in  convalescence. 

(J)  Splenic  tumor  is  per  se  suggestive  after  the  first  week.  Splenic 
pimcture,  to  detect  bacilli,  is  never  permissible. 

Secondary  Signs. — ^These  are,  in  order  of  importance,  the  typhoid 
tongue,  the  stools,  bronchitis,  tj^hoid  state,  leukopenia,  intestinal 
symptoms  and  the  diazo  reaction. 

Symptoms  contra-indicating  typhoid  are  coryza,  early  vomiting 
and  sweating,  herpes,  endocarditis,  retraction  of  the  abdomen,  negative 
diazo  test, 'leukocytosis  (unless  some  complication  has  occurred),  icterus 
and  rigors.  Any  of  the  above  symptoms  may,  exceptionally,  complicate 
typhoid. 

Differential  Diagnosis. — Differentiation  may  be  most  difficult  from  acute 
miliary  tuberculosis  which  may  develop  in  tj^hoid.  Typhoid  may  be 
complicated  with  septicemia,  very  rarely  with  malaria  in  this  climate, 
or  wdth  meningitis  {v.  table  on  pages  46  and  47). 

Exanihematous  typhus  {q.  v.)  and  recurrent  fever  {q.  v.)  are  easily  dis- 
tinguished. Exanthematous  diseases  are  rarely  confused,  except,  perhaps, 
in  the  initial  stage.  In  75  instances  typhoid  and  scarlatina  coexisted 
(Fournier) .  An  extensive  eruption  of  roseolae  resembling  measles  is  easily 
distinguished  by  the  catarrhal  symptoms,  temperature  curve  and  course. 

Fibrinous  pneumonia  rarely  resembles  typhoid,  and  still  more  rarely 
occurs  with  typhoid  in  its  earliest  stages  by  the  localization  of  typhoid 
bacilli  in  the  lungs.  Though  typhoid  may  begin  with  severe  bronchitis 
or  pneumonic  symptoms,  the  intestinal  and  cardinal  findings  of  typhoid 


TYPHOID  FEVER  45 

usually  appear  after  a  few  days.  Sudden  onset  with  chill,  pain  in  the 
side,  abrupt  rise  of  pulse  and  temperature,  rapid  respiration,  bloody, 
viscid  sputum,  herpes,  leukocytosis,  and  a  tympanitic  note  and  a  few 
crepitant  rales  over  one  lobe,  followed  later  by  typical  pneumonic  in- 
filtration as  consolidation  advances  from  within  toward  the  periphery  of 
the  lung,  establish  the  diagnosis  of  pneumonia  on  the  second  or  third  day. 

In  intestinal  anthrax  fever,  splenic  tumor  and  nervous  symptoms 
are  accompanied  by  hemorrhagic  vesicles  in  the  mouth,  vomiting,  colic, 
hemorrhage  from  the  intestine  and  kidney,  cyanosis  and  dyspnea,  an- 
thrax bacilli  in  the  blood,  urine,  stools  or  sputum,  and  inoculations 
establish  the  diagnosis. 

Febrile  gastritis  rarely  simulates  typhoid;  the  rare  fever  is  low  or 
irregular,  and  early  gastric  symptoms  are  not  common  in  typhoid.  With- 
out blood  cultures,  paratyphoid  may  not  be  distinguished  from  acute 
gastro-enteritis.  Febrile  enteritis  is  characterized  by  much  mucus  in  the 
stools,  whereas  the  typhoid  stool  seldom  contains  much  mucus.  Splenic 
tumor  is  most  uncommon  in  enteritis.  The  fever  in  enteritis  is  lower 
or  more  irregular  and  the  bronchitis,  slow  pulse  and  other  cardinal 
signs  of  typhoid,  are  absent.  Cases  of  typhoid  developing  suddeiily  may 
be  confused  at  first,  with  grippe,  diphtheria  or  other  diseases.  Febrile 
syphilis  seldom  causes  diagnostic  trouble  but  must  be  considered  in 
dubious  cases. 

Paratyphoid. — The  paratyphoid  bacillus  resembles  the  typhoid  bacillus 
morphologically  but  differs  biologically;  in  cultures  it  forms  no  indol, 
therein  resembling  the  Bacillus  typhosus,  but  like  the  colon  bacillus 
it  ferments  grape-sugar.  In  Bacillus  A,  the  growth  on  potato  is  very 
thin;  in  Bacillus  B,  very  thick;  it  may  very  closely  resemble  Gart- 
ner's bacillus  enteritidis.  Infection  may  occur  from  milk,  water  and 
tainted  meat.  The  bacilli  are  found  in  the  stools,  blood,  roseolse  and 
urine,  and  agglutinate  in  higher  dilutions  (1  to  1000  or  2000)  than  the 
typhoid  bacilli.  The  first  clear  cases  were  reported  by  Schottmiiller, 
in  1900  and  Gwynn,  though  the  term  paratyphoid  was  first  employed 
by  Achard  and  Bensaude  in  1896.  Paratyphoid  constitutes  4.5  per  cent, 
of  cases  with  the  general  clinical  picture  of  typhoid  fever.  In  para- 
typhoid the  temperature  is  more  brusque  in  onset,  shows  greater  re- 
missions, and  may  end  by  crisis.  The  pulse  is  slow  and  dicrotic.  Roseolse 
are  present  in  80  per  cent.,  the  spleen  is  less  often  enlarged  and  no  leuko- 
cytosis is  observed.  Prodromal  catarrhs,  reddening  of  the  throat, 
diarrhea,  cervical  adenitis,  edema  of  the  lids,  vomiting,  rigors,  epigastric 
pain,  herpes,  myositis,  arthritis,  pleurisy,  endocarditis  and  meningitis, 
are  more  common  than  in  typhoid  and  may  enable  the  practitioner  to 
differentiate  paratyphoid,  clinically.  The  diazo  reaction  is  positive 
in  45  per  cent.  The  clinical  course  covers  two  to  four  weeks.  Relapses 
are  common.  The  infection  is  usually  mild  and  rarely  fatal  (3.6  per  cent.) . 
Ulceration  of  the  intestinal  lymph  structures  is  rare  in  the  fatal  cases, 
though  other  necroses  occur,  thus  explaining  the  hemorrhage  (5  per  cent.). 
Pneumonia  and  perforation  are  unknown.  Nervous  symptoms  are  not 
prominent.  The  blood  seldom  responds  to  the  Widal  test.  Grunberg 
and  Roily  hold  that  the  Widal  reaction  is  less  a  specific  than  a  group 
reaction,  as  they  found  agglutination  in  the  paratyphoid  group  by  typhoid 


46 


BACTERIAL  DISEASES 


Pathognomonic 
signs. 


Pulse  and  circulation. 


Fever. 


Splenic 
enlargement. 


Blood. 


Typhoid  : 

Typhoid  bacilh  Relatively  slow  dicrotic  (Typical  rise,  acme,  de- 
in  the  blood,  ,  pulse  early  in  the  dis-  fer\'escence,  and  sub- 
urine,  roseolffi  ease,  especially  in  men,  normal  in  convales- 
or  stools.  Wi-  and  in  not  too  severe  cence.  Remissions 
dal  test.  infections.      Endocar-  ■  and  intermissions  fol- 

ditis   and   pericarditis     lowing     continuous 
very  rare.  fever    speak    for    ty- 

phoid. Responds  to 
hydrotherapy  as  a 
rule.  Sometimes 
chills  at  onset  or  in 


Very  frequent; 

larger  than  in 
miliarj-  tu- 
berculosis; 
appears  in 
first  week. 


Bacilh  in  blood, 
early;  Widal  test 
later.  Xo  leuko- 
cytosis unless  com- 
pUcations,  but 

leukopenia.  Poly- 
morphonuclears 
decreased.  Eosin- 
ophilia  rare.  Late 
anemia. 


MlLLi^RY 

TlTBERCULOSIS:         ' 

Rarely  tubercle  Rapid,  120  or  more, 
baciUi  in  the  ,  high  even  during  re- 
blood  or  splen-  missions;  slowed  in 
ic  pulp;  tuber-  tuberculous  meningi- 
cles  in  the  tis  and  in  the  aged. 
choroid.  Dicrotism  uncommon. 

Sometimes        pericar- 
dial rub. 


Xo  cycle;  irregular  or  Less  frequent; 
remittent.        Seldom     smaller     and 
long   continued,    and     usually      ap- 
if  so,  longer  than  in     pears  later, 
tj-phoid.      Exacerba- 
tions   ■n-ith    renewed 
dissemination   of  tu- 
bercle bacilli.     Brain  j 
involvement         may 
lower  fever  or  make  | 
it    variable,    as    in- 
versed  type. 


Sometimes  tubercle 
bacilli  in  blood. 
Xo  Widal.  Leuko- 
cjitosis  not  often 
but  more  than  in 
typhoid.  Eosino- 
philia  more  fre- 
quent. 


IMal.\1!ia: 

Plasmodium  in   Pulse  moderate  in  rate: 
the  blood.  sometimes        dicrotic; 

very    rarely    endocar- 
ditis. 


Intermittent,  begin- 
ning verj'  often  with 
chills ;  tjTJe  varies 
(quotidian,  tertian, 
etc.) ;  often  rises  high 
at  once;  if  continuous 
(subcontinuous),  at 
least  made  irregular 
by  qmnine  or  usually 
wholly  aboUshed  (for 
a  time  at  least) . 


Much  e  n- 
larged;  more 
than  in  ty- 
phoid; and 
persists  fre- 
quently as 
ague-cake. 


Plasmodium,  mel- 
anemia,  no  leuko- 
cytosis save  in 
pernicious  forms. 
Great  and  early 
anemia.  No 
Widal. 


Sepsis    (Ixcludixg 

ExDOC.iEDITIS)  : 

Cultivation  of 
pyogenic  or- 
g  a  n  i  s  m  s  , 
pneiunococcus, 
etc.,  from  the 
blood  or  va- 
rious foci. 


Usually  fast  and  irregu- 
lar; cardiac  localiza- 
tions verj'  frequent  in 
sepsis,  puerperal  es- 
pecially, and  in  endo- 
carditis (a  cardiac 
form  of  sepsis).  Car- 
diac enlargement, 
thrill,  bruit,  accentu- 
ated pulmonic  tone, 
etc. 


Chills,  sweats,  steep 
elevations,  and  sud- 
den depressions  al- 
most always  at  some 
time,  and  usually 
repeated  ■with  each 
discharge  into  the 
blood  of  infective 
material. 


Especially  en-   Various   organisms, 
larged     from     Marked   polymor- 
sepsis  and  in-     phonuclear  leuko- 
farcts.      Also     cj^osis    verj'    fre- 
often    the     quent ;    sometimes 
Ij-mph  nodes,     absent     in     endo- 
carditis.      Seldom 
eosinophUia.      Xo 
Widal. 


Mexixgitis: 

Lumbar  punc- 
ture (a)  men- 
ingococci, tu- 
bercle bacilli, 
pyogenic  or- 
ganisms, etc.; 
(b)  increased 
turbid  fluid, 
etc. 


Rate  differs  ■nith  type 
variable. 


Differs  with  variety, 
but  seldom  as  high 
as  tj^jhoid;  no  cycle. 


Leukocytosis  in  ep- 
idemic and  puru- 
lent types;  rarer 
in  tuberculous. 
No  Widal. 


serum.  A  mixed  infection  with  typhoid  may  occur.  In  about  half  the 
cases  due  to  the  paratyphoid  B,  the  symptoms  are  choleriform.  Bacilh- 
carriers  are  as  important  as  in  typhoid;  a  wide-spread  house  epidemic 
occurred  from  kitchen  infection  among  the  patients  and  physicians  in 
the  Allgemeines  Krankenhaus  in  Vienna. 

Trichinosis  is  differentiated  from  typhoid  by  the  history,  muscular 


TYPHOID  FEVER 


47 


Roseolse,  typical  in 
location,  crops, 
appearance,  con- 
taining typhoid 
bacilli.  Sweating 
and  miliaria  less 
often  and  later. 
Icterus  rare. 
Herpes  rare. 


Lungs. 


Breathing  somewhat 
increased  from  toxe- 
mia (cerebral  breath- 
ing), hypostasis  or 
other  complications 
Rales  below  and  be- 
hind. Tympanitic 
note  never  heard  in 
typhoid. 


Nervous  system. 


Early  headache,  re- 
placed later  by  de- 
lirium,  typhoid 
state;  actual  men- 
ingitis very  rare; 
intoxication  may 
closely  simulate 
meningitis.  Very 
rarely  disk  changes. 


Sputum,  urine. 


Typhoid  bacilli  in 
urine.  Diazo  test 
in  nearly  all  cases. 


Alimentary  tract. 


Mouse-like  breath, 
semi-character- 
istic  tongue, 
ochre  yellow 
stools,  tympany, 
diarrhea,  bowel 
hemorrhage,  per- 
foration, bacilli 
in  stools.  Re- 
tracted abdomen 
or  early  vomiting 
rare. 


Roseolse  absent  or 
extremely  rare, 
and  then  not  in 
crops.  Drench- 
ing sweats  com- 
mon. Herpes 
more  than  in  ty- 
phoid. Skin  ane- 
mic and  very 
often  cyanotic. 


Breathing  increased 
even  40  to  60;  cya- 
nosis and  dyspnea 
without  adequate 
physical  findings. 
Fine  and  localized 
rales  heard  above 
and  in  front.  Tym- 
panitic percussion 
note  from  lung  relax- 
ation. Evidences  of 
pleural  adhesions, 
apical  changes,  fresh 
pleural  rub. 


Meningitis  tubercu- 
losa very  frequent; 
optic  neuritis;  cho- 
roidal tubercles. 


Tubercle  bacilli 
sometimes  found 
in  sputum,  urine 
and  feces,  but 
indicate  old  tu- 
berculous lesions, 
not  of  miliary  tu- 
berculosis. Diazo 
test  less  frequent. 


Diarrhea  not  com- 
mon, but  may 
rarely  occur,  as 
indeed  may  hem- 
orrhages; both 
result  from  tuber- 
culous ulceration 
of     bowels. 


In  severe,  eyes  sub- 
icteric  or  marked, 
very  frequent  and 
urticaria  the  next 
most  frequent  ex- 
anthem. 


If  lung  congestion 
(severe  forms),  it  is 
variable,  recurrent, 
shifting  from  lobe  to 
lobe. 


Headache  at  onset 
is  rare;  later  is  of- 
ten pulsating  or 
neuralgic.  Delir- 
ium from  begin- 
ning in  estivo- 
autumnal  forms  is 
frequent.  Restless- 
ness, anxiousness. 
In  pernicious  forms 
may  have  convul- 
sions,  coma,  etc. 


Hemoglobinuria  in 
pernicious  ma- 
laria. Diazo  test 
fairly  frequent, 
though  much  less 
than   in   typhoid. 


Nauseating  breath. 
Sometimes  ab- 
dominal pain  even 
in  mild  types; 
may  rarely  have 
diarrhea,  even 

hemorrhage  in  ali- 
mentary pernic- 
ious types.  Liver 
congestion  fre- 
quent, also  icterus. 


Frequent  sweating, 
miliaria.  Septic 
polymorphous 
rashes.  Subic- 
terus,  frequently 
purpuric  skin 
eruptions,  herpes 
not  uncommon. 


Bronchitis  frequent. 
Pulmonary  infarcts 
and  pleurisy. 


Dependent  on  cause. 
Septic  meningitis 
(with  arthritis, 
pleurisy,  etc.),  cer- 
ebral embolism ;  re- 
tinal hemorrhages 
or  embolism. 


Acute  embolic  ne- 
phritis. Pepto- 
nuria. 


Septic  diarrhea. 


Herpes  in  epidemic 
cerebrosp  inal 
form.  Tache 
cerebrale. 


Variable       breathing; 
Biot's  breathing. 


Early  triad,  head- 
ache, retracted 
neck  and  hyper- 
esthesia. Head- 
ache  violent 
throughout  the 
disease,  convul- 
sions, paralysis, 
Kernig's  sign,  etc. 
Optic  neuritis,  ret- 
inal hemorrhage, 
tubercles  in  cho- 
roid. 


Early     cerebral 
vomiting.  Re- 

tracted,   scaphoid 
abdomen.' 


pain  and  edema  in  the  striped  muscles,  trichinae  in  the  muscles,  and  by 
eosinophilia.    Three  cases  of  double  infection  are  reported. 

Prognosis. — The  death-rate  was  20  per  cent,  in  50,000  cases  collected 
by  Jaccoud.  At  present  it  is  5  to  10  per  cent,  because  of  more  accurate 
diagnosis  (thus  including  lighter  cases)^  decreasing  virulence  and  better 
hygiene  and  treatment. 


48  BACTERIAL  DISEASES  / 

The  prognostic  factors  are: 

1 .  Age :  The  mortahty  is  least  between'  the  second  and  tenth  years, 
higher  after  the  twenty-fifth,  and  highest  in  babes. 

2.  Constitution:  Meagre  and  muscular  patients  are  more  likely  to 
recover  than  the  plethoric  or  adipose. 

3.  Sex  is  immaterial,  aside  from  pregnancy. 

4.  Acute  diseases  modify  the  prognosis,  e.  g.,  scarlatina,  measles, 
variola,  diphtheria,  malaria,  erysipelas,  etc. 

5.  Chronic  diseases,  such  as  gout,  cardiac,  pulmonary  and  renal  disease 
darken  the  outlook;  in  alcoholism,  34  per  cent,  mortality  results  from 
weak  heart  or  hemorrhagic  diathesis;  convulsive  affections,  such  as 
epilepsy  or  chorea,  may  cease;  in  diabetics  the  fever  is  low  and  the 
glycosuria  may  disappear. 

The  prognosis  is  better  in  relapses  and  worse  in  recrudescences.  In 
war  times  the  prognosis  is  usually  less  favorable;  the  Spanish- American 
war  was  an  exception,  the  death-rate  being  but  7  per  cent.,  as  against 
21  per  cent,  in  the  Boer  war. 

Death  usually  occurs  between  the  eighteenth  and  twenty-eighth  days, 
and  is  caused  by — 

1.  Toxemia,  the  most  frequent  cause  of  death  (40  per  cent.),  including 
hyperpyrexia,  hemorrhagic  types,  heart  weakness,  vasomotor  paralysis 
and  cerebral  toxemia. 

2.  Local  typhoid  lesions,  as  meteorism,  diarrhea,  peritonitis  (in  16  per 
cent,  of  fatal  cases),  or  hemorrhage  (in  20  per  cent.). 

3.  Complications,  as  lung  inflammations  (in  15  per  cent.),  nephritis 
(4.5  per  cent.),  etc.  In  septicemia  ("forme  septicemique  generalisee") , 
the  symptoms  are  high  fever,  chills,  sweats,  enlarged  glands  and  spleen. 
Pyemia  may  result  from  acute  osteomyelitis,  suppurative  parotitis, 
adenitis,  phlebitis,  etc. 

4.  Collapse.  Dieulafoy  estimates  that  sudden  death  occurs  in  2  per 
cent,  of  typhoid  cases  (see  page  31).  The  pulse  is  always  more  important 
than  the  fever,  and  early  rapidity  is  unfavorable.  Bradycardia  and 
marked  agglutination  are  favorable  prognostics. 

5.  We  have  already  considered  the  ominous  significance  of  pseudo- 
collapse,  the  typhoid  state,  early  delirium,  diarrhea  and  meteorism; 
of  the  various  severe  complications,  such  as  noma,  gangrene,  laryngeal 
perichondritis  and  pneumonia;  and  of  the  more  severe  types,  such 
as  the  hyperpyretic  and  hemorrhagic  and  of  the  ambulatory  variety. 
Typhoid  beginning  suddenly  entails  a  high  mortality. 

Treatment. — Dujardin-Beaumetz  said:  "The  best  treatment  for 
typhoid  is  a  good  physician."  Treatment  concerns  (A)  prophylaxis; 
(B)  hygiene;  (C)  intestinal  antisepsis;  (D)  antipyretic  measures;  (E) 
diet;  (F)  symptomatic  treatment;  and  (G)  convalescence. 

(A)  Prophylaxis. — 1.  Prophylaxis  has  as  wide  a  scope  in  medicine 
as  asepsis  and  antisepsis  in  surgery.  In  Chicago,  during  the  years  1889 
to  1892,  inclusive,  there  were  4747  deaths  from  typhoid.  In  the  four 
years  after  the  drainage-canal  was  opened  there  were  2235  cases,  that 
is,  the  mortality  was  reduced  75  per  cent.    In  1905  typhoid  was  rare. 


TYPHOID  FEVER  49 

General  prevention  is  difficult,,  because  of  the  ubiquity  of  the  germ  and 
the  carelessness  of  individuals.  Systematic  cooperation  regarding 
sewage  regulation,  water  supply  and  typhoid-carriers  could  efface  typhoid. 
Koch  particularly  emphasized  this  point  and  abolished  certain  typhoid 
foci.  The  difficulties  are  the  infrequent  recognition  of  the  particularly 
dangerous  light  cases,  light  forms  notably  in  children  (Koch) ,  carelessness 
and  the  bacilli-carriers.  It  is  easy  to  boil  water  for  home  use,  and  yet 
it  is  done  in  but  few  families,  even  in  those  of  physicians.  The  traveller 
should  avoid  unboiled  water  and  milk.  In  communities  where  sewers 
exist,  sewer  connections  should  be  compulsory;  if  privies  are  inevitable, 
they  should  be  water-  and  fly-tight.  Private  and  public  cisterns  should 
be  periodically,  tested.  Work  camps,  country  resorts  and  fair  grounds 
demand  careful  inspection.  The  dairies  and  depots  for  milk  distribution 
require  closest  scrutiny. 

2.  In  the  treatment  of  a  developed  case  everything  with  which  the  germ 
may  come  in  contact  must  be  sterilized.  Next  to  the  feces,  the  urine 
is  the  most  important  conveyer  of  the  bacillus;  these  are  the  usual 
means  of  dissemination,  and  their  proper  disinfection  in  every  case 
would  obliterate  typhoid.  The  bacilli  may  persist  for  years  in  the  feces, 
five  to  seventeen  years  in  the  bile  and  five  years  in  the  urine.  Chloride 
of  lime  should  be  placed  in  the  bottom  of  the  urinal  or  bed-pan  before 
and  after  use.  Acidulated  sublimate  (1  to  500)  may  also  be  used  for 
the  urine  and  10  per  cent,  crude  carbolic  solution  for  the  stools;  but 
neither  disinfects  at  once,  for  which  reason  the  dejections  should  stand 
an  hour  in  a  quart  of  the  disinfectant.  Both  the  pans  and  urinals  must 
then  be  sterilized.  The  same  disinfection  is  indicated  for  thermometers 
and  rectal  tubes.  The  perineum,  after  each  movement,  should  be  sponged 
with  a  1  to  2000  bichloride  solution,  and  also  the  back  and  thighs,  when 
there  are  involuntary  evacuations.  The  rubber  draw-sheets  and  linen 
should  be  sterilized  regularly  with  carbolic  acid  or  bichloride  of  mercury, 
and  the  blankets,  pillows  and  mattresses,  steamed  when  taken  off  the  bed. 
The  bath-tub  should  be  carefully  cleaned  with  carbolic  solution,  and  one- 
half  pound  of  chloride  of  lime  added  to  the  water  after  bathing,  as  the 
patient's  soiled  skin  and  the  urine  voided  during  the  bath  are  obvious 
sources  of  danger.  Cleansing  the  hands  after  examination  or  tubbing 
prevents  direct  transmission  of  the  disease  to  nurses,  orderlies  and  phy- 
sicians; 2  per  cent,  of  hospital  typhoid  is  acquired  by  direct  contact  in 
the  care  of  the  disease.  Rubber  gloves  are  the  safest  protection.  In  the 
Spanish-American  war  20  per  cent,  of  our  soldiers  were  directly  infected 
by  flies,  and  in  the  Boer  war  more  died  of  typhoid  than  were  kjlled 
by  bullets,  infection  being  carried  by  flies  and  sand.  The  few  cases 
among  the  Japanese  is  one  of  the  many  lessons  they  taught  us.  Flies 
should  be  carefully  excluded  from  the  house  by  screens.  Quarantine 
should  be  enforced. 

3.  Typhoid  Bacillus-carriers. — Since  2  to  4  per  cent,  of  typhoid  con- 
valescents become  chronic  carriers,  and  one  person  in  every  500  well 
people  becomes  a  carrier  (Park),  special  care  in  convalescence  is  indicated. 
Hexamethylenamine  (urotropin)  and  salol,  given  in  the  disease,  are  help- 
ful, but  they  are  useless  later.     Segregation,  draining  the  gall-bladder  and 

4 


50  BACTERIAL  DISEASES 

washing  the  urinary  bladder  are  ineffectuah     Vaccination  (v.  i.)  offers 
the  greatest  promise. 

4.  Typhoid  Vaccination  (Pfeiffer,  Kolle  and  Wright,  1896). — In  the 
Spanish-American  war  10,729  troops  were  quartered  at  Jacksonville, 
Florida;  among  them  2693  probable  cases  (1729  certain  cases)  of  typhoid 
developed,  with  248  deaths  and  in  contrast  with  these  figures:  in  our 
army  of  12,659  men  during  the  1911  maneuvers  in  Texas,  not  one 
typhoid  death  and  but  one  mild  case  developed  (here  vaccination  had 
not  been  completed) .  The  vaccines  are  given  as  follows :  the  first 
inoculation  of  500,  and  the  second  and  third  each  of  1000  million  bacilli 
at  ten-day  intervals,  into  the  subcutaneous  tissue.  Local  reactive 
erythema  develops  with  some  pain  and  a  small  percentage  suffer  a  rigor, 
generalized  erythema,  herpes,  fever  (101°  to  102°),  vertigo  or  diarrhea; 
reaction  is  less  after  the  second  and  third  injections.  An  immunity  of 
from  under  one  year  to  two  and  a  half  years  is  conferred.  The  agglutina- 
tive power  of  the  blood  is  increased,  the  opsonic  index  rises  and  the 
white  cells  increase.  Vaccination  is  indicated  in  "carriers,"  soldiers  and 
hospital  attendants,  as  internes,  nurses  or  laundry-women;  it  is  also 
advisable  in  children,  who  leave  home  for  schooling,  vacation  or  travel. 
Against  paratyphoid  infections,  a  similar  vaccine  is  employed.  Typhoid 
vaccines  are  clearly  indicated  in  prophylaxis,  but  their  value  in  the 
developed  disease  is  not  established. 

(B)  Hygienic  Treatment. — Absolute  physical  and  psychical  rest  is 
imperative,  and  the  best  results  are  obtained  in  cases  which  have  been 
put  to  bed  early.  Ambulatory  cases  never  fare  as  well.  The  invariable 
use  of  the  bed-pan  and  urinal  is  insisted  upon.  The  furniture,  carpets 
and  hangings  should  be  removed  from  the  room,  which  should  be  freely 
ventilated — fever  patients  do  not  catch  cold.  The  nurse  should  have 
written  instructions.  The  baths  should  be  supervised  by  the  physician, 
especially  at  the  onset.  The  single  bed  should  be  low,  should  have  a 
firm  mattress,  rubber  draw  sheet  and  perfectly  smooth  cotton  or  linen 
sheets.    A  second  bed  is  desirable  for  change  and  convenience. 

(C)  Antiseptic  Therapy. — iVntiseptic  therapy  is  largely  of  historical 
interest,  as  typhoid  is  not  a  local  enteric  disease  but  a  bacillemia.  Calomel 
given  early  in  typhoid  was  thought  to  reduce  the  virulence  of  the  attack 
and  lessen  bowel  complications;  it  is  harmful.  Salol  (phenylis  salicylas) 
in  doses  of  grs.  x,  t.  i.  d.,  is  the  least  objectionable,  since  it  is  mild.  The 
urine  should  be  closely  watched  for  signs  of  renal  irritation.  Dilute 
hydrochloric  acid,  5  ss  after  each  feeding,  prevents  diarrhea  and  tympany. 
No  one  of  this  group  of  agents  essentially  influences  the  clinical  course, 
and  at  the  most,  only  decreases  fermentation. 

(D)  Antipyresis. — 1.  Drugs  are  seldom  indicated,  for  they  merely 
reduce  fever  and  do  not  eliminate  its  cause,  the  toxins.  Quinine  in 
one  or  two  doses  of  fifteen  to  twenty  grains  has  little  influence  on  the 
fever.  Coal-tar  products,  in  full  repeated  doses,  depress  the  brain,  cir- 
culation, respiration  and  metabolism;  cause  vomiting  and  eruptions; 
increase  the  danger  of  collapse;  and  are  not  indicated  in  typhoid  as 
they  are  in  the  fugitive  fevers.  In  all  cases  drug  antipyresis  is  far 
inferior  to — 


TYPHOID  FEVER 


51 


2.  Hydrotherapy,  the  only  logical  febrifuge,  since  it  alone  eliminates 
the  fever-exciting  toxins.^  Nature's  method  of  reducing  temperature  by 
sweating,  evaporation  from  the  moist  skin,  should  be  helped  by  removal 
of  the  bedclothing.  (a)  The  full  cold  hath  of  Currie  (1787)  and  Brand 
is  given  with  water  at  64°  to  68°  F. ;  it  lasts  fifteen  to  twenty  minutes 
and  is  repeated  every  three  hours  for  temperature  of  over  102°  or  for 
toxemia.  Chilling  is  averted  by  vigorous  friction,  which  must  not 
abrade  the  skin;  by  cold  affusions  to  the  head;  or  by  administration 
of  alcohol.  The  apparent  brutality  of  the  Brand  method  excited  popular 
and  professional  prejudice,  but  it  is  a  most  valuable  measure.  Early 
resort  to  hydrotherapy  gives  the  best  results.  When  the  portable  bath- 
tub is  not  available,  A.  H.  Burr  uses  a  wooden  frame,  shaped  like  a 
large  box;  the  base  fits  over  any  bed;  its  upper  part  sustains  a  heavy 
rubber  sheet,  which  passes  under  the  patient  and  constitutes  the  sides 


Fig.  6. — Burr's  bed-tub. 


and  bottom  of  the  tub  (Fig.  6).  Its  use  obviates  the  necessity  of  lifting 
the  patient  and  saves  excitement.  Water  is  poured  over  the  patient  from 
pails  and  is  removed  with  a  siphon.  The  advantages  of  Brand's  method 
are:  (i)  The  mortality  is  lowered  6  to  8  per  cent.;  (ii)  toxemia  is  lessened, 
and  therefore  nervous  and  digestive  symptoms,  heart  weakness,  and 
pulmonary  complications  are  relieved;  fever  is  successfully  reduced 
and  there  is  less  visceral  degeneration;  (iii)  renal  secretion  is  stimulated, 
thereby  washing  the  toxins  out  of  the  blood ;  (iv)  the  skin  becomes  more 
active  and  bed-sores  less  frequent;  (v)  the  clinical  course  is  shorter 
and  fewer  complications  occur.  Contra-indications  to  Brand's  method 
are  hemorrhage,  perforation,  great  prostration,  alcoholism,  phlebitis 
and   advanced   arteriosclerosis.     Pregnancy,   nephritis   and  pneumonia 

^  Toxemia  disturbs  the  heat  centre,  located  in  the  corpus  striatum  and  connected  with 
various  parts  of  the  brain,  notably  the  vasomotor  and  other  vital  centres  in  the  medulla. 
Though  views  differ,  it  seems  that  in  fever  there  is  a  great  increase  in  the  production  of 
heat,  without  a  corresponding  increase  in  its  elimination. 


52  BACTERIAL  DISEASES 

are  no  contra-indications.  Various  substitutes  may  be  indicated  for 
special  reasons:  (b)  In  the  gradually  cooled  bath  the  temperature  of 
the  water  is  gradually  reduced  from  90°  to  75°  or  65°.  It  is  adapted  to 
cases  coming  under  treatment  late  and  to  those  with  tendency  to  collapse. 
(c)  The  yrotr acted  tepid  bath,  (d)  Cold  siJ07iging,  first  with  warm  water 
to  dilate  the  skin  vessels  and  then  with  cold  water;  equal  parts  of  alcohol 
aid  evaporation.  One  part  of  the  body  after  another  is  exposed  and 
sponged.  It  is  a  refreshing  and  quieting  placebo,  but  inferior  as  an  anti- 
pyretic, (e)  The  cold  pack  is  also  much  less  successful.  In  sthenic  cases, 
ice  applications  to  the  head,  axilla,  spine,  etc.,  may  be  used,  or  the  body 
may  even  be  ironed  with  ice.    Ice-water  enemas  are  never  used  in  typhoid. 

(E)  Diet. — The  mouth  and  pharynx  should  be  carefully  cleansed  of 
sordes  and  food  particles  lest  infection  travel  to  the  ears,  salivary  or 
lymphatic  glands.  Vaseline  keeps  the  lips  soft.  A  boric  acid  solution,  with 
tincture  of  myrrh  or  tincture  of  hydrastis,  meets  every  requirement.  The 
liquor  antisepticus,  U.  S.  P.,  contains  2  per  cent,  boric  acid  and  antiseptic 
oils.  The  cleansing  must  be  gentle  lest  fresh  abrasions  be  inflicted.  Fifty 
ounces  of  water  should  be  given  daily  at  definite  intervals.  It  flushes  the 
kidneys,  lowers  temperature  by  increasing  the  sweat  production,  and 
lessens  parenchymatous  degeneration  of  the  viscera.  Pure  water  is  superior 
to  barley-  or  albumin-water,  lemonade,  etc.,  which  dull  the  appetite. 

In  the  diet  no  reference  is  made  to  individual  symptoms,  as  there  is  no 
correspondence  between  the  clinical  symptoms  and  the  anatomical  ulcera- 
tion of  the  intestines.  Graves  was  the  first  to  feed  fever  patients,  who  up 
to  that  time  had  been  starved,  but  at  the  present  time  there  is  some  risk 
of  overfeeding.  Milk  is  the  standard  diet.  Six  to  eight  ounces  should  be 
sipped  at  intervals  of  three  hours,  day  and  night,  as  the  patient,  after 
being  wakened,  readily  falls  to  sleep  again.  It  may  be  diluted  with  half 
an  ounce  of  lime-water  or  a  little  carbonated  water,  which  should  not  be 
cold,  since  the  gas  expands  at  body  heat.  The  physician  himself  should 
inspect  the  stools  for  curds.  As  in  infant  feeding,  curds  indicate  reduction 
of  the  cream.  Very  few  patients  cannot  take  milk.  Recalcitrant  patients 
may  be  given  koumyss,  matzoon,  buttermilk,  whey  or  certain  baby 
foods.  If  digestion  is  weak,  peptonized  milk  may  be  given  with  thin, 
strained  gruels  or  egg.  Carbohydrates  are  indicated  to  lessen  nitrogenous 
waste  (Kendall),  and  well-boiled  cornstarch,  strained  vegetable  soups 
and  tapioca  are  allowed  if  no  tympany  results ;  taka-diastase  aids  their 
assimilation.  Meat-juice  is  obtained  from  freshly  slaughtered  beef,  by  a 
meat-press.  It  may  also  be  given  frozen  (meat-juice,  5iij;  sugar,  5ij; 
lemon-juice,  5  j;  yolk  of  one  egg;  cognac,  5j)-  Yolk  of  egg  in  soup  or 
wine,  and  white  of  egg  with  twice  its  weight  of  water  afi'ord  some  variety. 
Gelatin  conserves  metabolism  but  may  irritate  the  bowels.  Beef-tea 
contains  only  stimulating  substances,  less  than  1  per  cent,  albumin, 
and  no  fat  or  carbohydrates  and  may  irritate  the  kidneys  and  intestines. 
In  stupid  patients  with  anesthetic  throats,  food  may  enter  the  larynx 
and  cause  aspiration  pneumonia.  In  these  cases  the  nasal  catheter  is  indi- 
cated. To  its  outer  end  a  funnel  is  attached  through  which  food,  drink, 
and  medicines  are  given.  A  safety-pin  across  its  outer  end  prevents  its 
escape  downward.  The  catheter  should  be  long  enough  to  pass  into  the 
esophagus  beyond  the  larynx.    Rectal  feeding  is  sometimes  indicated. 


TYPHOID  PEVER 


53 


High  Calory  Feeding. — Years  ago  Shattuck,  Hare,  von  Miiller  and 
others  advocated  more  generous  feeding,  and  lately  Coleman  and  Schaffer, 
especially,  have  popularized  high  calorie  feeding.  At  the  height  of  the 
infection,  the  pyrexia  (fever  and  toxemia),  the  alimentary  disturbance 
and  the  starvation  increase  metabolism  about  34  per  cent.,  as  regards 
the  protein  and  fat  of  the  body,  somewhat  as  in  simple  starvation, 
although  more  extensively.  Magnus-Levy  demonstrated  that  metabolism 
is  qualitatively  the  same  in  the  febrile  as  in  the  well  individual.  To 
compensate  the  increased  nitrogenous  waste,  a  diet  more  ample  than 
is  usually  given,  is  desirable.  Coleman  and  Schaffer  hold  that  theoretic- 
ally 5000  calories  are  demanded;  3000  are  accepted  as  a  compromise. 
The  approximate  values  of  available  foods  in  calories  are  as  follows: 
One  quart  milk,  700  (plus  6  per  cent,  milk-sugar,  900) ;  1  pint  cream,  900; 
5  ounces  oatmeal  or  hominy,  with  2  ounces  cream  and  3  teaspoonfuls 
sugar,  300;  eggs,  each  80;  cup  of  custard,  100;  1  slice  of  well-buttered 
bread,  200;  8  ounces  milk-sugar,  1000.  Absorption  in  fever  is  90  per  cent, 
of  normal.  The  protein  and  fat  loss  is  about  6  per  cent,  each,  whereas 
carbohydrates  are  perfectly  assimilated.  Two  quarts  of  milk  give  but 
1400  calories  of  the  3000  or  more  needed.  Coleman  believes  that  the 
ampler  diet  decreases  indigestion.  Eggs  supply  protein  (6  eggs  =  7  gm. 
N.  =  480  calories)  and  are  of  higher  food  value  in  a  mixed  diet;  Coleman 
discards  meat,  except  for  its  extractives  in  soup  to  stimulate  appetite, 
though  V,  Miiller  advocates  brains,  hash,  etc.;  100  gm.  protein  (=16  gm. 
N.)  is  the  upper  limit.  Carbohydrates  should  constitute  half  the  calories 
and  are  supplied  by  bread,  toast,  crackers,  mashed  potatoes,  milk-sugar, 
and  gruels  (oatmeal  and  cream  of  wheat);  cellulose  is  shunned  (in 
vegetables  and  fruits).  Fats  include  cream,  butter  and  cocoa;  in  excess 
they  disturb  digestion,  but  as  much  as  200  to  250  gm.  are  sometimes 
tolerated.  If  the  milk-sugar  is  too  sweet  in  milk,  it  may  be  taken  in 
lemonade,  ice-cream  or  custard.  In  high  feeding,  two  to  four  bowel 
movements  a  day  are  usual.  In  every  instance  this  diet  must  be  indi- 
vidualized, regarding  the  weight,  appetite  and  digestion,  and  increasing 
slowly.  It  is  difficult  to  give  3000  calories  in  the  severest  types,  who 
most  need  the  diet.    Appended  are  caloric  values,  borrowed  from  White. 

DAILY  FOOD  DEMANDS. 


Adult. 


At  rest  in  bed 
Slight  activity 
Light  work 

Moderately  hard  work 
Very  hard  work  . 


Body 

Calories 

Total 

weight. 

pound. 

calories. 

150  lbs. 

12 

1800 

" 

15 

2200 

" 

17 

2600 

" 

20 

3000 

23-30 

3500-4500 

Child. 


Age  0-6  months. 

7-15  lbs. 

42-40 

300-600 

6-12      "       .      . 

15-20     " 

40 

500-800 

2  years   . 

25     " 

36 

900 

4       "        ... 

35     " 

34 

1200 

8      "       ... 

50     " 

28 

1400 

12      "       ... 

75     " 

22 

1600 

Total 
grams 
proteid. 


115 

120 

140-180 


1  gram 
per  lb. 
35-40 

42 

55 

60     ' 

75 


Calories. 
1  gram  proteid  =   4.1 

1     "      carbohydrate     =   4.1 
1     "      fat  =   9.3 

1     "      alcohol  =7.0 


54 


BACTERIAL   DISEASES 


FOOD   VALUES   IN  HOUSEHOLD   MEASURES. 


Approximate. 


Foods  as  eaten. 


Dairy: 

Milk       ....... 

Skimmed  milk  and  buttermilk 
Cream  /thin  (20  per  cent.)    . 
i.tnick  (40  per  cent.; 

Condensed  milk  /sweetened 

unsweetened 

Butter 

fCream      .... 
Cheese  <  Skim  milk     . 
.American 

Eggs,  whole 

Eggs,  yolk 

Me.vt  axd  Fish  (cookedj : 
Beef-tea,  clear  soups   . 
Fish     i^^^^  (cod,  flounder)    . 
fat  (shad,  salmon) 

[lean 

Meat  <  medium  fat 

i.fat 

Oysters,  medium  size  (raw)    . 

CERE.iLSAXDVEGET.4.BLES  (cooked) 

Bread,  white  or  Graham  . 

Vienna  roll 

Crackers  (Tneeda) 

Cereals,  cooked,  moist 

Cereals,  eaten  dry. 

Shredded  wheat     .... 

Gruels  (^cereal) 

Thickened  or  cream  soups 

Macaroni 

Potato,  boiled  or  baked    . 

Potato,  mashed      .... 

Rice,  boiled 

Corn,  canned 

Peas,  fresh 

Lima  beans,  canned    . 

Squash 

Fruits  : 

Apple,  pear 

Apple  sauce 

Banana        

Orange 

Strawberries 

Dried  figs,  dates,  raisins  . 

Fruit  jelly,  sweetened 
Desserts  : 

Custard ' 

Ice-cream • 

Sponge  cake 

Pudding  (rice,  tapioca,  bread) 
Alcohol  

Whisky,  brandy,  etc.  (.50  p.  c.) 

Wines  (8-45  per  cent.) 
Miscellaneous:  ' 

Sugar 

Honey ; 

Olive  oU ] 

OUves I 

Almonds,  shelled    .... 

Cocoa  powders       .      .      .      .      • 


Actual 
amount. 


Household  measure. 


Calories.  P^"*^^^-    ^at,      Cari,<>. 
grams,    grains.  "J  ^"  •*•'«=- 
grams. 


8  ozs. 
8  ozs. 

16  gms. 

20  gms. 
10  gms. 

15  gms. 

50  gms. 
15  gms. 


50  gms. 
50  gms. 


25  gms. 
40  gms. 

7  gms. 
40  gms. 

5  gms. 
30  gms. 

8  ozs. 
8  ozs. 

2.5  gms. 
95  gms. 
35  gms. 
30  gms. 
35  gms. 
35  gms. 
25  gms. 
35  gms. 

120  gms. 

45  gms. 
100  gms. 
130  gms. 
100  gms. 
100  gms. 

50  gms. 

40  gms. 
40  gms. 
20  gms. 
45  gms. 
12  gms. 

1  oz. 

1  oz. 

8  gms. 
10  gms. 

4  gms. 

7  gms. 
25  gms. 
10  gms. 


A  glass 

160 

7.5 

9.5 

12.0 

A  glass 

80 

7.5 

1.0 

11.5 

A  tablespoon 

!        /   30 
1   60 

0.5 

3.0 

0.5 

A  tablespoon 

0.5 

6.0 

0  5 

A  heaping  teaspoon 

70 

2.0 

2.0 

11  5 

A  heaping  teaspoon 

35 

2.0 

2.0 

2  5 

A  pat  or  ball 

80    ■ 

8.5 

One-inch  cube 

r  65 

4.0 

5.0 

0  5 

One-inch  cube 

45 

4.5 

2.5 

0  5 

One-inch  cube 

1  70 

4.0 

One 

75 

6.5 

5.0 

One 

55 

2.5 

5.0 

A  teacup 

5-20 

1-4.5 

0.5 

A  heaping  tablespoon 

./  35 

8.5 

A  heaping  tablespoon 

\105 

11.0 

6.5 

A  medium  slice 

70 

11.5 

2.5 

5  X  3  X  J  inch 

|150 

11.5 

9.0 

200 

8.5 

18.0 

One 

8 

1.0 

0.2 

0.5 

One  slice.  4  x  4  x  J  inch 

70 

2.3 

0.5 

13.0 

One 

115 

3.5 

1.0 

22.5 

One 

30 

0.5 

0.5 

5.0 

.\  heaping  tablespoon 

35 

1.0 

7.0 

A  heaping  tablespoon 

20 

0.3 

4.0 

One 

110 

3.0 

0.5 

23.0 

A  soup  plate 

75 

2.5 

1.0 

14.0 

A  soup  plate 

160 

o.o 

4.5 

24.0 

A  heaping  tablespoon 

25 

1.0 

0.5 

4.0 

One  medium  size 

90 

2.0 

20.0 

A  heaping  tablespoon 

40 

1.0 

1.0 

6.0 

A  heaping  taMespoon 

35 

1.0 

7.0 

A  heaping  tablespoon 

35 

1.0 

0.5 

6.5 

A  heaping  tablespoon 

40 

2.5 

1.0 

5.0 

A  heaping  tablespoon 

20 

1.0 

3.5 

A  heaping  tablespoon 

20 

0.5 

3.5 

One  medium  size 

75 

0.5 

0.5 

17.0 

A  heaping  tablespoon 

70 

0.5 

16.5 

One  medium  size 

100 

1.5 

0.5 

22.0 

One  medium  size 

70 

1.0 

15.0 

A  medium  saucerful 

40 

1.0 

0.5 

7.5 

A  medium  saucerful 

350 

2.5 

3.0 

76.0 

A  heaping  tablespoon 

160 

0.5 

38.5 

A  heaping  tablespoon  ■ 

55 

2.5 

0.5 

9.0 

A  heaping  tablespoon  i 

135 

1.5 

9.0 

11.0 

A  sUce  2  X  4  X  i  inch- 

75 

1.5 

2.0 

13.0 

A  heaping  tablespoon 

80 

2.0 

2.0 

13.0 

A  tablespoon 

85 

A  small  wineglass 

85 

A  small  wineglass 

1.5-50 

A  heaping  teaspoon 

33 

8.0 

A  heaping  teaspoon 

33 

8.0 

A  teaspoon 

37 

4.0 

One  medium  size 

15 

1.5 

0.5 

A  heaping  tablespoon 

165 

5.0 

13.5 

4.5 

A  heaping  teaspoon 

50 

2.0 

3.0 

3.5 

(F)  Sy^iptomatic  or  Expectant  TREATiiENT. — 1.  Digestive  System, 
(a)  Vomiting. — It  must  be  ascertained  that  the  patient  has  received 
no  solid  food  from  friends  and  that  perforation  has  not  taken  place. 
Rectal  feeding,  warm  carbonated  water,  cocaine  gr.  J,  or  tincture  iodine 
TTll,  for  several  doses,  sinapisms  or  an  ice-bag  to  the  epigastrium,  are 
indicated. 


TYPHOID  FEVER  55 

I^ — -Phenolis gr.  iv 

Bismuthi  subnitratis oiss 

Sacchari  albi  \  --  • 

.        .  > aa  q.  s. 

Acacise  j 

Aquse  menthae  piperitse q.  s.  ad.      gij 

M.  et  fac  emulsum. 

S. — One  teaspoonful.  undiluted,  every  fifteen  to  thirty  minutes. 

(b)  Constipntion  indicates  enemas  of  water  or  oil  every  other  day. 
Typhoid  cases  with  constipation  fare  better  than  those  with  diarrhea, 
and  cathartics  cause-  meteorism. 

(c)  Diarrhea  is  most  frequently  due  to  toxemia  and  is  therefore  most 
efficaciously  treated  with  the  cold  bath;  curds  (prevented  by  diluting  or 
skimming  the  milk),  beef-tea  or  impure  milk,  may  be  its  cause.  Treat- 
ment is  indicated  by  more  than  four  movements  daily,  colic,  tenesmus, 
unrest  or  weakness.  Cold  tea  with  whisky  and  pulv.  aromaticus,  gr.  xv; 
or  paregoric  and  bismuth,  eachSj  after  each  movement;  extr.  opii.,  gr.  i; 
or  the  starch-and-laudanum  enema  usually  give  relief  at  once. 

I^ — Bismuthi  subnitratis 3iij 

Extraeti  opii gr.  ij 

M.  et  div.  in  pulv.  xij. 
S. — One  to  four  a  day.     (Since  absorption  from  the  alimentary  tract  is  slow  and  uncertain, 
the  effects  of  powerful  drugs  given  by  mouth  should  be  watched  carefully.) 

I^ — Acidi  tannici 5J 

Tincturse  opii Tflxl 

Emulsi  terebinthinse q.  s.  ad.      §j 

M.  et  S. — One  teaspoonful  every  three  hours  for  3  or  4  doses. 

I^ — Plumbi  acetatis gr.  iss  ad  iij 

Opii  pulveris gr.  i  ad  iiss 

Sacchari  albi gr.  Ix 

M.  et  divide  in  pulv.  vj. 

S. — -A  powder  every  three  hours  (note  caution  under  first  formula). 

(d)  Tympany. — In  severe  cases  albumin-water  must  be  substituted 
for  milk.  The  cold  bath  often  gives  relief,  since  metieorism  is  generally 
toxemic.  Hydrochloric  acid  after  feeding  may  lessen  the  tympany. 
The  turpentine  stupe  of  Jenner  should  be  applied  to  the  abdomen, 
flannel  cloths  being  dipped  in  warm  water  and  5  ss  ol.  terebinthinse  and 
slapped  hard  together  to  spread  the  oil  evenly  and  thus  avoid  blistering. 
The  ice-coil  is  also  beneficial.  The  old  turpentine  emulsion  (emulsum  olei 
terebinthinse,  5j)  is  excellent,  though  the  urine  must  be  watched  for 
renal  irritation.  Whisky,  spices,  and  perhaps  eserine  sulphate  or  sali- 
cylate gr.  5^Q-  are  effective.  Emulsum  asafetidse,  Oj ;  spiritus  chloroformi, 
5  ij ;  and  ol.  terebinthinse,  5  ss,  as  a  warm  enema,  often  give  relief. 

(e)  Hemorrhage  necessitates  absolute  quiet,  mental,  physical  and  ali- 
mentary. The  patient  should  not  be  moved  for  any  reason.  In  severe 
cases  he  should  lie  in  the  voided  blood,  with  cotton  tucked  around  the 
hips  and  between  the  legs  to  catch  the  urine  and  feces,  which  should  pass 
into  it  without  his  being  lifted  on  the  bed-pan.  No  food,  no  water,  no 
enema,  no  bath,  should  be  given.  Morphine  quiets  the  excitement 
attending  hemorrhage,  lessens  peristalsis  and  enforces  bodily  quiet; 
gr.  \  is  injected  every  hour  for  three  doses,  or  enough  to  produce  its 


56  BACTERIAL   DISEASES 

full  physiological  effect.  The  sole  objection  to  morphine  is  that  it  may 
mask  coincident  perforation,  which  occurs  once  in  every  five  cases  of 
hemorrhage;  close  circumspection  invalidates  this  objection.  Opium 
or  styptics  by  the  mouth  are  dangerous  and  uncertain.  The  lead-  or 
iron-salts  probably  never  reach  the  bowel.  An  ice-coil  on  the  abdomen 
may  be  beneficial.  Gelatin  may  be  injected  as  in  aneurysm,  but  10  c.c. 
of  horse  serum  or  diphtheria  antitoxin  work  better  results;  the  latter 
should  be  fresh  and  not  of  the  concentrated  type,  which  largely  contains 
globulins.  Schreiber  employs  an  intravenous  infusion  of  5  to  10  per 
cent,  grape-sugar  solution.  The  question  of  stimulation  is  perplexing. 
There  is  the  risk  of  forcing  blood  through  the  leak  by  stimulation;  on 
the  other  hand,  the  volume  of  blood  must  not  sink  too  low;  but  first 
the  heart  must  be  allowed  to  run  dowTi — nature's  most  certain  method 
of  hemostasis.  At  a  later  time  only,  should  strychnine  or  digitalis  be 
administered  hypodermically,  or  saline  transfusions  be  given;  delay 
in  their  use  is  better  than  haste. 

(/)  Perforation  necessitates  an  early  diagnosis  and  immediate  opera- 
tion. ]Most  reported  recoveries  were  operated  on  in  the  first  twenty- 
four  hours.  Recovery  occurred  in  30  per  cent,  of  358  operations 
(Cazin).  In  twenty  cases  operated  on  at  Johns  Hopkins  Hospital,  35 
per  cent,  recovered. 

ig)  Quenu  tabulates  67  operations  on  the  gall-bladder;  82  per  cent, 
of  recoveries  occurred  in  the  cholecystostomies  and  80  per  cent,  in  the 
cholecystectomies. 

2.  Circulatory  System. — Heart  weakness  is  best  prevented  by  absolute 
rest  and  hydrotherapy.  An  ice-bag  placed  over  the  heart  tends  to  regulate 
and  calm  its  action.  Strychnine  is  the  best  vasomotor  tonic;  gr.  -^ 
may  be  given  three  times  a  day  in  cases  which  do  not  show  signs  of 
circulatory  failure,  but  it  is  best  to  await  definite  indications  for  stimula- 
tion. Digitalis  is  rarely  beneficial  in  fever  cases,  and  may  produce 
signs  of  cumulative  action;  the  author  saw  a  case  in  which,  with  sudden 
defervescence,  the  pulse  dropped  from  140  to  40.  Camphor,  gr.  ij, 
should  be  given  under  the  skin  in  1  to  10  parts  of  sterilized  olive  oil. 
Other  cardiants  are  considered  under  Valvular  Disease  and  Pneumonia. 
In  typhoid  alcohol  may  be  indicated  (a)  as  a  food,  "uith  milk  and  eggs, 
thus  aiding  digestion;  5j~iv  of  whisky  may  be  given  every  two  to 
four  hours  in  hot  milk.  Stokes's  mixture  contained  cognac,  §ij — ovi 
vitellus  1,  syr.  aurantii  5^,  and  water  q.  s.  ad.  §v.  (b)  As  a  cardiant 
(though  pharmacologists  hold  that  pure  alcohol  is  not  a  cardiant); 
Meltzer  states  that  it  equalizes  the  circulation.  Cognac  may  be  given 
by  the  mouth,  in  coffee;  or  by  rectum,  in  peptonized  milk  with  two 
drachms  of  tincture  of  valerian,  (c)  As  a  nervine  in  debility  or  old  age, 
as  whisky,  champagne  (especially  for  vomiting),  sherry  or  port,  (d) 
To  a  less  degree  as  an  antipyretic,  since  it  increases  the  sweat  production. 
Its  use  must  be  suspended  when  the  pulse  becomes  bounding,  the  res- 
piration hurried,  the  skin  or  tongue  dry,  when  there  is  restlessness,  or 
the  odor  of  alcohol  appears  on  the  breath.  Alcohol  has  been  abused, 
and  the  recent  reaction  against  its  use  is  in  part  sound.  With  discretion 
alcohol  is  invaluable  in  severe  cases  and  in  alcoholics. 


TYPHOID  FEVER  57 

Thrombophlebitis  is  treated  by  quiet,  elevation,  warmth  and  ban- 
daging from  the  toes  upward. 

3.  Respiratory  System. — Epistaxis  usually  ceases  spontaneously.  If 
the  blood  runs  into  the  throat  a  tampon  should  be  introduced.  Laryn- 
geal complications  may  necessitate  early  tracheotomy;  only  2  per  cent, 
of  severe  complications  recover  without  operation.  Bronchitis  is  treated 
by  hydrotherapy,  rarely  by  codeine.  Expectorants  are  avoided  since 
they  disorder  digestion.  Hypostasis  is  best  treated  by  hydrotherapy, 
cardiants  and  explicit  written  orders  for  change  of  posture  every  two 
hours. 

4.  Nervous  System. — The  initial  headache  may  be  relieved  by  hydro- 
therapy, the  ice-cap,  ergotin  and  acetphenetidinum  (phenacetin),  each 
gr.  V  (in  extreme  cases  lumbar  puncture  may  be  considered).  De- 
pression is  relieved  by  valerian  and  whisky.  For  delirium  and  insomnia, 
hydrotherapy  is  the  most  useful  measure;  veronal,  gr.  v-vij,  produces  a 
natural  sleep;  alcohol;  morphine,  gr.  |;  codeine,  gr.  |;  heroine,  gr.  ^Vs 
sodium  bromide,  5ss-j;  or  hyoscinse  hydrobromidum,  gr.  y-to  ^^Y  be 
indicated. 

I^ — -Morphinse  hydrochloridi gr.  i 

Sodii  bromidi gr.  xxx 

Syrupi  aurantii q.  s.  ad.  3iij 

M.  et  S. — -To  be  taken  at  bed-time  in  water. 

Typhoid  patients  should  never  be  left  alone,  lest  they  leave  the 
bed  or  leap  from  the  window.  Restlessness  may  suggest  a  full 
bladder. 

5.  The  Skin. — Massage  with  alcohol  or  olive  oil  is  useful.  The  skin 
functions  are  helped  by  the  full  bath.  In  the  formation  of  bed-sores, 
local  heat,  pressure,  moisture,  maceration  and  filth  are  factors.  These 
are  generally  avoided  by  frequent  change  of  posture,  thick  pads  or  rubber 
rings  and  cleanliness.  The  least  erythema,  papule,  abrasion  or  pustule 
on  dependent  parts  is  a  matter  of  solicitude;  skin  infections  may  cause 
ward  epidemics  (Edsall).  If  bed-sores  develop,  the  simplest  treatment 
is  the  best,  since  antiseptics  and  powders  may  aggravate.  Balsam 
of  Peru  is  excellent.  Scarlet-red  ointment  (8  per  cent.)  is  often  curative; 
it  should  not  be  used  in  deep  ulcerations,  as  poisoning  may  occur — 
faintness,  collapse,  cramps,  etc.,  as  in  anilin  poisoning.  Collodion  and 
adhesive  straps  are  always  to  be  avoided. 

6.  Bacilluria. — Bacilluria  is  met  by  phenylis  salicylas  and  hexa- 
methylenamina,  each  gr.  x,  t.  i.  d.  Urotropin  operates  best  when  the 
urine  is  acid  or  made  so,  by  acid  sodium  phosphate;  urotropin  may 
induce  alimentary  or  vesical  irritation  and  possibly  albuminuria.  If 
bacilluria  persists,  irrigations  with  silver  nitrate  or  bichloride  solutions 
are  indicated.     Special  care  is  necessary  in  the  use  of  catheters. 

(G)  Treatment  in  Convalescence. — The  convalescence  must  be 
actual  and  relapse  excluded  before  the  patient  can  have  substantial 
food.  It  is  best  to  err  on  the  safe  side,  as  embolism  and  collapse  are  not 
unknown  in  convalescence.  The  patient  should  not  leave  his  bed  for 
two  weeks.    Irregular  fever  lingers  in  some  cases  until  solid  food  is  given 


58  BACTERIAL  DISEASES 

and  the  patient  sits  up.    In  other  cases,  meat  causes  a  higher  temperature 
(fehris  carnis).    An  excellent  tonic  is  the  following: 

I^ — Strychninge  sulphatis gr.  j 

Acidi  nitrohydrochlorici 3J 

Tr.  gentianse  co q.  s.  ad.  gv 

M.  et  S. — One  teaspoonful  after  meals  in  half  a  glass  of  water. 


ERYSIPELAS. 

Synonym. — St.  Anthony's  Fire. 

Definition. — ^An  acute,  febrile,  contagion  caused  by  Fehleisen's  Strepto- 
coccus erysipelatis;  characterized  by  a  circumscribed  inflammation  of 
the  skin  and  adjacent  mucosse,  which  tends  to  rapid  and  broad  extension; 
and  self-limited  in  its  course. 

History. — Erysipelas  was  known  to  Hippocrates  and  Galen.  Trousseau 
(1848),  in  France,  held  it  was  a  wound  infection;  Werner,  in  England, 
maintained  that  it  was  infectious;  and  Koch  (1880)  found  the  streptococcus 
which  was  more  fully  described  by  Fehleisen  (1881)  and  bears  his  name. 

Etiology. — Sporadic  cases  are  seen  in  every  centre  of  population. 
It  occasionally  breaks  out  epidemically.  Sixty  per  cent,  of  cases  occur 
between  January  and  May.  In  the  pre-antiseptic  era  it  was  the  dread 
of  hospital  physicians,  and  even  at  this  day  it  occasionally  visits  the  most 
sanitary  institutions.  It  is  conveyed  by  a  third  person,  fomites  and, 
infrequently,  by  unclean  instruments  and  vaccine.  Cases  of  placental 
transmission  to  the  fetus  are  kno^vn.  The  virus  is  not  penetrative  but 
adheres  to  clothing  and  furniture  with  great  tenacity.  Many  persons 
exhibit  a  natural,  perhaps  an  hereditary,  susceptibility.  In  its  recurrence, 
it  resembles  rheumatism.  It  occurs  mostly  in  the  female  sex  (73  per  cent, 
of  cases).  Alcoholism,  debility  and  chronic  nephritis  are  predisposing 
factors.  Any  distinction  between  "idiopathic"  and  "wouncV  erysipelas 
is  artificial,  for  in  every  instance,  some  abrasion,  perhaps  too  small  for 
the  eye  to  detect,  occurs  in  the  skin  or  mucosae. 

Bacteriology. — The  Streptococcus  erysipelatos  was  found  in  the  lymph 
vessels  by  Fehleisen,  who  first  drew  the  distinction  between  erysipelas 
and  phlegmon.  Its  absolute  differentiation  from  the  Streptococcus 
pyogenes  is  impracticable.  Inoculations  from  cases  of  erysipelas  some- 
times produce  suppuration,  pus  has  caused  erysipelas  and  erysipelas 
and  suppuration  have  developed  simultaneously,  which  facts  give  weight 
to  the  theory  of  the  bacteriological  unity  of  erysipelas  and  suppuration. 

Symptoms. — 1.  Incubation  lasts  three  to  seven  days. 

2.  Eruption. — (a)  Usually  preceded  by  a  few  hours  of  general  dis- 
comfort, this  stage  begins  with  voviiting,  fever,  chill  and  the  eruption. 
The  fever  rises  rapidly  to  103°.  The  chill  occurs  in  75  per  cent,  of  cases 
and  is  chiefly  absent  in  erysipelas  secondary  to  other  diseases,  ih)  The 
eruption  first  appears  on  the  face  (95  per  cent.),  near  the  inner  canthus, 
nose  or  cheek.  It  consists  of  a  hard,  bright  red,  slightly  elevated,  and 
painful  area  which  pits  but  little  on  pressure,  though  its  color  may 
disappear.  Pathologically,  erysipelas  (literally,  red  skin)  is  simple 
inflammation;  in  the  skin  are  found  edema,  hyperemia,  white-  and  red- 


ERYSIPELAS  59 

cell  extravasation,  and  streptococci  which  advance  in  the  lymyh  clefts 
and  are  most  abundant  in  the  spreading  edge,  and  in  the  lymph  vessels 
beyond  it.  Its  elevated  red  edge  is  sharply  marked  or  ''wall-like.'''  As 
the  area  spreads,  the  shin  becomes  much  swollen,  edematous,  smooth,  tense, 
red  and  hot,  causing  a  shapeless  swelling  of  the  face  and  obliterating  its 
lines  and  expression.  The  extent  is  indicated  more  accurately  by  tender- 
ness than  with  the  eye.  The  skin  blisters  and  under  the  lens  small 
vesicles  are  always  found.  The  jyrong-like  advance  of  the  erwption  is  similar 
to  that  of  spilled  alcohol  or  burning  paper,  i.  e.,  it  disappears  behind  as 
it  advances  forward.  Its  extension  is  irregular,  because  the  streptococci 
follow  the  lines  of  least  resistance.  If  obstructed  by  dense  tissue,  deep 
attachments  or  the  so-called  ligamenta  cutis,  its  course  becomes  cir- 
cuitous, asymmetrical  and  tardy  in  one  area,  though  rapid  in  another. 
It  rarely  affects  the  chin,  or  passes  over  it  to  the  opposite  side.  The 
neck  resists  its  advance,  often  successfully,  but  erysipelas  may  course 
over  the  entire  body.  The  sternum,  condyles,  ilium  and  Poupart's 
ligament  check  or  divert  its  progress.  When  apparently  obstructed, 
new  islets  of  eruption  appear  near  by,  which  may  be  seen  to  be  consecutive 
by  the  faint  lymphatic  involvement  between  the  foci.  The  scalp  is 
often  unaffected,  but  if  invaded  it  becomes  swollen,  and  pale  or  blue 
rather  than  red,  and  the  hair  falls  out.  The  first  area  pales,  and  a  coarse 
desquamation  results,  while  the  eruption  at  more  remote  points  advances. 
The  lymph  glands  are  constantly  swollen,  tender  and  palpable,  unless 
hidden  by  edema.  They  enlarge  proportionately  to  the  dermatitis. 
The  eruption  presents  few  variations:  Erysipelas  vesiculosum;  E. 
bullosum;  E.  squamosum,  or,  in  old  or  cachectic  subjects,  E.  hemor- 
rhagicum.  (c)  The  fever  rises  suddenly,  and  is  103°  to  104°  by  the  fourth 
day  and  continuous,  then  remittent,  and  after  seven  to  nine  days  resolves 
by  crisis.  In  attenuated  erysipelas  there  is  little  fever  and  few  general 
symptoms,  though  the  rash  may  be  well  developed.  In  general  the 
intensity  and  progress  of  the  infection  are  marked  by  the  degree  of  fever. 
The  pulse  is  soft  and  ranges  between  100  and  120. 

Course. — When  limited  to  the  face  and  head  its  usual  duration  is 
eight  to  ten  days,  rarely  longer  than  two  weeks.  Erysipelas  migrans  may 
travel  from  limb  to  limb,  and  recur  repeatedly.  In  one  of  the  author's 
cases  it  lasted  six  months. 

Complications  and  Sequels.- — 1.  Nervous. — ^Toxemic  symptoms  are 
infrequent  except  in  aged,  debilitated  or  alcoholic  subjects.  Delirium 
is  an  unfavorable  toxemic  development  and  occurs  especially  when  the 
scalp  is  invaded.  Meningitis,  formerly  confused  with  toxemia,  in- 
frequently follows  orbital  cellulitis  or  extension  along  the  fifth  nerve. 
Postfebrile  psychoses,  multiple  neuritis,  degeneration  of  the  cord  and 
eye  inflammation  are  exceptional. 

2.  Circulatory. — Endocarditis,  pericarditis,  myocarditis,  acute  dila- 
tation, and  arterial  or  venous  thrombosis  are  infrequent.  High  leukocyte 
counts  indicate  concomitant  suppuration.  Streptococci  in  the  blood 
are  usually  ominous. 

3.  Respiratory. — Erysipelatous  coryza  and  otitis  are  infrequent 
and  difficult  of  recognition.     Erysipelatous  angina  is  characterized  by 


60  BACTERIAL  DISEASES 

much  pain,  sharply  marked  hvidity,  a  glazed,  varnished  surface,  marked 
edema  of  the  uvula  and  epiglottis,  the  formation  of  vesicles  or  bullae, 
and  sometimes  a  wall-like  margin.  Gangrene  may  develop  in  severe 
infections.  The  cervical  glands  may  be  swollen.  Laryngeal,  secondary 
to  pharyngeal  erysipelas,  is  rare,  severe,  easily  or  necessarily  confused 
with  glottis  edema,  and  marked  by  great  turgescence  and  rapid  swelling. 
Without  tracheotomy,  fatal  stenosis  and  extension  to  the  lower  air- 
passages  may  occur.  The  rare  so-called  "erysipelas  pneumonia"  is 
probably  a  septic  localization;  in  streptococcus  pneumonia,  the  spleen 
is  enlarged  more  frequently  than  in  ordinary  pneumonia.  The  advance 
is  rapid,  the  extension  wide,  the  gray  hepatization  great,  and  fibrin 
formation  scant  or  lacking.  In  pneumococcic  infection  the  same  "  wander- 
ing pneumonia"  may  be  seen.     Pleurisy  is  usually  metastatic 

4.  Alimentary. — Vomiting  is  toxemic.  Exceptional  complications 
are  parotitis,  esophagitis,  gastritis,  enteritis,  intestinal  ulceration,  hemor- 
rhage, pain,  icterus  and  pylethrombosis. 

5.  Genito-urinary. — Albuminuria  is  the  most  constant  visceral 
finding  (50  per  cent.).  Nephritis  (4  per  cent.)  is  often  of  the  acute 
glomerular  type.  Streptococci  have  been  found  in  the  urine  and  kidneys, 
especially  in  septic  types.  Erysipelas  may  begin  in  the  external  genitalia, 
especially  in  puerpercB  (page  22). 

6.  Septic. — Subcutaneous  abscesses,  which  resemble  cold  abscesses, 
appear  in  6  per  cent,  of  cases,  especially  in  alcoholic,  nephritic,  diabetic, 
aged  or  debilitated  patients.  Phlegmons  may  develop,  usually  on  the 
legs.  Gangrene  is  fortunately  rare  (y  of  1  per  cent.);  it  develops  early 
over  the  eyelids,  genitalia  or  joints,  or  later  in  the  extremities.  Herpes 
is  not  infrequent.  Baldness  may  also  result.  The  joints  may  be  painful; 
suppurative  arthritis  or  adenitis  is  metastatic.  Generalized  fatal  sepsis, 
aside  from  the  puerperal  form,  is  infrequent.  It  bears  the  same  relation 
to  local  erysipelas  as  does  miliary  tuberculosis  to  a  local  tuberculous 
focus. 

Diagnosis. — Diagnosis  is  easy,  when  the  area  is  the  size  of  a  dollar, 
(a)  because  of  its  very  location;  (b)  the  early  involvement  of  the  lym- 
phatics ;  (c)  often  the  atrium  can  be  found ;  (d)  the  redness,  smoothness, 
swelling  and  edema ;  (e)  the  elevated,  wall-like  margin ;  and  (/)  the  prong- 
like, irregular  progression. 

In  weeping  eczema,  the  edges  are  not  raised,  the  skin  is  not  smooth, 
there  is  less  fever,  the  development  is  slower  and  itching  is  present. 
Malignant  pustule  causes  redness  and  swelling,  but  anthrax  bacilli  are 
found  under  the  primary  papule  and  crust.  Dermatitis  mnenata  or 
medicamentosa,  and  pemphigus,  are  unlike  erysipelas.  Erythema  nodosum 
is  discrete  and  does  not  spread.  Diffuse  simple  erythema  is  a  febrile 
affection,  and  of  short  duration.  Dermatitis  exfoliativa  in  the  newborn 
is  afebrile,  develops  first  about  the  mouth  and  chin,  and  reaches  the  body 
and  limbs  later.  Its  dift'useness  and  redness  are  characteristic.  In 
lymphangitis  the  swelling  of  the  lymphatics  advances  centripetally  and 
presents  cord-like  areas,  which  are  not  confluent,  vesiculated,  uniformly 
red  or  evenly  edged.  In  phlegmon  and  deep  cellulitis,  the  process  is 
deeper  and  harder,  and  the  blisters  and  margin  of  erysipelas  are  lacking. 


ERYSIPELAS  61 

Erysipelatous  angina  may  not  be  diagnosed  without  coincident  facial 
erysipelas.    The  local  findings  are  not  pathognomonic. 

Erysipeloid,  a  zoonotic  affection  described  first  by  Rosenbach  (1884), 
occurs  especially  in  persons  who  handle  meat;  the  bacillus  is  identical 
with  that  of  mouse  sepsis  and  hog  cholera.  It  is  recognized  by  the 
"butterfly"  eruption  on  the  cheeks  or  finger-ends,  and  is  unaccompanied 
by  fever  or  general  symptoms.  The  edge  of  the  eruption  is  clear-cut, 
its  advancement  slow,  its  color  a  dark  livid-red,  and  its  course  lasts  one 
to  three  weeks  with  spontaneous  recovery.  Gilchrist  reported  329  cases, 
of  which  323  were  caused  by  crab-bites. 

Prognosis. — (a)  In  uncomplicated  facial  erysipelas,  the  mortality  is 
3  per  cent,  in  private  practice,  and  double  that  figure  in  hospitals.  (6) 
In  erysipelas  migrans  the  outlook  is  less  favorable,  (c)  Erysipelas  neo- 
natorum is  fatal  within  a  week.  It  begins  on  the  navel,  and  less  often 
on  the  vulva  or  circumcision  wounds.  Vomiting,  diarrhea,  peritonitis, 
icterus,  pneumonia,  necrosis,  gangrene,  suppuration  and  sepsis  are  much 
more  common  than  in  adult  forms.  Fortunately,  like  puerperal  fever, 
this  form  is  now  infrequent,  {d)  Erysipelas  secondary  to  other  infections 
is  serious,  especially  in  chronic  maladies,  such  as  alcoholism,  diabetes, 
nephritis  and  tuberculosis,  and  also  in  bed-ridden  or  senile  subjects, 
in  whom  the  asthenic,  hemorrhagic  and  gangrenous  types  are  chiefly 
observed.  In  acute  diseases  such  as  typhoid,  diphtheria  and  pneumonia, 
erysipelas  is  dreaded,  (e)  Puerperal  forms  or  involvement  of  the  larynx 
are  unfavorable  (Hippocrates).  (/)  Recurrence  is  more  frequent  than 
in  any  other  infection,  and  no  permanent  immunity  is  conferred.  Re- 
lapses (10  per  cent.)  are  attacks  recurring  within  a  few  days.  Recurrence 
(35  per  cent.)  suggests  the  possibility  of  a  bacterial  latency  and  develops 
after  months  or  years;  in  some  individuals,  erysipelas  may  be  called 
habitual.  It  is  observed  most  frequently  in  the  young  and  in  women 
(75  per  cent.),  and  mostly  on  the  face.  Five  to  fifteen  attacks  are  not 
uncommon,  and  Roger  saw  forty  in  one  person. 

Treatment. — 1.  Prophylaxis. — In  this  bacteriological  era,  the  disease 
has  decreased  by  asepsis  and  isolation,  though  in  the  latter  regard 
many  physicians  are  still  remiss.  Chronic  rhinitis,  rhagades,  decayed 
teeth  and  neglected  ulcers,  must  be  considered  in  habitual  erysipelas. 
(See  Smallpox;  Disinfection.) 

2.  Mechanical  Means. — Mechanical  efforts  to  limit  extension  of 
the  disease  are  always  futile.  These  consist  of  binding  with  elastic 
strips,  elastic  constriction  or  massive  applications  of  collodion. 

3.  Local  Applications. — Iodine,  creolin,  bichloride  of  mercury,  mag- 
nesium sulphate  (saturated  solution),  phenol,  alcohol,  iodoform,  boric 
acid  and  other  topical  applications,  are  recommended,  but  the  water 
they  contain  is  their  most  potent  ingredient,  and  was  recommended 
by  Hippocrates.  No  application  can  reach  the  deeply  situated  cocci. 
Cold  compresses  afford  a  certain  relief  for  pain  and  tension.  Ichthyol 
ointment,  10  per  cent.,  is  soothing  but  not  curative. 

IJ — Creolin 1  part 

Iodoform]' 4  parts 

Adipis  lanae  hydrosi  (lanolin) 10  parts 

M.  et  f.  ung.     (Koch.) 


62  BACTERIAL  DISEASES 

4.  Drugs. — Erysipelas  is  a  self-limited  disease.  Iron  (Hamilton 
Bell,  1851)  is  well  tolerated  in  large  doses,  but  neither  shortens  nor  miti- 
gates the  disease. 

I^ — Tincturse  ferri  chloridi     .      .      .      .      .      . oiiss 

Quininse  sulphatis       ............      gr.  xxiv 

Spiritus  chloroformi 3ij 

Aquae q.  s.  ad.      gvj 

j\I.  et  f.  mist. 

S. — Two  tablespoonfuls  every  three  or  four  hours.     (J.  Burney  Yeo.) 

5.  General  Treatment. — The  symptoms  are  managed  expectantly, 
i.  e.,  as  they  arise.  Headache,  delirium,  pain,  vomiting  and  cardiac 
weakness  are  treated  as  in  typhoid.  Rest  in  bed  and  as  generous  nourish- 
ment as  the  stomach  will  tolerate  are  indicated. 

6.  Serum. — Chantemesse  reduced  the  death-rate  to  2.5  per  cent,  by 
serum  treatment  (a  figure  often  reached  by  more  simple  measures). 
Vaccines  have  not  proven  successful. 

Erysipelas  as  a  curative  agent  (erysipelas  salutare) :  Permanent  cure 
of  lupus  has  followed  a  complicating  erysipelas.  Syphilitic  manifesta- 
tions quickly  subside  after  this  infection,  and  its  beneficial  eft'ects  have 
been  observed  in  leukemia,  Hodgkin's  disease,  carcinoma,  sarcoma, 
chronic  arthritis,  tuberculous  adenitis,  diphtheria  and  tuberculosis. 

PNEUMONIA. 

Synonyms. — Fibrinous,  croupous  or  lobar  pneumonia,  pleuropneumonia, 
pneumonitis,  lung  fever. 

Definition. — An  acute,  specific,  self-limited  infection  caused  by  the 
pneumococcus,  characterized  by  fibrinous  inflammation  of  the  lung, 
toxemia,  pneumococcemia,  and  solution  of  the  fever  by  crisis. 

Frequency. — Pneumonia  constitutes  6.5  per  cent,  of  all  internal  diseases, 
4  per  cent,  of  all  diseases,  6.6  per  cent,  of  all  medical  deaths,  and  8  per 
cent,  of  all  deaths. 

Bacteriology. — 1.  The  pneumococcus  or  Diplococcus  pneumoniee  (Plate 
II)  was  recognized  by  Frankel  (1884),  and  \Yeichselbaum  (1886)  first 
demonstrated  its  frequency  and  importance.  It  is  a  lanceolate,  encap- 
sulated diplococcus;  it  is  easily  seen  in  cover  slips,  it  readily  stains  by 
the  Gram  method,  and  presents  many  cultural  variations.  Its  atrium 
in  pneumonia  is  the  respiratory  tract,  although  it  may  enter  the  blood 
by  other  avenues  in  sepsis  {q.  v.).  l^rom  the  lung  it  may  spread  diffusely, 
chiefly  through  the  bloodvessels.  It  is  found  in  dust,  saliva,  and  in  30 
per  cent,  of  healthy  noses  and  throats,  though  usually  with  attenuated 
virulence.  Experimental  inoculation  has  produced  pericarditis,  endo- 
carditis and  empyema.  In  lobar  pneumonia  or  apart  from  this  acute 
bacteriemia  the  pneumococcus  has  been  found  in  the  blood,  joints,  brain, 
bone-marrow,  etc.;  in  otitis  media,  endocarditis,  peritonitis,  cholangitis 
and  endometritis;  in  the  urine  and  feces;  in  the  nasal  sinuses;  and  it 
may  pass  from  the  mother  to  the  fetus.  It  may  be  a  terminal  septic 
infection.  Until  recently  it  was  thought  that  typhoid  and  pneumonia 
were  local  infections  and  that  bacteriemia  was  a  serious  complication; 


PLATE  II 


L.   SCHMIDT,    FEC. 


The  Diploeoecus  Pneumoniae,  Stained  ^A^ith  Methylene  Blue 
and  Fuehsin  as  a  Counterstain.  Taken  from,  the  Sputuni  of  a 
Case  of  Acute  Croupous  Pneumonia.     (Simon. j 


PNEUMONIA  63 

the  typhoid  bacilhis  is  found  in  the  blood  in  100  per  cent,  of  early  typhoids 
and  the  pneumococcus  in  from  90  to  100  per  cent,  of  pneumonics  (».  i.). 
It  is  assumed  that  a  pneumotoxm  exists  producing  the  toxemia;  when  an 
antitoxin  develops,  the  crisis  occurs,  but  the  factors  of  resistance  to, 
and  recovery  from,  pneumonia  are  not  known.  Immunity  does  not 
result  from  one  attack;  recurrence  is  likely  in  23  per  cent.;  ten,  even 
twenty-eight  recurrences  are  known.  The  pneumococcus  is  the  sole 
cause  of  typical  pneumonia,  but  other  microorganisms  are  sometimes 
found,  as  the  pneumobacillus  (Friedlander),  and  the  typhoid,  colon, 
diphtheria,  proteus,  influenza,  plague,  and  pyogenic  organisms. 

Indirect  Causes. — (a)  Age. — Pneumonia  may  develop  even  in  the  new- 
born. Predisposition  to  infection  is  great  up  to  the  sixth  year,  then 
much  less  until  the  fifteenth  year,  when  its  frequency  increases  with 
each  decade.  Over  half  the  cases  of  pneumonia  occur  between  the 
twentieth  and  fortieth  years,  and  over  80  per  cent,  between  the  tenth 
and  fiftieth  years. 

(6)  Sex. — Eighty  per  cent,  of  cases  are  males.  The  relation  to  trauma 
is  in  doubt. 

(c)  Cold. — ^Three-quarters  of  all  cases  of  pneumonia  occur  in  cold 
months  (February,  March  and  April)  when  the  weather  varies,  the  tem- 
perature is  low,  the  moisture  is  great  and  the  winds  are  high.  Dust 
disseminates  the  dried  sputum.  Pneumonia  is  half  again  as  frequent 
in  the  cities  as  in  the  country.  In  the  winter  of  1903-4,  when  4000 
died  of  pneumonia  in  Chicago,  practitioners  in  towns  not  one  hundred 
miles  distant  did  not  see  a  case. 

(d)  Individual  predisposition  is  a  more  important  factor  than  in  any 
other  infection.  Susceptibility  is  increased  by  debility,  overwork  and 
alcoholism. 

General  Clinical  Course. — After  a  short  incubation  of  some  hours  the 
disease  begins  suddenly.  In  infants  it  often  begins  with  convulsions — 
in  the  young  with  vomiting,  and  in  older  subjects  with  a  severe  chill, 
often  brusquely  in  persons  of  robust  health.  On  the  first  day  there  is  a 
sudden  rise  of  temperature;  the  face  becomes  red,  even  livid;  the  eyes 
are  injected;  the  pulse  and  respiration  are  accelerated;  the  patient  lies 
characteristically  flat  in  bed;  there  is  much  depression;  headache  and 
sudden  sharp  pain  in  the  side  develop,  accompanied  by  cough.  On  the 
second  day  the  cough,  pain,  respiration-rate  and  headache  increase; 
the  expiration  is  short  and  grunting,  with  dilatation  of  the  alse  nasi, 
and  speaking  is  difficult;  leukocytosis  develops.  The  bloody  sputum 
appears,  which  with  the  above  symptoms  establishes  the  diagnosis  before 
consolidation  appears.  On  the  second  or  third  day  there  are  evidences 
of  lung  consolidation,  such  as  tympany,  soon  followed  by  dulness,  the 
crepitant  rale,  and  bronchial  breathing;  there  is  an  increase  in  the 
pulse  and  respiration;  herpes,  anorexia,  coated  tongue,  constipation, 
moderate  delirium  and  febrile  urine  develop.  The  coughing  is  frequent 
but  short  in  duration,  voids  a  viscid  red  sputum,  and  causes  catching 
respiration,  pain  and  broken  sleep.  The  clinical  course  may  be  unfavor- 
ably modified  (a)  especially  by  collapse  due  to  myocardial  or  vosomotor 
paralysis,   or  to  pulmonary  embolism;  (6)    by  profound  toxemia;  (c) 


64 


BACTERIAL    DISEASES 


by  delirium  tremeii:^:  or  d  by  deatli,  though  at  this  ~ta,2:e  it  is  rare. 
In  favorable  cases,  when  the  toxemia  i-  spent,  the  crisis  occurs,  usually 
on  the  fifth,  seventli  or  ninth  day  with  gradual  disappearance  of  the 
local  findings.  A  ""  critical"  fall  of  temperature,  pulse-  and  respiration- 
rate,  sweating  and  relief  of  nervous  s\Tnptoms  result.  Lysis  is  less 
frequent.  Toxemia  is  the  dominant  feature  of  pneumonia,  and  the  con- 
solidation is  secondary.  The  degree  of  toxemia  has  no  constant  relation 
to  the  amount  of  consolidation,  just  as  the  toxemia  of  typhoid  does  not 
depend  on  the  presence  or  degree  of  the  intestinal  changes. 

Analysis  of  Individual  Symptoms. — 1.  Ox.-et. — In  over  7-5  per  cent. 
the  onset  of  pneiunonia  is  sudden.  Chill.  con^"ulsions,  vomiting  and 
ferer,  after  a  short  incubation,  usually  mark  the  brusque  onset.    Repeated 

chilly  sensations  do  not  as  accurately 
designate  the  onset  as  does  an  initial 
rigor.  In  no  other  acute  disease  except 
malaria  is  the  chill  so  severe  and  con- 
stant in  75  per  cent.  .  The  onsd  is 
rifiipirnj  \i\  senile  pneumonia  and  in 
pneumonia  secondary  to  other  diseases 
— e.  g..  delirium  tremens,  typhoid  and 
psychoses — the  chill,  cough,  dyspnea, 
pain  and  sputum  are  often  absent,  so 
that  the  exi-tence  of  pneumonia  may 
not  be  -u.-pected.  Prodromes  occur  in 
25  per  cent,  of  cases,  mostly  in  men 
between  thirty  and  forty  years,  and 
rarely  last. over  five  days;  depression, 
headache,  bronchitis,  backache  and  low 
fe^"er  may  be  noticed.  In  one  of  the 
author's  cases  a  pneumococcus  infection 
began  in  the  throat,  then  invaded  the 
larynx,  and  only  after  three  weeks  in- 
vaded the  lung.  In  four  cases,  low 
fe\'er  and  hemoptysis  for  several  days 
suggested  tuberctilosis . 

2.  Fever, — Its  usual  course  is,  first, 
a  mry  sudden  rise:  the  fever  is  then 
continuous,  often  with  not  more  than  1'  or  2'  \'ariation:  in  three- 
quarters  of  the  cases  the  maximum  fever  average-  lij2'  to  liJ5'.  It  may 
then  remit,  which  is  of  good  prognostic  import  and  then  at  the  end  of  a 
week's  illness  follows  the  crisi.-  v.  i.  .  liemittent  fever  throughout 
the  disease  occurs  in  some  cases.  liecrurle-cence-r  occur  when  consolida- 
tion pas-ses  from  one  lobe  to  another.  The  fe\'er  i-  lower  or  even  absent  in 
the  aged,  alcoholics,  and  in  secondary  pneumonia :  the  writer  saw  a  total 
pneumonia,  with  normal  rectal  temperature  in  a  man  aged  forty-eight. 
Fever  causes  a  loss  of  weight  of  even  twenty  to  thirty  pounds.  The  rise 
preceding  the  crisis  (perturhatio  critica)  may  be  rni-taken  for  an  ante- 
mortem  rise;  in  both  conditions  there  may  be  rlelirium.  chill  or  an 
alarmingly  irregular  pulse.     A  pseudocrisis  may  deceive  the  phy.-ician, 


Fig.  7. — Fever  curve  of  tj-pical  case 
of  pneumonia:  A,  sudden  rise;  B, 
pseudocrisis;    C,  crisis. 


PNEUMONIA 


65 


the  fever  resuming  its  original  elevation.  Crisis  occurs  in  80  per  cent, 
of  cases,  usually  on  uneven  days,  as  noted  by  Hippocrates — the  fifth 
seventh,  ninth  or  eleventh  day — usually  between  evening  and  early 
morning.  It  very  rarely  occurs  on  or  before  the  third  day.  It  marks 
the  end  of  the  toxemia  but  not  of  the  consolidation  which  lasts  several 
days  more.    In  six  to  ten  hours  the  temperature  falls  to  or  below  normal. 


Days 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

TEMP. 

105 

104 

103 

A 

1 

y 

H 

\ 

10-2 

Tl/Ji  M 

'    \A 

101       / 

I'A 

V 

V  » 

\A 

100 

V 

/ 

\ 

Al 

\ 

99 

f 

^ 

7\| 

\ 

;       1       1       i 

V 

!                                            1 

Fig.  8. — Pneiiinonia;   remittent  (subcontinuous)  fever. 

accompanied  by  sleep,  euphoria,  lessened  pulse  and  respiration,  lateritious 
deposits,  reappearance  of  the  chlorides  in  the  more  abundant,  limpid 
ui^ne,  and  ''critical"  sweating  or  even  diarrhea.  The  fall  may  measure 
even  10°  or  11°  and  the  pulse  may  reach  30.  Lysis  occurs  in  20  per  cent, 
of  cases.  It  is  likely  to  occur  when  the  fever  lasts  more  than  ten  days, 
but  lingering  fever  may  indicate  progression  in  other  lobes  or  compli- 
cations, as  empyema  or  endocarditis. 

3.  Respiratory  Fixdixgs. — (1)  Pain  in  the  side  is  generally  pleural 
and  its  presence  in  90  per  cent,  of  cases  gives  it  a  diagnostic  value;  this 


Uajsl-.iS    X|2i3i-tlj|C     7      8|9  j  10 1 11 1 12  i  l:i  1 14  llo  |1G  117  I  IS  1 19  20  21122  23  j24  h-ia  I'^G  ^27  I'^S  29130 


Fig.  9. — Pneumonia  fever  curve;    exceptionally  protracted  though  uncomplicated  fever. 


most  frequent  respiratory  symptom  appears  early,  is  increased  by  cough- 
ing or  motion,  and  is  sharp  or  even  agonizing.  It  is  usually  localized 
over  the  consolidated  focus,  but  in  8  per  cent,  is  referred  along  the  lower 
intercostal  nerves  to  the  abdomen,  in  children  especially,  and  sometimes 
in  adults.  Appendicitis  or  cholecystitis  may  be  thus  simulated.  Some- 
times the  pain  is  radiated  to  the  opposite  side  of  the  chest.     Pain  is 


66 


BACTERIAL  DISEASES 


absent  in  central,  secondary  and  upper-lobe  pneumonias;  often  in  the 
aged  and  in  children;  and  in  cases  with  great  delirium. 

(2)  Dyspnea  is  frequent;  it  is  caused  especially  by  toxemia,  but  also 
by  pain,  cardiac  weakness  and  bronchitis. 

(3)  The  Respiration-rate. — ^Because  of  cerebral  toxemia,  or  pleuritic 
pain,  the  respiration-rate  is  increased  to  24  or  40  (or  more  in  children); 
and  in  two-thirds  of  all  cases,  it  ranges  between  30  and  50;  it  almost 
never  rises  to  60  or  80  except  in  the  death  agony.  The  author  saw  a 
rate  of  96  with  recovery;  the  pulse  was  90.  Dilatation  of  the  nares  is 
said  to  be  ominous,  but  to  the  author  seems  common  in  ordinary  cases. 
Alteration  of  the  pulse  and  respiration  ratio  was  first  noted  by  von  Jiirgen- 
sen;  the  normal  ratio  of  1  to  4  becomes   1   to  3  or  2.     In  a  personal 

observation  with  the  entire  right 
lung  consolidated,  the  respiration- 
rate  was  18. 

(4)  The  Cough. — The  cough  always 
irritates,  and  seldom  relieves  the 
patient.  It  is  present  from  the 
onset  to  the  crisis,  is  due  to  the 
bronchitis  and  almost  invariably 
occurs  in  lower-lobe  pneumonia;  it 
is  often  absent  in  upper-lobe,  term- 
inal or  secondary  pneumonia,  in  very 
delirious  subjects,  in  the  aged  and 
young. 

(5)  The  Sputum. — The  sputum, 
at  first  transparent,  mucous  aad 
scanty,  soon  becomes  viscid,  and 
difficult  to  raise  and  to  expectorate, 
as  it  adheres  to  the  mouth  and  lips. 
It  is  so  viscid  that  the  sputum-cup 
may  be  inverted  mthout  spilling  the 
sputum.  In  two  days  it  becomes 
red  and  rusty  (80  per  cent,  of  cases). 
Later  it  becomes  more  abundant. 
Increased  fluidity  may  rarely  result 
from  weak  heart.      Rusty    sputum 

is  often  absent  in  children  who  swallow  sputum;  in  upper-lobe  pneu- 
monia, in  which  there  is  less  hemorrhage,  less  consolidation  and  less 
cough  to  dislodge  exudation;  and  finally  in  the  senile  and  secondary 
pneumonias,  because  of  weakness  or  toxemia.  The  cause  of  unusual 
color  in  the  sputum,  such  as  lemon-  or  brick-color,  is  unkno"\^Ti;  it  is 
sometimes  observed  in  pulmonary  edema  or  incipient  gangrene  and 
obscures  the  prognosis.  Safranin  color  (sputum  croceum)  indicates 
resolution.  The  rusty  sputum  is  of  great  diagnostic  value — e.  g., 
in  the  beginning  of  the  disease  or  in  central  pneumonia — and  gener- 
ally is  of  good  import.  Fibrin  threads  or  "casts"  of  the  bronchioles  are 
usually  seen  between  the  third  and  seventh  days.  On  shaking  the 
sputum  in  water  and  catching  the  shreds  on  a  slide,  they  appear  clubbed 


Fig.  10. — Fibrinous  coagulum  from  a  case 
of  croupous  pneumonia  (Bizzozero). 


PNEUMONIA  67 

at  their  alveolar  ends;  they  are  also  found  in  tuberculosis  and  fibrinous 
bronchitis.  They  consist  of  fibrin,  white  cells,  fatty  cells  and  epithelium. 
The  sputum  contains  blood  cells,  epithelia  and  pneumococci,  found 
first  by  Wolff  in  sputum  and  by  Weichselbaum  in  the  lung. 

(6)  Lntig  Pathology. — Laennec,  the  first  to  differentiate  pneumonia 
from  pleurisy  (1819),  described  three  stages:  (a)  The  stage  of  hyper- 
emia is  very  exceptionally  observed  unless  the  subject  dies  in  twenty- 
four  to  thirty-six  hours,  although  hyperemia  may  be  seen  at  the 
edges  of  the  consolidation  where  the  pneumonia  is  beginning  to 
extend.  The  lung  crepitates  less  and  floats;  it  is  red,  tears  readily, 
since  it  has  lost  its  elasticity,  and  on  section  exudes  a  serosanguineous 
fluid.  Under  the  microscope,  congestion,  serum  and  diplococci  in  the 
alveoli  are  observed.  The  alveolar  epithelial  cells  swell  and  desquamate, 
which,  according  to  some  observers,  are  the  primary  changes,  (h)  In 
the  stage  of  red  hepatization,  the  lung  is  evenly  red,  friable,  airless  (not 
wholly  so  in  penumonia  of  an  upper  lobe),  and  sinks  when  put  into  water. 
Its  weight  is  increased  ten  to  fifty  ounces.  The  lung  has  marks  of  the 
ribs  on  its  fibrin-coated  surface  and  is  enlarged  to  the  size  of  deepest 
inspiration  (Rokitansky,  who  developed  the  gross  anatomy  of  pneumonia). 
On  scraping  the  cut  surface,  fibrinous  plugs  or  casts  of  the  bronchioles 
are  observed.  The  lung  is  granular  on  section  (Laennec),  from  fibrinous 
exudation  into  the  alveoli;  these  granulations  are  seen  best  by  oblique 
illumination.  Under  the  microscope,  coagulated  blood  and  exudate, 
alveolar  epithelium,  injected  bloodvessels,  emigration  of  leukocytes, 
diplococci  and  meshes  of  fibrin  are  noted,  (c)  In  the  stage  of  gray  hepaii- 
zatio7i,  the  granulations  are  grayish-j^ellow — not  red,  because  the  blood 
is  absorbed;  they  are  larger  and  looser  than  in  the  second  stage.  The 
connective  tissue  is  grayer  than  the  granulations,  and  is  sharply  defined 
by  the  lung  pigment.  It  has  been  claimed  that  death  always  occurs 
if  this  stage  is  reached.  If  the  patient  lives,  the  granulations  disappear; 
the  lung  exudate  becomes  semifluid  (purulent  infiltration)  and  can  be 
washed  out;  resorption  of  this  fatty  emulsion  occurs  by  the  lymphatic 
vessels  and  not  by  evacuation  through  the  sputum.  Proteolytic  ferments, 
probably  derived  from  the  leukocytes,  dissolve  the  exudate;  the  products 
of  this  autolysis  are  excreted  by  the  kidneys. 

Seat  of  Pneumonia. — The  process  begins  at  the  hilum  and  extends  to 
the  pleura,  as  proved  by  the  ar-rays.  If  it  remains  at  the  hilum  it  is  central 
pneumonia  (1.7  per  cent.);  if  the  entire  lung  is  involved,  it  is  pneumonia 
totalis  or,  if  the  bronchi  are  plugged,  massiva;  the  terms  "double  pneu- 
monia" and  "crossed  pneumonia"  are  self-explanatory.  The  lobes  are 
involved  in  the  following  order  of  frequency:  (a)  Right  lower  lobe;  ib) 
left  lower;  (c)  right  middle;  {d)  right  upper;  {e)  left  upper  lobe.  Jiir- 
gensen's  15,614  cases  of  pneumonia  show  that  the  right  lung  is  afi^ected 
in  53  per  cent.,  the  left  in  37,  and  both  lungs  in  10  per  cent.  The  upper 
lobes  are  involved  in  16  per  cent,  and  the  lower  in  84  per  cent. 

(7)  Physical  Signs. — The  physical  signs  develop  in  the  lungs,  at  the 
earliest,  only  after  twelve  to  twenty-four  hours. 

(a)  Inspection. — The  decubitus  is  often  dorsal  in  lower-lobe,  and  erect 
in  upper-lobe  pneumonia;  the  patient  at  first  lies  on  the  sound  side  to 


68  BACTERIAL  DISEASES 

avoid  pain;  on  the  diseased  side  later,  for  better  expansion  of  the  sound 
lung.  The  spinal  column  is  concave  toward  the  diseased  lung  for  its 
better  immobilization.  The  excursion  is  less  on  the  diseased  side  because 
of  pleuritic  pain.  Litten's  sign  is  absent  and  the  sound  lung  is  vicariously 
active.  The  diseased  side  is  larger,  by  one  inch  or  so.  The  accessory 
muscles  of  respiration  are  active  and  dilatation  of  the  nares  is  seen. 
Systolic  pulsation  of  the  lung  occurs  when  the  lingual  lobe  is  consolidated, 
or,  in  the  first  stage,  when  the  heart  beats  against  semifluid  exudation. 

(b)  Palpation. — Lessened  excursion  is  detected  more  readily  than  by 
inspection;  vocal  fremitus  is  usually  increased  because  of  better  sound 
propagation,  fremitus  being  normally  greater  on  the  right  side.  It  is 
decreased  by  (i)  bronchial  occlusion  by  fibrinous  plugs,  usually  dislodged, 
however,  by  having  the  patient  cough;  (ii)  coincident  pleural  effusion; 
and  (iii)  great  consolidation  rendering  the  chest  wall  tense.  Pleural 
friction  may  be  felt. 

(c)  Percussion. — (i)  A  tympanitic  note  (Skoda's  resonance)  is  obtained 
in  the  first  stage,  caused  by  decreased  elasticity  of  the  lung  and  therefore 
decreased  amplitude  of  vibration,  due  to  the  swelling  of  the  alveolar 
epithelium  and  turgescent  capillaries.  This  condition  lasts  one  or  two 
days,  and  may  cause  doubt  as  to  the  side  involved.  Tympany  may 
denote  new  pneumonic  extension  (relaxation  of  the  lung  tissue  contiguous 
to  areas  already  consolidated).  Tympany  in  the  later  stages  is  not 
uncommon  in  upper-lobe  pneumonia  where  exudation  is  usually  incomplete 
or  in  moderate  compression,  e.  g.,  of  a  right  upper  lobe  when  the  right 
middle  and  lower  are  consolidated.  It  is  rare  in  lower-lobe  pneumonias. 
Tympany  may  persist  days  after  the  crisis,  (ii)  Dulness  usually  develops 
on  the  second  day  and  is  the  percussion  sign  of  the  second  stage.  When 
complete  it  corresponds  to  the  lobe  confines.  The  dulness  is  not 
absolute.  It  is  usually  first  detected  in  the  posterior  axillary  line  in 
lower-lobe  pneumonia,  and  generally  is  more  complete  behind  than  in 
front,  and  more  in  lower-  than  in  upper-lobe  involvement.  Dulness 
is  difficult  to  detect  if  the  area  is  not  at  least  1  by  2  inches,  or  if  it  is 
deeper  than  2  inches  from  the  surface.  It  is  absent  in  central  pneumonia. 
With  resolution  it  is  replaced  by  tympany. 

(d)  Auscultation. —  Decreased  breathing,  or  sudden  local  puerile  breath- 
ing is  often  noticed  at  first. 

First  Stage. — The  crepitant  rale  of  Laennec  remains  the  auscultatory 
sign  of  the  first  stage;  but,  as  he  stated,  it  is  not  specific,  because  it  also 
occurs  in  tuberculosis,  lung  edema,  infarct,  hypostasis  and  bronchiolitis. 
It  originates  in  the  viscid  exudate  in  the  finest  tubules  and  alveoli. 
It  is  coarser  in  the  aged  and  in  children  because  the  large  tubes  are 
more  involved.  It  is  heard  at  the  height  of  inspiration  as  a  succession 
or  shower  of  delicate  crackles;  when  not  heard,  a  coughing  effort  may 
elicit  it;  it  often  disappears  after  a  number  of  deep  inspirations,  e.  g., 
when  demonstrated  to  a  class,  only  the  first  students  hear  it.  The  crepi- 
tant rale  disappears  during  the  second,  and  reappears  in  the  third 
stage. 

Second  Stage. — The  intense  bronchial  breathing  is  due  to  increased 
transmission  of  the  breath  sounds  through  the  solidified  lung.    It  sounds 


PNEUMONIA  69 

as  though  nothing  intervened  between  the  hmg  and  the  stethoscope 
and  is  especially  near  when  the  ear  is  applied  directly  to  the  chest.  It 
is  absent  or  partial,  especially  anteriorly,  in  central  pneumonia,  coincident 
pleurisy,  and  obstruction  of  the  bronchi  by  fibrinous  casts.  In  the  latter 
case,  several  coughs  usually  loosen  the  obstruction  and  restore  the 
bronchial  breathing.  Bronchophony,  also  explained  by  increased  con- 
duction, is  heard  when  the  patient  counts  or  speaks,  but  especially  after 
each  involuntary  expiratory  grunt.  Egoyhony  is  occasionally  heard, 
as  well  as  Baccelli's  phenomenon  (auscultatory  whispering).  The 
crepitant  rale  disappears  in  this  stage,  except  at  the  edges  of  the  hepati- 
zation where  extension  occurs. 
^      Third  Stage. — The  crepitant  rale  reappears — the  rale  redux. 

4.  Circulation. — (a)  The  pulse-rate  is  usually  100  to  120,  or  higljer 
in  children,  the  aged,  and  severe  toxemia.  In  adults,  a  rate  of  130  to 
140  or  a  slow  pulse,  indicating  grave  heart  or  brain  complications,  irreg- 
ularity and  gallop-rhythm  make  the  prognosis  less  favorable.  Ante- 
critical  irregularity  frequently  occurs.  The  pulse  is  deceptive  and  its 
fulness  is  of  no  value  in  prognosis.  Extensive  pneumonias  may  compress 
one  subclavian  artery,  making  the  corresponding  radial  smaller,  (b) 
In  the  right  heart,  dilatation  from  toxemia  frequently  occurs;  the  second 
pulmonic  tone  is  accentuated  unless  the  right  ventricle  becomes  greatly 
weakened.  There  may  be  functional  bruits.  In  very  rapid  cardiac  action, 
the  two  heart  tones  sound  alike,  resembling  the  fetal  tones  (embryocardia) . 
(c)  Collapse,  usually  due  to  myocardial  or  to  central  vasomotor  paralysis, 
may  occur  at  any  stage,  {d)  The  blood  shows  anemia.  The  fibrin  increase 
is  readily  noted  in  fresh  blood  preparations.  A  polymorphonuclear 
leukocytosis  appears  early,  and  slightly  survives  the  fever.  The  leuko- 
cytosis ran  between  15,000  and  30,000  in  75  per  cent,  of  Cabot's  counts; 
it  may  reach  100,000.  The  eosinophiles  are  decreased  or  absent  until 
the  acme  whence  the  favorable  significance  of  their  reappearance.  The 
lymphocytes  are  decreased.  During  convalescence  many  myelocytes 
appear.  The  white  count  remains  high  in  delayed  resolution  or  complica- 
tions. A  low  count  generally  is  unfavorable.  Pneumococcemia,  until 
recently  considered  of  bad  import,  is  of  no  prognostic  value,  since  it  occurs 
in  90  to  100  per  cent,  of  cases,  perhaps  even  before  hepatization.  The 
agglutinative  power  of  the  serum  increases  until  the  crisis  occurs. 

5.  Digestive  System.— There  is  the  febrile  thirst  and  anorexia. 
Vomiting  occurs  in  25  per  cent,  of  cases,  from  toxemia  or  coughing. 
The  distressing  tympanites  occurs  in  the  severer  cases — and  invariably 
in  alcoholic  subjects — from  toxemic  paresis  of  the  intestinal  muscularis. 
The  occasional  diarrhea  is  toxemic;  constipation  is  the  rule.  There  is 
often  intumescence  of  the  liver  and  spleen  (in  15  per  cent,  of  all 
cases). 

6.  Skin. — The  red  cheek  on  the  affected  side  was  known  to  Aretseus. 
The  skin  is  usually  dry,  but  miliaria  and  sweating  may  be  seen.  Herpes 
is  found  more  often  than  in  any  other  disease  (40  per  cent.),  from  the 
third  to  fifth  day,  chiefly  on  the  face;  Howard  found  causal  changes 
in  the  Gasserian  ganglion;  herpes  may  develop  on  the  body,  limbs, 
genitalia,  etc.     It  is  of  diagnostic  and  generally  of  favorable  import. 

■% 


70  BACTERIAL  DISEASES 

Rarer  eruptions  are  erythema,  roseolfe  and  purpura.    The  lymph  glands 
are  enlarged  in  25  per  cent,  of  cases. 

7.  Urine. — Characteristic  fever  urine  is  found,  and  the  urea  is  increased 
threefold  after  the  crisis  from  overproduction  and  accumulation  during 
the  fever;  from  the  resolving  exudate,  uric  acid  and  xanthin  result. 
The  chlorides  are  decreased  (from  225  grains  daily  to  30  grains)  or 
absent  until  the  crisis,  when  they  reappear  in  increased  quantities  (Rotten- 
bacher);  no  satisfactory  explanation  for  the  chloride  retention  is  kno^Aii; 
The  urine  often  becomes  neutral  or  alkaline  two  days  after  the  crisis. 
Albuminuria  and  cylindruria  appear  in  50  per  cent,  of  cases;  peptonuria 
and  acetonuria  are  not  uncommon;  and  the  diazo  reaction  appears  in 
20  per  cent.,  hematuria  in  1.6  per  cent.,  nephritis  in  1  per  cent.,  and 
uremia  very  uncommonly. 

8.  Nervous  System. — Headache  is  constant.  There  may  be  insomnia, 
restlessness,  or  stupor  which  is  always  ominous.  Delirium  (22  per  cent.) 
occurs  with  upper-lobe  pneumonia,  alcoholism  or  marked  toxemia; 
nervous  symptoms  resulting  from  exhaustion  may  occur  even  a  week 
after  the  crisis  (2.5  per  cent.).  The  patellar  reflexes  are  often  absent  and 
the  pupils  may  be  dilated  or  sluggish.  Convulsions,  coma  and  rigid 
neck,  in  children,  result  from  toxemia,  brain  edema  or  meningitis. 
Hemiplegia  may  result  from  brain  edema  or  anemia,  or  arteriosclerosis 
plus  a  weakened  heart. 

Mechanism  of  Death  in  Pneumonia. — Death  is  rare  in  the  first  three 
days,  except  from  some  antecedent  malady,  as  nephritis.  (1)  Toxemia 
is  all-important  in  its  action  on  the  heart,  brain  and  vasomotor  nerves. 
Death  ensues  with  rapid  pulse  and  respiration,  algid  extremities  and  ob- 
tunded  sensorium.  (2)  Pulmonary  edema  is  cardiac,  or  inflammatory, 
from  an  extending  pneumonia.  (3)  The  extent  of  pneumonia  is  the  least 
important  factor.  A  massive  pneumonia  in  a  robust  person  causes  less 
disturbance  than  a  small  patch  in  a  nephritic.  There  is  no  parallelism 
between  the  area  hepatized  and  the  resulting  toxemia.  (4)  Pneumococci 
in  other  tissues  cause  pneumococcic  meningitis,  endocarditis,  etc. 

Complications. — -These  are  few  but  severe. 

1.  Pleurisy.— Dry  pleurisy  is  so  constant  as  to  justify  the  name  of 
pleuropneumonia,  the  pleura  being  covered  with  a  thick,  tenacious, 
exudate,  usually  pneumococcic;  if  due  to  the  streptococcus,  it  is  a 
complication  of  great  danger.  Frankel  saw  serofibrinous  pleurisy  in  but 
1  per  cent,  of  1000  cases,  yet  Maragliano  aspirated  some  fluid  in  66  per 
cent,  of  his  pneumonic  patients.  The  ^^Titer  has  seen  three  cases  of 
pneumonia  on  one  side  and  pleurisy  on  the  other.  Pneumococcic  empyema 
occurs  in  2  per  cent,  of  pneumonias  and  is  notable  since  the  pneumococcus 
seldom  provokes  suppuration  in  the  lung  {v.  Pleurisy).  Recovery  is 
possible  even  without  operation.  Interlobar  empyema  is  most  serious, 
because  it  so  often  escapes  detection. 

2.  Endocarditis. — Acute  endocarditis  complicates  pneumonia  in 
1  per  cent,  of  all  cases  and  5  per  cent,  of  fatal  cases.  Endocarditis  is 
malignant  in  80  per  cent,  of  cases;  25  per  cent,  of  all  ulcerative  endo- 
carditides  are  pneumococcic.  The  pneumococcus  is  found  in  the  vegeta- 
tions.    The  valvular  exudate  is  voluminous,  though  ulceration,  valvular 


PNEUMONIA  71 

aneurysm  and  perforation  are  less  common  than  in  staphylo-  and  strepto- 
coccic forms.  Endocarditis  develops  especially  on  old  valvular  lesions 
in  the  left  heart,  most  frequently  on  the  aortic  valves.  The  right  heart 
is  involved  three  or  four  times  as  frequently  as  in  endocarditis  due  to 
other  bacteria.  Sixty  per  cent,  of  cases  are  associated  with  meningitis. 
Middle-aged  adults  are  most  often  affected.  Endocarditis  is  probable 
when  a  murmur,  systolic  or  particularly  diastolic,  occurs  with  irregular 
protracted  fever,  chills,  sweats,  positive  blood  cultures  and  embolism 
(50  per  cent.).  Symptoms  may  directly  follow  the  pneumonia  or  develop 
after  one-half  to  one  week  of  normal  temperature.  Fever  is  sometimes, 
and  leukocytosis  frequently,  absent.  Symptoms  may  be  absent  (v.  Septic 
Infections  and  Ulcerative  Endocarditis). 

3.  Pericarditis. — Its  frequency  is  1  per  cent.,  and  the  pericardial 
rub  is  absent  in  60  per  cent,  of  cases.  Dry  pericarditis  occurs  more 
often  in  children,  at  the  height  of  the  disease  and  when  the  left  lung  is 
involved.  Effusive  pericarditis  is  less  common  than  the  fibrinous 
form. 

4.  Arteritis  and  Phlebitis  are  less  frequent  than  in  typhoid.  Steiner 
collected  forty-eight  cases  of  venous  thrombosis.  (1903);  it  develops 
in  convalescence  and  heals  usually  (75  per  cent.),  though  embolism 
or  permanent  venous  obstruction  may  develop. 

5.  Nervous  Complications. —  Delirium  tremens  may  develop  in  an 
alcoholic  from  the  shock  of  the  pneumonia  onset;  or,  during  the  course 
of  delirium  tremens,  pneumonia  may  develop  insidiously  and  is  easily 
overlooked  and  remarkably  fatal  («.  Prognosis).  Meningitis  occurs  in 
5  per  cent,  of  autopsies,  and  in  0.3  per  cent,  of  clinical  cases,  in  asthenic 
patients,  in  upper-lobe  pneumonia,  and  often  accompanies  endocarditis. 
One  of  the  author's  cases  died  a  week  after  apparent  convalescence,  and 
the  autopsy  showed  a  quarter  inch  of  pus  over  the  convexity.  The 
usual  meningitic  symptoms  develop  if  infection  reaches  the  base  of  the 
brain,  but  this  is  not  usual  (see  Meningitis).  The  mortality  is  93  per 
cent.;  the  author  has  seen  recoveries. 

6.  Alimentary  Complications. — Parotitis  and  peritonitis  occur,  each 
0.3  per  cent.  Dieulafoy  described  an  ulcerative  gastritis  caused  by 
pneumococcic  embolism  and  attended  by  gastrorrhagia.  Fussell  col- 
lected 12  cases  of  acute  dilatation  of  the  stomach.  Icterus  averages  1  per 
cent. ;  its  causes  are  hepatic  stasis,  duodenal  catarrh,  and  hematogenous 
jaundice  from  toxemic  hemolysis.    (See  Pneumococcic   Peritonitis.) 

7.  Lung  Complications. — Suppurative  mediastinitis  was  regarded 
as  the  connecting  link  between  pneumonia,  meningitis  and  pericarditis. 
Pulmonary  induration  may  follow  incomplete  resolution.  Abscess 
develops  in  5  per  cent. ;  pus  and  elastic  fibers  in  the  sputum,  less  frequently 
cholesterin  and  hematoidin  crystals  may  be  the  sole  signs,  and  continual 
coughing  the  chief  symptom.  Gangrene  occurs  in  1  to  2  per  cent,  of  the 
cases.    Clinically  it  is  recognized  by  the  horribly  fetid  sputum. 

8.  Arthritis. — Hematogenous  pneumococcic  arthritis  may  be  serous 
or  purulent;  its  incidence  is  0.5  per  cent,  and  its  mortality  28  per  cent. 
In  62  per  cent,  it  is  monarticular,  and  the  knee  is  involved  in  30  per 
cent.;  158  cases  are  reported. 


r2  BACTERIAL  DISEASES 

Clinical  Types  and  Variations.- — These  are  as  follows: 

1.  Abortive  PNEr:MOXiA  is  recognized  by  the  sputum,  fever  and 
respiratory  disturbance,  but  produces  no  hepatization. 

2.  Ephemeral  Pkel^monia  is  characterized  by  one  day  of  fever,  and 
very  rapid  resolution.  The  onset  is  brusque  and  severe  but  the  symptoms 
speedily  abate. 

.3.  Relapsixg  Type. — After  the  crisis,  the  entire  cycle  recurs  (in  0.3 
per  cent.).    Recurrent  type  (v.  s.). 

4.  Local  Vaelations. — ^Apex  pneumonia  is  often  more  severe,  atypical, 
adjTiamic  and  complicated.  ^Migratory  pneumonia  travels  from  one 
part  to  another  (so-called  erysipelas-pneumonia).  Central,  total  and 
massive  pneumonia  (v.  page  67). 

5.  In  Children.- — ^An  abrupt  onset  occurs  without  chill  before  the 
seventh  year,  but  with  vomiting  (50  per  cent.),  convulsions  (7  per  cent.), 
and  other  cerebral  symptoms.  Cough  is  often  absent,  no  sputum  appears, 
and  the  pain  is  referred  to  the  abdomen  (third  to  fifth  year).  Pain  is 
more  important  than  increased  respiration,  which  occurs  in  any  fever;  the 
respirations  may  number  eighty  under  two  years  of  age;  in  older  children, 
fifty.  Crepitant  rales  are  usually  absent  because  of  the  superficial 
breathing  caused  by  pain.  Latency  of  physical  signs,  such  as  absence  of 
bronchial  breathing,  bronchophony  or  dulness  is  sometimes  noted. 
Localization  is  more  often  central,  apical  or  migratory.  Lysis  is  more 
frequent  than  in  adults. 

6.  In  TkE  Aged. — Pneumonia  is  frequently  latent,  insidious  and 
asthenic,  with  ill-marked  signs,  without  chill,  even  T^ithout  fever,  and 
often  without  cough,  pain  or  sputum.  It  is  remarkable  that  so  severe  an 
infection  can  exist  with  so  few  of  its  usual  symptoms.  In  this  type, 
pneumonia  is  declared  by  the  physical  findings  only. 

7.  In  Alcoholics. — (See  page  71). 

8.  Asthenic  Pnel^ionia. — In  asthenic  or  "typhoid"  pneumonia, 
toxemia  is  dominant,  with  high  fever,  enlarged  spleen,  albuminuria, 
icterus,  severe  complications  and  high  mortality.  In  contrast  to  these 
cases,  the  author  had  two  patients  who  worked  throughout  the  disease. 

9.  Secondary  Pneumonia. — Pneumonia  may  be  secondary  to  emphy- 
sema, arteriosclerosis,  hepatic  cirrhosis,  nephritis,  diabetes,  tuberculosis, 
typhoid  or  other  conditions.  The  frequency  of  ether  pneumonia  in 
abdominal  operations  suggests  the  possibility  of  embolism  as  a  factor; 
ether  predisposes  to  pneumonia  by  irritation  of  the  respiratory  tract. 
The  nose  and  mouth  should  be  cleansed  before  anesthetization  to  remove 
native  germs. 

This  type  is  atypical,  ill  developed,  or  masked  by  the  primary  disease ; 
the  hepatization  is  rarely  typical  and  is  more  lobular  than  lobar;  the  lung 
section  is  smooth  and  moist,  and  the  exudation  is  more  cellular  than 
fibrinous. 

10.  Delayed  Resolution. — Resolution  is  effected  by  lymphatic 
absorption,  (a)  Resolution  may  require  weeks  or  even  months,  especially 
in  apical  involvement,  and  more  often  after  a  lysis  than  crisis ;  the  toxemia 
disappears  but  dulness  and  bronchial  breathing  persist,  (b)  Imperfect 
resolution  may  be  caused  by  abscess  formation,  or  inflammatory  involve- 


PXEUMOXIA  73 

ment  of  the  connective  tissue  and  lymphatic  vessels.  Induration  of 
the  lung  by  organization  of  the  exudate  is  usually  febrile. 

Diagnosis. — ■Mistakes  are  rare  in  the  diagnosis  of  frank  pneumonia 
in  adults — they  occur  mostly  in  aged  individuals,  alcoholics,  children 
and  secondary  pneumonia.  All  subjects  with  chronic  disease  must  be 
closely  examined  when  the  respiration,  pulse  and  temperature  rise,  or 
when  the  subject  is  not  doing  well. 

1.  OxsET  Symptoms. — ^The  chill  in  adults,  or  convulsions  and  vomiting 
in  children,  suggest  the  possibility  of  pneumonia.  Chill,  pain  in  the 
side,  sudden  high  fever  and  rusty  sputum,  are  almost  final,  because 
practically  the  only  other  disease  in  which  they  occur  is  infarct  of  the 
lung — in  which  the  sputum  is  reddish,  not  viscid,  usually  darker,  and 
more  abundant.  In  25  per  cent,  of  cases  the  onset  of  pneumonia  is 
not  brusque  and  the  physical  findings  of  pneumonia  are  present  without 
a  typical  history;  indeed  it  may  rather  be  suggestive  of  simple  pleurisy, 
etc.    Pneumococcemia  without  lung  involvement  mav  simulate  influenza 

(^^  ^")- 
The  occasional  reference  of  the  initial  pain  to  the  abdomen  may 

simulate  appendicitis.  As  a  rule  the  abdominal  pain  exists  without 
tenderness  or  with  superficial  tenderness  only.  Consideration  of  the 
toxemia  and  respiration-rate  generally  prevents  errors  in  diagnosis; 
collapse,  intense  abdominal  tenderness  and  rigidity  may  simulate  per- 
foration. 

2.  Physical  Findings  in  the  typical  case  appear  within  two  days  after 
the  onset:  lessened  expansion,  increased  vocal  fremitus,  dulness,  bronchial 
breathing,  the  crepitant  rale,  the  grunting,  short  expiratory  "huh," 
and  a  bronchial  tone  to  the  whispered  or  louder  voice  sounds.  These 
findings  are  modified  by  many  conditions;  thus  the  fremitus  is  decreased 
in  massive  consolidations,  in  coincident  pleural  effusions  or  in  fibrinous 
plugging  of  the  bronchi;  usually  the  plugs  are  dislodged  by  repeated 
coughing.  The  dulness  is  preceded  and  followed  by  a  tympanitic  note. 
The  crepitant  rale  is  found  only  in  the  first  and  third  stages,  but  in 
almost  every  case  can  be  found  in  some  part  of  the  aft'ected  lung. 
Bronchial  breathing  is  rudimentary  or  absent  in  incomplete  hepatization, 
is  often  so  in  upper-lobe  pneumonias,  in  complicating  effusive  pleurisy, 
and  in  obstructed  bronchi.  The  physical  signs  are  pathognomonic  only 
in  connection  with  the  cyclic  course,  disturbed  pulse  and  respiration 
ratio,  pneumococcemia,  herpes  and  leukocytosis. 

3.  Localization. — ^Massive  pneumonia  not  infrequently  simulates 
pleurisy,  because  fibrinous  plugging  of  the  bronchi  abolishes  bronchial 
breathing,  bronchophony,  the  crepitant  rale  and  vocal  fremitus;  there 
may  be  slight  luxation  of  neighboring  viscera.  Consideration  of  the 
onset,  cyclic  course  and  the  dislodging  of  the  plugs  by  forcible  coughing 
almost  invariably  determines  the  diagnosis.  Conservatism  is  necessary 
in  the  diagnosis  of  central  pneumonia;  all  pneumonias  are  central  in 
their  incipiency;  in  two  personal  cases  the  local  findings  did  not  appear 
for  a  week. 

4.  In  Children. — Pneumonia  may  be  mistaken  for  abdominal  disease 
or  pleurisy.     "Cerebral  pneumonia"  may  be  (a)  convulsive,  occurring 


74  BACTERIAL  DISEASES 

under  two  years,  with  fever  and  vomiting,  but  the  evenly  high  fever  is 
suggestive  even  if  the  cough  and  dyspnea  are  obscured  by  the  brain 
symptoms;  or  (6)  meningeal,  occurring  between  the  second  and  sixth 
years ;  but  the  pulse  is  not  slow,  and  there  is  no  other  sign  of  meningitis. 
5.  Differentiation. — Differentiation  from  pleurisy  is  usually  easy 
(v.  i.).  In  lung  tumors,  bronchial  breathing,  bronchophony,  dulness, 
red  or  green  sputum,  are  also  noted,  but  the  history  and  course  differen- 
tiate. The  course  differentiates  acute  tuberculous  infiltration  from  an 
upper-lobe  pneumonia  in  which  cough,  sputum  and  typical  physical 
findings  are  absent.  Mistakes  in  both  directions  are  made,  by  forgetting 
that  in  apical  pneumonia  the  incomplete  exudation  may  impart  a  tym- 
panitic note,  and  that  the  breath  sounds  are  not  always  bronchial,  at 
least  anteriorly.  Some  tuberculous  pneumonias  may  commence  like 
lobar  pneumonia  (see  Course  of  Pulmonary  Tuberculosis). 

Pneumonia vs. Pleuritic  Effusion. 

Onset  sudden,  with  rigor,  herpes.  Gradual;   chilly  sensations  commoner. 

Friction  less  common;  may  be  present.  Usual  at  some  time  in  its  course. 

Cyclical  short  course;  high  fever,  crisis.  Longer  duration,  lower  fever,  lysis.     Often 

tuberculous  foci  at  apex,  etc. 
Sputum  rusty.  Mucous,  if  any. 

Leukocytosis.  Usually   absent,    unless    purulent   or    com- 

plicating a  pneumonia. 
Ectasia  absent.  Present. 

Fremitus  increased    (coughing  usually   dis-         Absent     over     effusion     (unless     adhesions 
lodging  bronchial  plugs).  bind    the    lung    to    the    chest    wall;     in- 

creased   above,    over    compressed    lung 
or  in  the  interscapular  region). 
Dulness,  preceded  and  succeeded  by  tym-         Flatness,    increased    downward;      entering 
pany  (tympany  or  partial  dulness  in  upper  Traube's  space  on  the  left  side.     Level 

lobe  pneumonia  is  not  uncommon).  seldom   shifts   with    change   of   position. 

Crepitant    rales,    bronchial    breathing,    and         Decreased    or    absent     respiratory    murmur 
bronchophony       (unless       bronchus       is  (bronchial     breathing     in     interscapular 

plugged).  region  from  compression,  or  even  through 

the  fluid ;   ego  phony) . 
No    essential    luxation    of    heart,    liver  or         Luxation  of  viscera  usual  in  large  effusions. 

spleen. 
Paracentesis  negative.  Tapping    nearly    always    decides    doubtful 

cases ;    fluid  found  beneath  the  flat  area. 

Prognosis. — Pneumonia  is  the  most  fatal  acute  disease  and  has  even 
a  greater  death-rate  than  tuberculosis.  In  1903,  4629  persons  died  of 
pneumonia  in  Chicago,  and  in  1904,  8360  in  New  York  City,  From 
1851  to  1860  the  mortality  in  Chicago  from  tuberculosis  was  35  per 
cent,  more  than  from  pneumonia;  from  1891  to  1901,  the  pneumonia 
death-rate  was  9  per  cent.  more. 

There  are  various  prognostic  factors:  1.  The  Virulence  of  the  pneu- 
mococcus,  which  varies  from  year  to  year  (5  to  31  per  cent,  mortality). 
The  mortality  of  85,000  cases  in  the  German  army  was  3.6  per  cent. 
In  465,400  collected  cases,  E.  F.  Wells  found  the  death-rate  20  per  cent. 

2.  Age, — The  mortality  is:  one  to  five  years,  30  per  cent.;  five  to 
ten  years,  3;  ten  to  twenty  years,  5;  twenty  to  thirty  years,  8;  thirty 
to  forty  years,  25;  forty  to  fifty  years,  39;  fifty  to  sixty  years,  43;  sixty 
to  seventy  years,  53;  seventy  to  eighty  years,  87  per  cent.    Cruveilhier 


PNEUMONIA  75 

spoke  of  pneumonia  as  the  most  formidable  scourge  of  the  aged,  and 
Peter  characterized  pneumonia  as  the  natural  end  of  old  people. 

3.  Sex. — ^The  mortality  is  over  50  per  cent,  higher  in  women. 

4.  Location. — Right-sided  is  more  fatal  than  left-sided  pneumonia, 
and  upper-  is  more  fatal  than  lower-lobe  involvement. 

5.  Unfavorable  conditions  include  cirrhosis  and  nephritis  (almost 
100  per  cent,  mortality);  delirium  tremens  and  inveterate  alcoholism 
(50  per  cent.);  cardiovascular  disease,  etc. 

6.  Unfavorable  symptoms  are  long  prodromata,  hyperpyrexia, 
enteritis,  jaundice,  albuminuria,  severe  pain,  marked  cyanosis,  pul- 
monary edema,  diffuse  bronchitis,  and  a  white  cell  count  under  10,000. 
"When  the  blood-pressure,  expressed  in  millimeters  of  mercury,  does 
not  fall  below  the  pulse-rate  expressed  in  beats  per  minute,  the  fact  may 
be  taken  as  an  excellent  augury;  the  converse  is  equally  true"  (C.  A. 
Gibson).  The  mortality  is  60  per  cent,  with  the  respirations  constantly 
over  60  per  minute,  and  50  per  cent,  with  the  pulse  over  130.  Over  50 
per  cent,  of  delirious  subjects  die. 

7.  Unfavorable  Complications. — Endocarditis  and  meningitis  are 
almost  always  fatal;  abscess,  gangrene  and  arthritis  are  always  serious; 
pericarditis  is  fatal  in  75  per  cent,  of  the  cases. 

Death  is  due  to  cardiac  toxemia.  Mechanical  overwork  of  the  heart 
or  diminished  respiratory  space  is  of  small  importance. 

Treatment. — 1.  Prophylaxis  concerns  disinfection  of  the  sputum, 
cleansing  of  the  room  (page  258),  isolation  and  maintenance  of  the 
physiological  resistance. 

2.  Serotherapy. — Serotherapy  and  vaccines  have  not  proved  suc- 
cessful and  pneumonia  remains  a  self-limited  disease. 

3.  Hygiene  is  the  same  as  in  typhoid;  quiet,  frequent  change  of  pos- 
ture, etc.;  the  patient  should  be  clothed  with  a  light  flannel  jacket 
open  down  the  back.  The  fresh  air  treatment  works  wonders  in  pneu- 
monia; the  bed  should  be  placed  out  of  doors  or  the  windows  widely 
opened.  Aretseus  spoke  of  the  pneumonic's  desire  for  cold  air.  Cold  air 
often  raises  the  blood-pressures  10  to  20  mm.  and  allays  delirium. 

4.  Diet. — ^The  diet  consists  of  milk,  eggs,  beef-juice  and  cereals  (v. 
page  53) .  Plenty  of  water  is  indicated ;  some  is  retained  in  connection  with 
the  chloride  retention  and  much  voided  by  the  increased  respiratory  effort. 

5.  Symptomatic  Therapy. — (a)  The  chill,  which  is  rarely  seen  by 
the  physician,  is  managed  as  in  malaria. 

(6)  Cough. — Expectorants  are  unnecessary;  codeine  gr.  \  to  quiet 
irritation  and  carbonate  of  ammonium  gr.  iij  to  stimulate  secretion, 
may  be  given  every  four  hours;  morphine  may  be  indicated  {v.  i.). 

(c)  Pain. — The  chest  should  be  firmly  strapped  with  adhesive  plaster, 
applied  in  several  oblique  directions  so  that  the  pieces  cross  each  other. 
Morphine  lessens  the  irritability  of  the  respiratory  centre  and  relieves 
pain.  Ice,  blisters,  leeches,  and  the  cautery  are  superfluous;  heavy 
poultices  impede  respiratory  movement.  In  pneumonia,  general  is 
more  important  than  local  treatment. 

{d)  Care  of  the  heart  is  the  main  objective  in  treatment.  Constant 
watching  is  imperative  lest  the  patient  leave  his  bed;  it  is  a  safe  rule  to 


76  BACTERIAL  DISEASES 

consider  all  pneumonics  delirious.  Sitting  up  to  drink,  defecate  or 
urinate  is  never  permissible  in  a  disease  of  sudden  and  alarming  changes, 
with  constant  danger  of  collapse.  No  measure  which  depresses  the  heart 
should  be  employed,  and  acetanilide,  antimony  and  aconite  are  always 
to  he  avoided. 

Cardiac  Stimidation. — Strychnine  is  the  best  vasomotor  tonic,  and  should 
be  given  in  every  case  because  vasomotor  paralysis  and  collapse  develop 
without  warning,  attended  by  accumulation  of  blood  in  the  abdominal 
vessels.  Strychnine  is  here  indicated,  because  it  constricts  the  deep 
abdominal  vessels;  the  peripheral  vascular  tonus  is  not  increased,  but 
the  brain  vessels  are  flushed  and  the  bulbar  A'asomotor  centre  is  stimu- 
lated. The  drug  stimulates  the  central  nervous  system;  the  digestive 
tract,  its  secretions  and  musculature;  the  circulation,  the  tonicity  of  the 
heart,  but  chiefly  the  vasomotor  centre;  and  the  respiratory  centre. 

The  dose  is  gr.  ^^q-  to  -rij,  every  two  to  four  hours.  (For  dosage  in 
children  see  page  269.)  Some  strychnine  remains  in  the  system  over  three 
days,  some  is  destroyed  at  once  by  the  liver,  and  some  is  quickly  elimi- 
nated by  the  kidneys.  If  the  kidneys  or  Hver  are  diseased  as  in  old  age, 
the  drug  may  accumulate.  Full  doses  produce  twitching,  nervousness, 
palpitation  or  renal-vessel  spasm.  Hj-podermic  administration  gives 
less  chance  for  the  liver  to  destroy  the  drug. 

Caffeine  is  of  great  value,  particularlj'  when  morphine  is  indicated, 
supporting  its  tonic  effect  and  neutrahzing  its  somnifacient  action. 
Rhomberg  ranks  caffeine  above  strychnine  and  camphor,  (v.  Therapy 
of  Valvular  Heart  Disease). 

Ammonia  is  of  great  clinical  importance.  It  stimulates  the  heart- 
muscle,  increases  its  frequency,  and  raises  arterial  tension.  Its  super- 
ficial effects  are  flushing,  warmth,  exhilaration  and  increased  secretion 
of  urine,  sweat  and  mucus.  Its  prime  indication  is  sudden  functional  car- 
diac ad\Tiamia,  e.  g.,  at  the  crisis.  It  is  a  local  irritant  to  the  skin,  and 
respiratory  and  alimentary  mucosae,  and  therein  lie  its  therapeutic  value 
and  its  clinical  disadvantages.  Its  application  to  the  upper  respira- 
tory passages  or  its  ingestion  by  mouth  causes  a  sudden  reflex  stimula- 
tion of  the  respiratory  and  circulatory  centres  before  the  drug  is  absorbed. 
Gastric,  intestinal,  renal  and  bronchial  irritation  from  overdosage,  and 
irritation  following  subcutaneous  administration  may  be  observed.  The 
corrosiveness  and  fugitive  action  of  ammonium  carbonate  are  obviated 
by  small,  frequent  doses,  gr.  iij,  CA'ery  two  hours. 

Digitalis  was  once  exhibited  in  enormous  doses,  which  simply  proves 
that  the  drug  is  not  absorbed;  Thomas,  in  1865,  remarked  its  inac- 
tion in  fevers.  The  author  considers  digitalis  far  inferior  to  camphor, 
and  has  repeatedly  noticed  toxic  symptoms  at  the  crisis  when  the  repeated 
doses  of  digitalis  were  absorbed  together.  Digitalis  is  a  last  resort 
(TTlij-v  of  the  fluidextract  hypodermicallyj .  Strophanthin  should  not 
be  used  if  digitalis  has  been  administered,  as  it  may  cause  sudden 
death.     (See  Treatment  of  Valvul-Ui  Heart  Disease.) 

Alcohol  was  first  recommended  by  Todd  for  fevers.  The  chief  interest 
centres  in  its  action  upon  the  circulation.  Formerly  called  a  heart  stimu- 
lant, pharmacologists  now  hold  that  alcohol  does  not  stimulate  the 


PXEUMOXIA  77 

heart,  except  by  preparations  like  champagne  "U'hich  contain  other  ingre- 
dients. The  heart's  frequency  is  increased,  but  the  drug  acts  as  a  vaso- 
dilator or  as  a  blood  distributor.  Some  clinicians  reject  it  because  it  is 
narcotic  to  the  respiratory,  circulatory  and  vasomotor  centres  in  the 
lov\-er  brain,  or  because  it  is  a  vasodilator.  Alcohol  is  effective  in  all 
varieties  of  sepsis  and  it  protects  the  tissues  from  excessive  waste. 
Alcohol  is  indicated  by  collapse  or  cardiac  toxemia,  in  which  hot 
whisky  and  water  unquestionably  stimulate  by  reflex  action  on  the 
throat  and  stomach;  cognac,  or  whisky  in  hot  water,  and  coft'ee  can 
also  be  given  by  rectum.  Alcohol  may  not  be  used  in  any  routine 
fashion;  within  limits,  it  is  valuable. 

Opiates. — The  cardiovascular  value  of  morphine  is  not  sufficiently 
appreciated.  ^Nlany  A^-itlihold  opiates  even  when  the  drug  is  indicated  by 
maniacal  outbursts,  active  delirium,  and  harrassing  coughing  or  pain, 
lest  it  depress  respiration  and  the  heart.  However,  it  decreases  the 
irritability  of  the  respiratory  centres,  lessens  cough,  dyspnea,  headache, 
and  insomnia.  Its  renal  effects  are  negligible,  as  little  morphine  is 
eliminated  by  the  urine.  ^lorphine  of  itself  helps  to  sustain  life,  and  in 
critical  cases  its  h^-podermic  use  strengthens  and  regulates  respiration. 
It  is  a  most  valuahle  adjunct  to  strychnine,  camphor,  or  caffeine,  which 
latter  has  an  excellent  effect,  given  by  rectum,  in  neutralizing  its  nar- 
cotic action. 

Camphor  is  an  excellent  dift\isive  stimulant,  grain  ij  hj^odermically 
in  10  parts  of  sterilized  almond  oil,  every  two  to  four  hours. 

Saline  infusions  are  indicated  in  profound  toxemia  -^ith  weak  heart 
— two  drams  of  salt  in  one  quart  of  water.  They  "lavage  the  blood." 
Continuous  use  of  the  salt  solution  by  rectum,  by  the  drop  method,  is 
valuable.  Although  once  abused,  venesection,  employed  by  Hippocrates, 
has  again  come  more  into  vogue.  It  is  valuable  at  the  onset  in  the  robust 
for  severe  pain,  active  delirium  and  urgent  dyspnea,  and  later  when 
great  engorgement  of  the  right  heart  occurs.  Heart  stimulants  must  be 
used  with  phlebotomy. 

Oxygen,  said  to  relieve  dyspnea,  is  often  irritating  and  injurious.  The 
mouth-piece  should  be  held  near,  not  over,  the  mouth.  (An  excess, 
experimentally,  produces  hepatization.) 

Atropine  is  valuable  for  collapse,  low  temperature  and  clammy  skin,  in 
a  daily  dosage  of  not  over  one-fiftieth  of  a  grain. 

Adrenalin  (1  to  1000),  in  5-10  drop  doses,  is  as  efficacious  given  intra- 
muscularly as  intravenously;  acting  on  the  nerve-endings  of  the  sym- 
pathetic, it  is  a  vasoconstrictor;  small  and  repeated  doses  are  better 
than  larger  doses  which  may  induce  pulmonary  edema. 

(e)  Antipyretics. — A  high  temperature  is  not  per  se  injurious;  patients 
with  fever  between  103°  and  105°  progress  most  favorably  and  those 
with  temperature  above  or  below  these  limits  run  a  more  severe  course. 
All  measures  which  suddenly  reduce  the  temperature  must  be  avoided, 
especially  at  the  crisis,  when  the  heart  sometimes  staggers  under  the 
sudden  fall  of  the  fever. 

Hydrotherapy  is  opposed  by  many  clinicans;  by  others  the  tonic  vaso- 
motor effects  are  thought  to  outweigh  the  shock.    It  is  contra-indicated 


78  BACTERIAL  DISEASES 

in  the  obese,  the  weak  and  the  aged.  Cool  sponging  with  water  and 
alcohol  is  the  safest  method.  Quinine  has  no  effect  except  in  large  doses; 
so-called  specific  action  is  a  phantasy. 

(/)  Nervous  syiwptoins  are  toxemic,  but  may  be  considered  with  regard 
to:  (i)  fever;  the  greater  the  temperature  variation,  the  more  marked 
are  the  nervous  symptoms,  which  are  most  efficaciously  treated  by  baths 
or  cool  affusions;  (ii)  deficient  oxygenation,  in  which  cardiants  and 
oxygen  are  indicated;  (iii)  insomnia,  which  is  treated  by  morphine, 
hyoscine  hydrobromide,  sulphonal,  and  cool  sponging,  but  rarely  by 
chloral;  and  (iv)  delirium  tremens  (q.  v.). 

(g)  Iodides  are  indicated  in  delayed  resolution. 

DIPHTHERIA. 

Definition. — An  acute  specific  infective  disease,  usually  of  the  throat 
or  upper  air-passages,  and  characterized  by  a  membrane  formed  by  the 
Klebs-Loeffier  bacillus,  and  by  toxemia. 

History. — Diphtheria  was  knowm  to  Hippocrates.  Asclepiades,  100 
B.C.,  performed  the  first  tracheotomy.  The  first  full  account  was 
Aretseus',  in  the  first  century,  a.d.  Diphtheria  literally  means  mem- 
brane and  originated  with  Bretonneau  (1821). 

Terms. — ^True  diphtheria  implies  a  membrane  formed  by  the  Klebs- 
Loeffler  bacillus  whose  absorbed  toxins  produce  toxemia.  Membrane, 
however,  may  be  due  to  the  scarlatinal  virus,  strepto-,  pneumo-,  staphylo- 
cocci, etc. ;  while  these  are  diphtheritic  membranes  in  the  old  anatomical 
sense,  they  are  not  diphtheritic  in  the  bacteriological  sense,  and  we 
term  them  pseudodiphtheritic,  or  diphtheroid.  Therefore,  clinically, 
there  are  some  discrepancies:  (a)  what  seems  diphtheria,  anatomically, 
may  not  be  due  to  the  Klebs-Loeffler  bacillus;  (b)  what  apparently  is 
angina  or  tonsillitis,  may  show  no  membrane  or  an  atypical  membrane, 
but  bacteriologically  is  due  to  the  Klebs-Loeffler  bacillus;  (c)  the 
diphtheria  bacillus  is  found  in  1  per  cent,  of  perfectly  healthy  throats; 
(d)  there  are  bacilli  which  closely  simulate  the  diphtheria  bacillus.  The 
pseudodiphtheritic  membrane  is  most  often  due  to  the  streptococcus 
and  is  seen  oftenest  in  scarlatina,  but  also  in  t^^phoid,  measles,  Vincent's 
angina,  syphilis  and  pertussis.  It  develops  wherever  the  true  diphtheritic 
membrane  may  occur,  e.  g.,  the  throat,  larynx,  bronchi,  eyes,  skin,  etc. 
Most  cases  (72  per  cent.)  clinically  resembling  diphtheria  are  proved 
diphtheria  by  repeated  bacteriological  tests. 

Bacteriology. — The  diphtheria  bacillus  (described  by  Klebs,  1883, 
and  cultivated  by  Loefflet,  1884)  is  1.2  to  2/x  long  and  0.3  to  O.o/i  wide, 
with  small  round  or  slightly  enlarged  ends.  It  stains  readily  by  Gram's 
method,  Loeffler's  methylene  blue  and  carbol  fuchsin.  There  are  many 
variations  in  form,  but  the  serum  culture  always  reveals  the  wedge-  or 
mallet-like  forms.  Their  grouping  is  characteristic,  like  Chinese  letters,  in 
lines  set  asymmetrically  at  various  irregular  or  slight  angles.  They  are 
immotile  and  sporeless.  The  bacillus  overgrows  other  associated  bac- 
teria on  blood  serum  mixed  with  glucose  bouillon;  the  culture  is  visible 
in  ten  hours  as  yellow  streaks,  whose  surface  is  slightly  granulated  and 


PLATE    III 


A 


B 


MV,^ 


^\ 


w 


X"^ 


A.  Culture  of  diphtheria  bacillus. 

B.  Same  magnified. 

C.  Diphtheria  bacilli. 


DIPHTHERIA  79 

edges  somewhat  thick.  In  twenty-four  hours  the  growths  diffuse,  with 
a  wave-Uke  surface-,  undulating  edges,  and  a  succulent  appearance.  The 
diphtheria  bacillus  is  -very  resistant,  and  though  it  usually  disappears 
three  weeks  after  the  patient  has  shed  the  membrane,  it  may  live  for 
weeks  in  the  throat  (even  fifteen  months)  or  for  a  long  period  in  clothing. 
It  is  found  chiefly  in  the  membrane,  and  is  less  frequently  detected  in 
the  submucosa,  heart  (endocarditis),  blood  (diphtheriemia) ,  lungs 
(bronchopneumonic  foci),  spleen,  liver,  brain,  cord,  kidney  or  urine. 
In  one  report,  it  was  found  in  the  blood  and  viscera  eleven  times  in  four- 
teen cases.  Symbiosis  with  the  streptococcus,  the  most  common  of  all 
secondary  infections,  increases  the  virulence  of  the  diphtheria  toxin 
(Roux  and  Yersin);  the  streptococcus  is  found  in  septic  types,  broncho- 
pneumonia and  glandular  suppuration.  Less  important  are  the  staphylo- 
cocci— which  rarely  enter  through  the  throat,  but  then  with  increased 
virulence — the  proteus,  colon  bacillus  and  pneumococcus. 

The  action  of  the  bacillus  is  (a)  local;  when  inoculated  in  animals, 
local  necrosis  develops,  whereon  fibrin  exudes  and  forms  a  membrane  in 
which  the  bacillus  is  found;  and  (b)  general,  forming  toxins,  absorbed 
by  the  blood  and  lymph  vessels.  Roux  and  Yersin  found  that  the  toxins 
injected  alone,  after  killing  the  bacillus,  produce  no  membrane  or  necrosis, 
but  toxemia  and  paralysis  similar  to  the  postdiphtheritic  paralysis. 
Ehrlich  distinguishes  two  toxins :  the  toxin  producing  the  ordinary  pheno- 
mena of  diphtheria,  and  the  toxon  producing  the  later  anemia  and  paraly- 
sis. The  chief  receptors  of  the  virus  are  the  nervous  and  lymphatic 
tissues. 

The  virulence  of  the  germ  varies.  This  is  tested  by  inoculating  a 
guinea-pig  with  -^-^  of  its  body-weight  of  a  forty-eight-hour  bouillon 
culture,  and  noting  the  results;  (a)  death  in  three  days  or  less  results 
from  fully  virulent  cultures;  (b)  death  in  three  to  five  days  from  one 
of  medium  virulence;  (c)  death  after  a  longer  time,  or  only  local  changes, 
from  weak  cultures. 

Bacilli,  known  as  the  pseudodiphtheria  bacillus.  Bacillus  xerosis,  etc., 
resemble  the  Klebs-Loeffler  bacillus,  and  may  become  virulent;  they 
are  not  antagonized  by  the  diphtheria  serum  but  only  by  the  pseudo- 
diphtheria  serum. 

Dissemination. — Diphtheria  is  disseminated  (1)  by  patients  acutely  ill 
with  the  disease;  the  secretion  or  membrane  may  be  coughed  into  the 
mouth  of  one  of  the  family,  nurse  or  attending  physician.  Children 
going  to  school  may  impart  to  others  a  most  virulent  diphtheria,  though 
the  same  bacilli  have  produced  in  them  little  constitutional  reaction.  (2) 
By  healthy  individuals,  in  1  per  cent,  of  whom  the  germ  is  found  without 
causing  diphtheria;  these  carriers  may  or  may  not  have  been  in  contact 
with  the  disease.  (3)  By  fomites,  especially  damp  cloths,  in  which 
the  germ  may  live  for  five  months.  (4)  The  germ  probably  may  be 
spread  by  dust,  cheese,  milk  and  eating  utensils.  It  is  not  demonstrated 
that  domestic  animals  convey  the  disease.  Diphtheria  is  endemic  in 
all  thickly  populated  districts,  from  which  epidemics  develop. 

Age. — Most  infections  occur  between  the  second  and  fifteenth  years, 
^nd  most  deaths  occur  between  the  second  and  fourth  years.     Jacobi 


80  BACTERIAL  DISEASES 

observed  three  cases  in  the  newborn,  but  infants  at  the  breast  are  less 
exposed  than  creeping  children  who  come  into  close  contact  with  dirt. 
Adults  are  frequently  affected. 

Hypertrophied  tonsils,  nasopharyngeal  and  bronchial  catarrh,  measles, 
nervous  affections  and  cold  weather  are  predisposing  factors.  Some 
individuals  are  temporarily,  and  some  permanently,  immune.  One 
attack  confers  no  immunity,  wherein  diphtheria  resembles  erysipelas, 
pneumonia  and  rheumatism. 

Symptoms. — ^There  are  three  major  localizations  of  diphtheria:  the  throat, 
the  nose  and  the  larynx. 

1.  Pharyngeal  Diphtheria. — ^The  typical  case  is  pharyngeal. 

(a)  The  simple  localized  diphtheria  after  an  incubation  of  two  to  seven 
days  begins  with  fatigue,  pallor,  coated  tongue,  anorexia,  dysphagia, 
vomiting,  and  pain  beneath  the  angle  of  the  jaw.  Chilly  sensations, 
fever  and  thirst  and  pharyngeal  voice  ensue. 

The  pharynx  is  glistening  and  characteristically  purple-red,  with,  later, 
areas  of  gray,  yellowish  or  dirty  green  color,  as  small  white  bands  or 
irregular,  gelatinous  masses,  located  on  the  tonsils,  palate,  pillars  or 
pharynx.  Except  in  their  very  incipiency,  they  are  adherent,  and  on 
removal  leave  red,  bleeding  spots  which  are  rapidly  covered  again  with 
membrane. 

Wagner,  Weigert  and  Oertel  showed  that  the  diphtheritic  membrane 
is  composed:  (i)  Of  necrobiotic  tissue;  the  superficial  and,  later,  the 
deeper  structures  are  necrosed;  bacilli  are  found  in  the  superficial  layers 
and  streptococci  and  staphylococci  may  be  found  more  deeply  situated; 
the  necrobiosis  may  be  noticed  also  in  the  connected  lymph  glands  and 
internal  organs  (Weigert's  coagulation  necrosis),  (ii)  Somewhat  deeper 
the  membrane  is  composed  of  fibrin  exudation,  which  is  a  conservative, 
walling-off  process,  (iii)  In  the  deepest  part  of  the  membrane  emigra- 
tion of  leukocytes  occurs.  In  most  adults  the  membrane  is  thrown  off 
by  the  fourth  or  fifth  day;  in  children  by  the  seventh  or  eighth  day. 

The  breath  is  septic  in  odor.  Some  nasal  discharge  is  the  rule.  The 
glands  at  the  angle  of  the  jaw  are  tender.  Fever  may  be  irregular  or 
absent;  in  90  per  cent,  of  patients  who  recover  it  does  not  exceed  102°. 
The  patient  usually  recovers  in  seven  to  ten  days,  and  seldom  exhibits 
marked  toxemia. 

The  form  described  is  the  classical  type  of  mild  local  infection;  the  bacilli 
may  be  virulent  but  the  tissues  and  blood  resist  the  infection.  Several 
deviations  from  this  type  may  be  misinterpreted:  (1)  In  "catarrhal 
diphtheria"  the  membrane  is  absent  or  atypical  and  pultaceous;  this 
type  is  common  in  families  where  the  more  t^^ical  forms  are  seen.  (2) 
Diphtheria  may  resemble  follicular  pharyngitis;  between  them  there  is 
no  absolute  distinction  except  bacteriologically,  although  in  diphtheria 
the  red  is  brighter,  the  tendency  to  fuse  is  greater,  and  the  spots  are  more 
yellow,  gray  or  green.  (3)  Follicular  tonsillitis  may  be  very  closely  simu- 
lated, and  then  is  only  distinguished  bacteriologically.  (4)  In  chronic 
diphtheria,  there  is  a  deposit  upon  a  red,  edematous  pharynx.  The 
glands  may  be  swollen,  but  usually  there  are  no  toxemic  symptoms. 
(5)  The  latent  diphtheria  in  marantic  subjects  may  easily  escape  detection. 


DIPHTHERIA  81 

(6)  The  diphtheritic  general  infection  begins  with  high  fever  and  toxemic 
symptoms  as  headache,  prostration,  increasing  anemia,  d.ysphagia  and 
vomiting.  The  heart  movement  follows  the  fever,  the  tones  being  dull 
and  often  accompanied  by  a  systolic  murmur.  The  pharynx  is  dark  red, 
swollen  and  a  thin  gray  membrane  is  seen  on  the  tonsils  or  pharynx; 
it  begins  as  streaks,  or  a  thin  veil  over  the  pharynx  and  spreads  rapidly. 
The  secretion  is  offensive.  The  hard  palate  and  upper  soft  palate 
are  usually  normal.  The  neck  is  tender  from  glandular  intumescence. 
The  nose  is  often  closed  by  a  purulent  secretion  and  diffuse  membrane, 
and  oral  breathing  results,  of  great  moment  in  nurslings.  There  is  a 
type  peculiar  to  young  children  who,  with  initial  nasal  symptoms  and 
without  throat  symptoms,  suddenly  develop  laryngeal  stenosis,  and  in 
the  pre-antitoxin  days,  almost  invariably  died.  In  severe  cases  the  heart 
is  irregular;  there  are  throat  paralysis,  neck  infiltration,  dyspnea,  albu- 
minous urine,  tympany',  swollen  liver  and  spleen,  antemortem  fall  of 
temperature,  and  death  from  pneumonia,  cardiac  insufficiency,  toxemia, 
paralysis  or  nephritis. 

(c)  In  septic  diphtheria  the  exudate  becomes  dirty  green  or  brown,  is 
horribly  fetid,  and  may  reach  the  nose  or  larynx,  causing  necrosis  and 
stenosis.  It  excites  lymphadenitis  and  periadenitis.  The  respiration 
is  difficult;  and  nephritis,  generalized  hemorrhage  or  local  arterial  ulcera- 
tion, failing  pulse,  low  temperature,  and  intumescence  of  the  abdomen, 
liver  and  spleen,  usually  result  fatally.  In  1881,  94  per  cent,  of  cases 
of  this  type  died.  According  to  Baginsky,  it  is  due  to  the  diphtheria 
toxin,  and  is  seldom  observed  since  the  introduction  of  antitoxin.  Others 
maintain  that  symbiotic  streptococcus  infection  determines  this  septic 
type. 

The  initial  fever  in  diphtheria  may  be  maintained  by  otitis,  pneumonia, 
adenitis  and  other  complications  in  the  severer  types.  Septic  tempera- 
ture may  prevail.  A  pre-agonal  rise  may  be  observed,  or  an  antemortem 
collapse.  These  developments  relate  chiefly  to  cases  untreated  with 
antitoxin. 

Leukocytosis  of  the  polymorphonuclear  type  develops  in  90  per  cent, 
of  cases.  It  does  not  correspond  to  the  severity'  of  the  disease.  When 
absent  the  infection  is  either  very  severe  or  light. 

2.  Nasal  diphtheria  may  usher  in  the  disease  or  accompany  the 
benign,  or  more  usually,  the  severe  forms.  The  serous  and  often  sanious 
or  bloody  nasal  discharge  excoriates  the  alse  nasi,  lips  and  cheeks  (every 
"coryza"  in  which  this  occurs,  must  excite  alarm);  membrane  often 
protrudes.  Cervical  adenitis  is  suggestively  frequent.  The  prognosis 
is  grave,  arid  convalescence  very  tardy.  In  contrast  with  this  severe 
form  there  is  a  fibrinous  rhinitis  usually  subacute  or  chronic,  which  is 
due  to  the  Klebs-Loeffler  bacillus  (82  per  cent.),  or  the  streptococcus 
(18  per  cent.);  it  is  obviously  dangerous  to  other  children,  since  the 
remarkable  absence  of  constitutional  reaction,  despite  the  menacing 
discharge,  does  not  prevent  play  or  school-going. 

3.  Laryngeal  Diphtheria  or  Croup. — Most  cases  are  diphtheritic 
(85  per  cent.),  though  some  are  streptococcic.  Diphtheria  involves  the 
throat  in  84  per  cent,  and  the  larynx  in  16  per  cent,  of  cases.    Forms 

6 


82  BACTERIAL  DISEASES 

(a)  Catarrhal  laryngitis,  due  to  the  diphtheria  bacillus,  produces  symp- 
toms of  two  or  three  days'  duration;  they  may  be  severe,  even  stenotic. 

(b)  Diphtheritic  laryngitis  (croup)  is  descending  in  97  per  cent,  of  cases, 
i.  e.,  secondary  to  pharyngeal  or  nasal  diphtheria;  even  in  seemingly 
primary  cases  there  is  usually  some  pharyngeal  involvement.  The  child 
becomes  hoarse  in  the  night  or  early  morning,  coughs  the  hoarse,  croupy 
cough,  and  after  twelve  to  twenty-four  hours  is  dyspneic.  Aphonia  is 
the  rule.  The  stridor  becomes  menacing  and  then  the  enduring  croup  is 
surely  diphtheritic.  The  stenosis  is  due  to  memhrane  in  the  epiglottis, 
true  cords,  trachea  or  even  in  the  bronchi.  The  accessory  muscles  of 
respiration  come  into  play,  T\*ith  inspiratory  retraction  of  the  thorax  and 
epigastrium,  especially  in  rhachitic  children,  up-and-down  excursion  of 
the  larynx,  extreme  restlessness,  and  temporary  improvement  after 
expectorating  the  membrane.  The  stenosis  is  accentuated  by  the  central, 
immovable  position  of  the  vocal  cords,  swelling  in  the  subchordal  tissue 
and  muscular  spasm.  The  cough  may  disappear  because  of  decreased 
reflex  bronchial  excitability.  Fever  is  usually  absent.  The  pulse  increases 
with  augmentation  of  the  stenosis.  The  respite  jolloicing  the  raising 
of  the  membrane  is  usually  transient;  exacerbations  occur  and  finally, 
without  intubation  or  tracheotomy,  dyspnea  becomes  continuous,  with 
stagnation  of  secretion  and  membrane  in  the  tubes,  absence  of  the 
vesicular  murmur,  stridor,  increasing  rapidity  and  weakness  of  the 
pulse,  cold,  clammy  skin — in  short,  the  complete  picture  of  carbon 
dioxide  poisoning  and  total  asphyxia  develops. 

4,  Other  Localizatioxs. — (a)  Diphtheria  of  skin  is  usually  asso- 
ciated with  pharyngeal  diphtheria.  The  skin  is  hard  and  infiltrated, 
the  secretion  corrosive,  the  contiguous  lymphatics  involved,  and  cellu- 
litis or  phlegmon  may  result.  ]\Iost  instances  of  "wound  diphtheria" 
and  the  membrane  which  forms  in  tracheotomy  wounds  are  usually 
streptococcic. 

(b)  Diphtheritic  vulvovaginitis  (under  1  per  cent.)  is  dangerous,  and 
usually  follows  severe  pharyngeal  diphtheria;  it  consists  of  diffuse 
niembrane,  painful  rhagades,  ulcers  and  foul  secretion.  A  streptococcic 
form  is  also  encountered. 

(c)  Diphtheritic  ophthalmia  is  fi)  false  or  diphtheroid  (due  to  pus 
cocci)  or  (iij  genuine  or  diphtheritic,  which  occurs  in  .3  per  cent,  of  cases, 
chiefly  in  young  children.  It  may  be  primary  in  the  eye,  or  secondary 
to  nasopharyngeal  diphtheria. 

(d)  Diphtheritic  otitis  occurs  in  6  per  cent,  of  cases  (as  against  .33  per 
cent,  of  otitis  in  scarlatina  and  nearly  100  per  cent,  in  measles).  The 
diphtheria  bacillus  travels  from  the  throat  to  the  Eustachian  tube  or 
middle  ear. 

Complications  and  Sequels. —  The  most  important  are  heart  weakness, 
nephritis,  and  paralysis. 

1.  Cardiac  Complicatioxs. — Anatomically,  the  heart  muscle  is 
altered  early.  It  is  soft,  friable,  light  brown  or  yellow,  and  fatty;  it  is 
the  occasional  seat  of  endocardial  and  mvocardial  hemorrhages,  acute 
interstitial  myocarditis  and  fragmentation  or  myolysis,  which  Eppinger, 
in  describing  eighteen  cases  of  sudden  death,  considers  the  usual  cause 


DIPHTHERIA  83 

of  death;  degeneration  may  be  found  in  the  bundle  of  His.  Pericarditis, 
with  septic  or  hemorrhagic  effusion,  or  permanent  changes  due  to  endo- 
carditis (in  2  per  cent,  of  fatal  cases)  or  myocarditis  are  uncommon. 

CUnicalh/,  the  first  tone  is  impure  or  obscured  by  a  systolic  murmur 
in  one-half  the  cases;  the  second  pulmonic  is  accentuated,  the  rhythm 
is  disturbed  (60  per  cent.)  and  sometimes  there  is  gallop-rhythm  and 
embryocardia.  The  pulse  is  rapid  and  soft  but  it  may  be  ominously 
slow,  even  14.  Heart-failure  is  more  frequent  than  in  any  other  infection, 
and  occurs  early  in  severe  or  gangrenous  types,  or  only  after  three  to  six 
weeks  (in  20  per  cent.).  It  is  marked  by  copious  vomiting  from  vagus 
neuritis,  pain  in  the  chest  and  epigastrium,  cardiac  dilatation,  pallor, 
dyspnea,  cyanosis  and  convulsions.  Heart  failure  is  explained  in  various 
ways  (o)  acute  interstitial  myocarditis;  (6)  myolysis;  (c)  centric  vaso- 
motor paralysis;  id)  neuritis  of  the  vagus;  (e)  degeneration  of  the  bundle 
of  His;  33  per  cent.  die. 

2.  Diphtheritic  Nephritis. — (a)  Albuminuria  occurs  in  33  per  cent, 
of  all  and  in  100  per  cent,  of  severe  cases.  (6)  In  light  forms  of  neph- 
ritis there  is  some  albumin,  the  specific  gravity  and  quantity  of  urine 
are  about  normal,  and  there  are  leukocytes  or  epithelial  cells  with 
indistinct  nuclei,  the  cells  being  highly  refractive  and  coarsely  granular. 
Blood  is  rarely  found.  There  are  some  hyaline  and  granular  casts. 
These  toxemic  findings  correspond  in  time  and  degree  to  the  diphtheritic 
process  in  the  pharynx,  (e)  The  severe  forms  of  nephritis  occur  in  severe 
or  septic  t\'pes  and  are  characterized  anatomically  by  diffuse  parenchy- 
matous changes,  necrosis,  hemorrhage  and  exudation.  iUbumin,  epithe- 
lium, casts  and  cylindroids  are  abundant.  Hematuria  is  rare;  aceto- 
nuria  occurs  in  65  per  cent,  of  cases.  Nephritis  rarely  produces  hydrops 
or  uremia  as  in  scarlatina.    It  rarely  becomes  chronic. 

3.  Diphtheritic  paralysis  occurs  clinically  (and  experimentally) 
from  toxemia  in  20  per  cent,  of  cases.  Paralysis  rarely  develops  in  patients 
receiving  antitoxin  on  the  first  day  but  most  often  develops  in  those  in- 
jected after  the  third  day,  or  with  insufficient  doses.  Its  frequency  and 
intensity  is  directly  proportional  to  the  severity  of  the  diphtheria. 

(a)  Early  yaralysis  occurs  in  septic  cases  at  the  acme.  Dysphagia 
is  its  most  common  form.  There  is  danger  of  inhalation  pneumonia, 
especially  in  stupid  cases.    Most  cases  die. 

(6)  Postdiphtheritic  Paralysis. — This,  the  typical  variety,  occurs  after 
two  or  three  weeks  and  usually  follows  throat  lesions  since  laryngeal 
cases  are  likely  to  die  early;  all  throat  infections  leading  to  paralysis 
are  probably  diphtheritic.  The  most  common  paralysis  is  that  of  the 
palate,  which  was  described  by  xEtius  in  the  sixth  century,  and  causes 
dysphagia,  anesthesia  of  the  throat  and  nasal  speech.  The  pupils  widen, 
and  react  to  light  but  not  tg  accommodation.  The  arms  frequently 
escape.  Ataxia  may  be  the  first  symptom.  The  reflexes  disappear  early 
and  the  muscles  react  slowly,  if  at  all,  to  the  faradic  current,  although 
the  reaction  of  degeneration  by  no  means  runs  parallel  to  the  degree 
of  loss  of  voluntary  motion.  The  muscles  waste,  the  palsied  limbs  are 
sometimes  painful  and  the  muscles  and  nerve  trunks  are  often  tender. 
The  trunk,  bladder,  and  rectum  are  sometimes  involved.     The  sensory 


84  BACTERIAL   DISEASES 

nerves  suffer  less,  sensation  being  largely  retained  above  the  knees. 
Sensory  disturbance  may  be  noted  in  the  rectal,  genital  and  vesical 
twigs.  The  cranial  nerves  ('strabismus,  ptosis,  diplopia  i,  the  phrenic 
nerve  and  vagus  may  be  involved;  fearfid  abdominal  pains  with  threaten- 
ing collapse  attribtitable  to  sympathetic  involvement  may  be  noted. 
Anatomically,  disintegration  of  the  medtdlary  substance,  midtiplication 
of  nuclei  in  Schwann's  sheath,  granular  degeneration,  and  even  total 
loss  of  the  axis-cylinder  are  present,  the  changes  being  almost  totally 
parench\Tnatous;  neuritis  'actual  nerve  inflammation)  is  seen  almost 
wholly  in  the  palate,  due  to  local  invasion  from  the  inflamed  throat. 
The  patient  recovers  in  two  or  three  weeks  if  the  pharynx  alone  is 
involved,  and  in  three  to  eight  months  if  the  limbs  are  affected.  Death 
results  in  18  per  cent,  of  cases,  chiefly  from  vagus  involvement. 

(c)  Organic  Cenirnl  Changes. — Accidental  findings  are  cerebral  hemor- 
rhage, embolism  and  acute  encephalitis.  The  literature  contains  So 
instances  of  hemiplegia  fRolleston,  1905;.  The  Babinski  reflex,  found 
in  20  per  cent,  of  severer  cases,  is  due  to  toxemic  action  on  the  pyramidal 
tracts.  Degenerative  cerebrospinal  lesions  not  infrequently  occur  with 
multiple  neuritis. 

d.  RespiR-\tory  CoiirLiCATioxs. — The  bronchi  and  trachea  exhibit 
membrane  in  50  per  cent,  of  fatal  cases.  Brotichopneirmonia  is  present 
in  65  per  cent,  of  fatal  cases,  caused  by  the  Klebs-Loeffler  bacillus  alone, 
or  by  the  pus  or  pneumonia  cocci,  etc.  Anatomically,  some  cases  are 
due  to  downward  extension  of  the  bronchitis:  some  are  hematogenous; 
others  are  due  to  inhalation,  and  stfll  others,  seen  after  intubation  or 
tracheotomy,  are  elevated  and  granular.  Increase  of  pulse  and  respira- 
tion-rate, local  consolidation  and  accession  of  fever  are  observed.  Serotis, 
hemorrhagic  or  purident  pleurisy  is  seldom  encountered. 

5.  Albiextary  Tract. — Fissures,  sordes,  membrane  or  ulcers  on  the 
lips,  suppuration  in  the  tonsils  or  retropharyngeal  space  and  gangrene 
sometimes  occtir.  In  septic  cases  the  esophagus  may  be  occluded  by  mem- 
brane. Epigastric  pain  and  vomiting  are  chiefly  cardiac;  death  is  usual 
when  vomiting  develops  late  in  the  disease;  the  rare  hemorrhage  and 
membrane  formation  escape  clinical  recognition.  Constipation  is  usual; 
in  septic  forms,  thick,  fotd  or  dysenteric  evacuations  may  be  exceptionally 
observed;  there  may  be  membrane  formation  and  sweUing  of  Peyer's 
patches.  The  liver  is  swollen  from  fatty  or  cloudy  degeneration  or  from 
congestion,  in  which  latter  case  it  also  becomes  painful.  Splenic  tumor 
is  found  in  septic  tj-pes  especially. 

6.  Skin". — ^The  skin  is  ustially  normal,  except  for  the  febrile  hyperemia, 
cardiac  pallor,  croup-cyanosis  or  septic  grayness.  Herpes,  in  4  per  cent., 
petechiae,  symmetrical  gangrene  'of  which  9  cases  exist  in  the  literature), 
and  septic  dermatomyositis  u-ually  occur  with  adenitis,  nephritis 
or  ulcerative  endocarditis.  Scarlatina  or  measles  may  complicate 
diphtheria. 

7.  Glaxd.s. — The  anterior  cervical  glands  are  swollen  and  painfid.  In 
the  severest  forms  periadenitis  follows,  with  diffuse  cellulitis  fangina 
Ludovici),  section  of  which  evacuates  serum,  seldom  pus.  Glandular 
and  articular  changes  are  less  frequent  than  in  scarlatina.      IMuscular 


DIPHTHERIA  85 

degeneration,  interstitial  infiltration  and  fragmentation  are  observed 
in  the  heart  and  diaphragm. 

Diagnosis. — ^4  thick,  adherent  membrane,  which  is  not  removable  without 
hemorrhage,  with  subjacent  ulceration  (Bretonneau)  and  enlarged  glands, 
is  characteristic.  .4  positive  bacteriological  diagnosis  is  important  in 
cases  with  membrane,  diffuse  reddening  and  tonsillitis,  yet  four  negative 
examinations  are  necessary  to  exclude  diphtheria  positively.  Statistics 
show  positive  findings  in  92  to  98  per  cent,  of  cases  in  which  the  clinical 
diagnosis  of  diphtheria  has  been  made.  The  nose,  nasopharynx  and 
pharynx  must  be  examined  in  every  sick  child  and  adult.  In  suspicious 
cases  antitoxin  should  be  given  at  once. 

The  health  departments  in  large  cities  pro\'ide  cultures,  stations  at 
which  cultures  and  antitoxin  may  be  obtained,  and  central  and  subsidiary 
laboratories  for  diagnosis.  In  smaller  towns  communal  laboratories  can 
be  maintained  easily.  The  Chicago  Health  Department  has  an  able 
corps  of  physicians  for  free  treatment,  consultation  and  intubation.  It 
is  easy  to  obtain  a  smear  from  the  suspicious  focus,  to  rub  it  on  the 
serum  without  breaking  its  surface,  and  to  put  the  tin  box  containing  it 
under  the  axilla  until  the  brood-oven  can  be  reached.  In  half  a  day 
characteristic  cultures  are  obtained.  Direct  smears  very  often  show 
the  bacillus.  In  lar^^lgeal  diphtheria  the  bacillus  is  usually  found  on 
the  pharynx,  but  not  on  the  tonsils.  Repeatedly  negative  findings  are  of 
value  in  the  yseudodiphtheritic  pharyngitis,  rhinitis  and  laryngitis,  e.  g., 
membranes  due  to  strepto-,  staphylo-,  and  pneumococci,  aphthous  growth, 
syphilis,  etc.  The  scarlatinal  membrane  {q.  v.).  In  Vincent's  angina 
{q.  ■}).)  described  by  Vincent  (1898),  the  whitish-yellow  or  grayish-brown 
membrane  may  be  confused  with  diphtheria  and  syphilis  and  is  caused 
by  the  symbiosis  of  two  otherwise  innocuous  parasites,  the  Bacillus  fusi- 
formis,  and  the  Spirocheta  darticola. 

Course  and  Prognosis. — ^Aside  from  complications,  the  average  course 
is  one  or  two  weeks.  It  is  more  favorable  in  diphtheria  of  the  tonsils 
than  of  the  nose.  The  prognosis  concerns  the  toxemia,  mechanical 
obstructions,  as  of  the  larynx,  mixed  infection,  and  the  therapy,  (a) 
Without  serotherapy  the  danger  is  great,  since  light  infections  may 
intensify  or  extend,  (b)  Epidemics  vary  in  virulence,  30  to  50  per  cent, 
mortality  having  been  observed  twenty  years  ago.  (c)  In  the  first  year 
the  mortality  is  77  per  cent.,  and  sinks  with  each  year  until  it  is,  at  ten 
years,  20  per  cent.;  after  ten,  3  per  cent.;  after  thirty  and  forty,  2.5  per 
cent,  (d)  Other  factors  are  debility,  adenitis  and  croup;  the  general 
diphtheritic  infection  or  septic  forms;  renal  complications;  rapid  and 
weak  or  slow  pulse;  ecchymoses  and  late  vomiting;  and  paralysis,  (e)  In 
940  fatalities  studied  by  AMiite  and  Smith,  about  50  per  cent,  died  of 
bronchopneumonia,  usually  after  intubation  or  tracheotomy;  25  per 
cent,  died  of  cardiac  complications,  and  25  per  cent,  of  early  severe 
toxemia,  though  some  succumbed  to  asphyxia  or  late  paralysis.  (/) 
Coincidence  with  other  infections  is  ominous,  such  as  measles,  in 
which  the  exanthem  may  become  hemorrhagic,  and  a  lethal  res- 
piratory catarrh  usually  results.  Diphtheria  belongs  to  the  recurrent 
infections. 


86  BACTERIAL   DISEASES 

Treatment.— 1.  Prophylaxis  begins  T^-ith  the  case  in  hand.  In  Boston 
the  isolation  hospital  has  reduced  the  mortality  of  diphtheria  to  one- 
sLxth  of  its  former  rate.  All  suspicious  throat  cases  should  be  isolated 
pending  their  cultural  evolution;  other  children  in  the  family  should  be 
kept  from  playmates  and  school.  The  patient  is  isolated  until  the  throat 
gives  two  negative  cultures,  successively,  requiring  three  weeks.  The 
physician  may  protect  himself  by  examining  the  throat  through  a  piece 
of  glass,  and  avoid  carrying  the  germs,  b}'  a  surgical  go\\Ti  and  washing 
face  and  hands  with  bichloride  solution.  In  fatal  cases  the  body  should 
be  -^Tapped  in  a  sheet  saturated  with  bichloride,  and  buried  privately 
in  a  tightly  closed  casket.  Those  exposed  to  infection  may  receive 
antitoxin,  and  should  gargle  the  throat  often  with  bichloride  (toVo")- 
The  clothing,  blankets,  rugs,  etc.,  must  be  steamed.  After  convales- 
cence, the  walls  of  the  room  should  be  rubbed  mth  bread  which  is  then 
burned,  the  woodwork  washed  with  2  per  cent,  phenol  solution  or  bichlo- 
ride and  the  room  fumigated  (page  258).  Under  prophylaxis  maj^  be 
included  the  building  up  of  the  physiological  resistance  and  the  treatment 
of  chronic  catarrh  of  the  nose,  throat  and  bronchi.  "Carriers"  must 
be  isolated;  Hewlett  reports  success  from  vaccines.  Schi5tz  advocated 
the  use  of  a  staphylococcus  spray;  a  fresh  bouillon  culture  is  sprayed 
into  the  nose  and  throat,  until  they  are  moist;  recent  reports  are  encour- 
aging. V.  Behring  recently  reports  a  new  prophylactic  against  diphtheria 
— a  mixture  of  very  strong  diphtheria  toxui  and  antitoxin  combined  in 
such  a  proportion  that  the  mixture  shows  only  a  slight  surplus  of  the 
toxin;  the  method  is  a  result  of  experiments  which  shows  that  it  is  impos- 
sible to  produce  in  a  test-tube  complete  neutralization  of  the  diphtheria 
toxin. 

2.  Local  Treatment. — Though  local  treatment  of  the  throat  is  less 
important  than  before  the  days  of  serotherapy,  the  antitoxin  does  not 
always  kill  the  bacilli,  and  does  not  affect  the  associated  streptococci. 
Caustics  are  never  indicated.  In  children  such  mild  antiseptics  as 
3  per  cent,  boric  solution  and  3  to  10  per  cent,  potassium  permanganate 
solution,  should  be  used  lest  they  be  swallowed.  The  child  is  held  in 
the  nurse's  arms  with  its  arms  and  body  firmly  wrapped  in  a  sheet. 
The  mouth  is  opened  by  closing  the  nostrils,  and  a  piece  of  cork  is  inserted 
between  the  teeth.  The  throat  is  then  swabbed.  It  is  a  harsh  procedure 
and  the  benefit  is  apparently  more  than  offset  by  the  resultant  exliaus- 
tion.  In  adults  1  to  1000  bichloride,  25  per  cent,  hydrogen  peroxide, 
1  per  cent,  carbolic  solution,  or  iodoform  salve,  may  be  used,  or  the 
somewhat  irritating  LoefHer's  solution,  which  is  as  follows: 

I^— Mentholis 10  parts 

Toluolis 30  parts 

Liq.  ferri  chloridi 4  parts 

Alcoholis  absoluti 60  parts 

It  should  be  kept  corked  in  a  dark  bottle.  Local  injury,  opening  up  new 
wound  surfaces  for  infection,  must  be  avoided.  In  nasal  irrigation  the 
tube  is  held  horizontally,  so  that  fluid  may  return  by  the  other  nostril. 
A  kettle  should  be  kept  steaming  in  the  room. 


DIPHTHERIA  87 

3.  Serotherapy. — Behring  (1890)  borrowed  Ehrlich's  results  with 
ricin  and  abrin  to  establish  the  units  of  immunization,  and  used  the 
diphtheria  antitoxin  on  diphtheria  patients  (1893).  Antitoxin  is  obtained 
from  horses  which  have  been  rendered  immune  by  the  injection  of  pro- 
gressively increasing  doses  of  diphtheria  bacilli.  Accordmg  to  Ehrlich's 
"side-chain"  theory,  toxins  combine  chemically  with  the  cells  of  the 
body,  just  as  food  unites  with  cells  in  ordinary  metabolism.  Parts  of 
the  cells,  which  combine  with  toxins,  are  called  receptors.  The  stimula- 
tion or  injury  excited  by  toxins  causes  in  the  process  of  repair,  an  over- 
production of  receptors,  which  are  thrown  free  as  antibodies,  into  the 
circulation.  Thus  the  horse  serum  unites  with  toxins  and  spares  the 
cells  in  human  diphtheritic  toxemia.  Immunity  may  result  from  the 
body  cells  being  devoid  of  receptors  or  an  excess  of  receptors  in  the  blood 
may  unite  with  the  toxins  and  spare  the  cells. 

1.  Techiique. — The  glass  syringe  is  the  best;  it  should  be  cleaned  after 
each  injection,  with  water  to  remove  the  serum,  and  then  washed  with 
alcohol,  which  should  be  thoroughly  removed  lest  it  coagulate  the  anti- 
toxin at  the  next  injection.  With  ordinary  surgical  antisepsis,  inject 
the  antitoxin  into  the  muscular  tissue  of  the  thigh  in  adults,  and  into 
the  interscapular  region  in  children.  Intravenous  injections  act  in  16 
hours,  intramuscular  in  24  hours,  and  subcutaneous  in  72  hours. 

2.  As  we  cannot  measure  the  toxins  the  dosage  is  empirical,  depending 
on  the  localization,  age,  severity  of  the  disease  and  the  results  obtained 
(the  discharge  should  lessen,  the  membrane  exfoliate,  the  fever  fall,  and 
toxemia  decrease).  After  eight  hours,  three  times  as  much  is  necessary 
as  at  the  beginning;  after  twenty-four  to  thirty-six  hours,  eight  times 
as  much.  The  author  prefers  an  initial  dosage  of  5,000  units  to  insure 
results  and  avoid  frequent  repetition.  The  unit  is  1  c.c,  which  counter- 
acts ten  times  the  minimum  dose  of  diphtheria  poison  fatal  to  a  300  gm. 
guinea-pig.  The  decreased  bulk  of  present  preparations  allows  a  larger 
dosage.  In  severe  cases  twice  the  above  amount  should  be  given.  Mc- 
Callum  emphasized  the  importance  of  full  doses,  10,000,  30,000  or  50,000 
units  in  desperate  cases.  Sutherlin  gave  a  total  of  498,000  units  in  one 
case.  The  present  practice  reverts  to  smaller  doses,  1200  to  2000  in 
mild,  and  3000  to  6000  in  severer  infections. 

3.  Effects. — (a)  The  mucosa  becomes  redder,  and  the  membrane 
exfoliates  in  one  to  three  days,  with  decrease  in  glandular  swelling;  (b) 
The  fever  falls;  antitoxin  is  given  until  the  fever  falls,  (c)  The  pulse 
and  hyperleukocytosis  decrease.  Light  cases  rarely  become  severe, 
and  non-septic  rarely  become  septic.  Paralysis  and  heart  failure  are 
less  frequent  with  early  serotherapy;  many  patients  now  live  who  pre- 
viously died  before  developing  paralysis,  (d)  The  mortality  is  reduced 
from  40  to  15  per  cent.  (Siegert's  collection  42,000  cases);  to  10  per 
cent.  (Wenner,  9.8  per  cent.,  132,500  cases,  American  cities);  or  to 
6.7  per  cent.  (Chicago  Health  Department).  According  to  Bayeux, 
the  mortality  in  230,000  diphtheria  patients  was  55  per  cent,  before,  and 
16  per  cent,  after,  the  introduction  of  antitoxin.  The  fatal  cases  and 
severe  complications  are  lessened  in  direct  ratio  as  the  antitoxin  is  given 
early;  if  on  first  day  of  disease,  less  than  1  per  cent.;  second  day,  2  per 


88  BACTERIAL  DISEASES 

cent.;  third  day,  8  to  10  per  cent.;  fourth  day,  14  per  cent.  Failure  to 
use  antitoxin  is  criminal  neglect,  (e)  Antitoxin  is  a  prophylactic,  and 
should  be  given  in  special  instances,  e.  g.,  to  weak  or  very  young  children 
(in  smaller  doses) ;  this  passive  immunity  lasted  for  two  or  three  weeks 
in  all  but  0.7  per  cent,  of  1000  cases  (Zuppinger).  (/)  The  sequels  are: 
(i)  Abscess  formation;  (ii)  nephritis,  always  due,  however,  to  the  diph- 
theria itself;  (iii)  serum  disease  and  anaphylaxis.  In  one  or  two  weeks 
fever  and  exanthems  appear  in  33  per  cent,  of  cases — urticarial  mostly, 
but  also  morbilliform,  scarlatiniform  and  petechial.  In  3  to  4  per  cent. 
there  is  also  acute  pain  and  swelling  in  the  joints  or  tendons.  Another 
type  comes  on  more  rapidly  (12  hours  to  6  days),  the  "accelerated 
reaction" — with  the  above  symptoms  plus  vomiting,  albuminuria, 
prostration,  and  weak  heart.  A  third  type  appears  at  once,  the  "  imme- 
diate reaction,"  with  high  fever,  convulsions,  dyspnea,  cyanosis,  vaso- 
motor paralysis,  and  rigors.  In  a  fourth  form,  sudden  death  ensues, 
of  which  some  35  instances  are  on  record  (in  all  but  2  instances, 
death  followed  the  first  injection);  most  deaths  occurred  in  persons  of 
asthmatic  tendencies  or  in  those  experiencing  discomfort  in  the  neigh- 
borhood of  horses.  This  condition  is  termed  serum  disease,  hypersus- 
ceptibility,  anaphylaxis,  allergy,  etc.  In  its  varying  degrees  it  is  due  to 
hypersusceptibility  of  the  tissues  to  a  specific  foreign  proteid;  thus,  the 
first  dose  of  antitoxin  causes  a  gradual  increase  of  the  antibodies  which 
have  the  properties  of  a  ferment;  if  a  second  injection  be  given  8  to  10 
days  later,  the  antibodies  (now  increased)  acting  like  a  ferment,  produce 
a  rapid  disintegration  of  the  proteids,  with  liberation  of  toxic  substances, 
causing  the  anaphylaxis,  which  is  closely  related  to  the  immunity  problem. 
Auer  and  Lewis  proved  that  the  lungs,  in  fatal  cases,  are  enormously 
distended,  due  to  a  tetanic  muscular  contraction  of  the  finer  bronchioles; 
the  heart  is  also  paralyzed.  How  may  these  disasters  be  avoided ?  First: 
There  is  greater  danger  of  anaphylaxis  in  immunizing  serotherapy  than 
in  its  use  for  actual  diphtheritic  infection;  the  writer  has  seen  high  fever, 
renal  suppression  and  the  most  alarming  vasomotor  instability  (pallor, 
cyanosis  and  scarlet  flushing  occurring  in  succession).  Immunizing 
serotherapy  must  not  be  indiscriminate.  (Schick  uses  0.1  c.c.  of  toxin 
solution  intradermically  and  finds  that  subjects  not  immune  to  diph- 
theria develop  a  reaction  similar  to  v.  Pirquet's  in  tuberculosis).  Second: 
One  large  dose  is  less  dangerous  than  doses  repeated  at  frequent  intervals. 
Third:  A  small  dose  (0.5  c.c.)  is  given  first  and  if  there  is  no  reaction,  a 
second  full  injection  is  given.  Fourth:  The  second  or  later  injections 
should  be  from  some  other  animal  than  the  horse,  e.  g.,  sheep  antitoxin, 
etc.  Fifth:  Give  the  smallest  possible  bulk  of  serum.  Sixth:  Use 
atropine  before  the  second  dose,  and  if  anaphylactic  symptoms  have 
developed,  use  salt  solution  and  adrenalin  (1  to  40,000);  digitalis  is 
injurious,     (iv)  Seibert  collected  18  cases  of  tetanus  following  antitoxin. 

4.  Symptomatic  Treatment. — A  rich  fluid  diet  of  milk,  eggs,  etc.,  is 
given.  In  marked  dysphagia,  rectal  feeding  is  indicated.  Forced  feeding 
by  the  nasal  catheter  injures  the  throat. 

Sepsis. — Alcohol,  saline  enemata,  strychnine  and  iron  should  be  given; 
all  measures  fail  if  tens  of  thousands  of  units  do  not  give  relief. 


CEREBROSPINAL  FEVER  89 

Paralysis. — Electricity  is  of  no  avail;  massage,  baths  and  strychnine 
are  useful  in  the  later  stages. 

Heart  Failure. — The  ice-bag  is  indicated  for  stormy  heart  action; 
strychnine,  coffee  and  camphor  should  be  given  (dosage  v.  page  269)  for 
severe  abdominal  pain  and  vomiting,  usually  evidences  of  cardiac  failure, 
and  champagne  with  menthol  and  carbolic  acid,  and  twenty  drops  each 
of  adrenalin  and  tr.  belladonnse  in  nutrient  enemata.  The  heart  must 
be  watched  far  into  convalescence. 

NeijJiritis. — Alcohol,  tincture  of  iron,  beef-tea  and  eggs  are  avoided; 
milk  diet,  baths,  laxatives  and  care  of  the  skin  are  indicated. 

Local  Diphtheria. — Two  per  cent,  nitrate  of  silver  in  balsam  of  Peru 
affords  relief  in  vaginitis;  ice  applications,  atropine  and  silver  in  ophthal- 
mia; local  diphtheria  necessitates  antitoxin. 

Croup. — Steam  tents  and  ice  locally  are  applied;  the  child's  head  may  be 
held  over  a  pail  of  water  into  which  live  coals  are  thrown;  emetics  may 
be  administered.  Retraction  of  the  chest  walls,  suffocation  and  cyanosis 
necessitate  intubation  or  tracheotomy. 

(fD  layer's  Intubation. — Advantages. — It  is  bloodless,  easier  and  quicker 
than  tracheotomy,  and  is  less  objectionable  to  the  family. 

Disadvantages. — Membrane  may  rise  beneath  the  tube  and  the  tube 
sometimes  produces  false  passages,  necrosis,  perichondritis  and  stricture. 
The  tube  is  usually  replaced  two,  three  or  four  times,  and  rarely  need 
remain  more  than  five  days  when  the  serum  is  used.  It  is  removed  by 
the  extubator  or  pressure. 

Tracheotomy  is  indicated  by  heart  weakness,  asphyxia,  much  secretion, 
or  gangrenous,  diffuse  or  septic  infiltration.  The  after-treatment  requires 
a  moist  atmosphere  and  daily  cleaning  of  the  tracheotomy  tube.  The 
tube  is  not  permanently  removed  until  all  stenotic  symptoms  and  all 
plaques  disappear,  which,  with  serotherapy,  may  be  done  on  the  fourth 
day.  The  prognosis  depends  upon  possible  wound-infection  with  erysipe- 
las or  diphtheria,  phlegmon,  thrombophlebitis,  mediastinal  suppuration, 
ulceration  of  trachea  and  inhalation  pneumonia.  Rapid  rise  of  tem- 
perature is  ominous.  Antitoxin  reduced  the  mortality  from  66  per  cent, 
to  25  per  cent. 

CEREBROSPINAL   FEVER. 

Definition. — An  acute  infection,  caused  by  the  meningococcus,  charac- 
terized anatomically  by  fibrinopurulent  exudation  in  the  meninges  and 
marked  clinically  by  headache,  rigidity  of  the  spine,  hyperesthesia, 
vomiting,  Kernig's  sign  and  often  by  paralyses. 

In  1805  Vieusseux  described  epidemic  meningitis;  in  1806  Danielson 
and  Mann,  in  New  England,  made  the  first  autopsies. 

Bacteriology. — The  Diplococcus  intracellularis  meningitidis  of  Weich- 
selbaum  or  meningococcus  resembles  the  pneumococcus,  though  wider 
and  less  lanceolate.  It  lies  in  pairs  or  tetrads  and  resembles  two  coft'ee 
grains  with  their  flat  sides  apposed.  It  is  usually  enclosed  in  the  poly- 
morphonuclear leukocytes.  Unlike  the  pneumococcus,  it  has  no  capsule, 
although  one  may  develop  in  serum  cultures.  It  decolorizes  by  Gram's 
method.    It  develops  best  on  agar  or  blood  serum  as  white,  viscid,  shin- 


90  BACTERIAL   DISEASES 

ing  colonies.  Subcutaneous  inoculations  are  usually  negati^'e,  therein 
differing  from  the  pneumococcus,  but  it  produces  inoculation-meningitis 
and  peritonitis.  The  meningococcus  is  found  in  the  nose,  from  -s^'hich 
it  is  thought  to  invade  the  brain,  in  cases  with  and  without  meningitis. 
Von  Lingelstein  found  it  in  the  nasopharynx  in  94  per  cent,  of  cases  in 
the  SUesian  epidemic  and  every  time  in  OS  personal  observations.  He 
asserts  that  the  disease  is  communicable  only  by  direct  contact  with 
the  mucus  from  the  nasopharynx  of  patients  or  of  those  in  contact  with 
them.  Its  presence  has  been  demonstrated  in  the  blood  in  25  per  cent, 
of  cases  by  Elser;  kidneys,  herpetic  vesicles,  conjunctiva,  joints,  spleen, 
ear,  tonsils,  lymphatic  nodes,  pleura,  lung,  heart  and  more  rarely  in 
the  sputum  and  urine;  it  travels  by  way  of  the  lymph  or  bloodvessels. 
Meningococcus  septicemia  without  meningitis  is  recorded  in  four  instances 
(Bovaird). 

Predisposing  Etiology. — Fifteen  per  cent,  occurs  under  two  years  of 
age  and  60  per  cent,  between  the  second  and  fifteenth  years;  it  is  often 
epidemic  in  barracks,  prisons  and  tenements  or  closely  follows  the  move- 
ments of  armies.  Its  contagiousness  is  proven.  As  many  as  seven  members 
of  a  family  have  been  successively  stricken.  Between  epidemics,  1.7 
per  cent,  of  persons  are  said  to  be  "carriers,"  and  during  epidemics,  2.5 
per  cent.;  Fliigge  estimates  that  the  healthy  carriers  outnumber  by  ten- 
fold those  sick  with  the  disease.  Fortunately  the  coccus  has  little  resist- 
ing powers  outside  the  body.  Most  cases  are  seen  in  the  late  winter  and 
early  spring;  3455  deaths  occurred  in  New  York  in  1904  and  1905.  In 
a  Silesian  epidemic  in  1905  there  was  a  mortality  of  57.6  per  cent,  in  3102 
cases.  Councilman  collected  five  instances  of  recurrence.  The  disease 
is  also  seen  in  the  horse  and  goat. 

Pathology. — The  findings  are  those  of  the  suppurative  form,  viz.,  those 
of  an  acute  fibrinopurulent,  or  less  often  a  seropurulent  leptomeningitis. 
The  exLidate  is  rich  along  the  fissures,  fossa  of  Sylvius  and  at  the  base 
about  the  chiasm  or  the  surface  of  the  pons  and  cerebellum.  The  inflam- 
mation follows  the  lymphatics  and  vessels  penetrating  the  brain  and 
cord,  resulting  in  encephalitic  or  myelitic  foci,  small  abscesses,  paren- 
chymatous and  interstitial  changes.  Flexner  and  Barker  observed  rows 
of  cells  "like  miniature  tubercles,"  two  to  eight  times  the  size  of  the 
leukocytes.  Hydrops  ventriculorum  is  frequent  in  cases  of  long  standing. 
The  cerebral  dura  is  seldom,  and  the  spinal  dura  often,  involved.  In 
other  organs  the  changes  are  those  of  acute  infection;  the  muscles  are 
brownish-red,  dry  and  degenerated,  there  is  parenchymatous  degenera- 
tion in  the  heart  and  kidneys,  and  sometimes  acute  splenic  tumor, 
arthritis,  pneumonic  foci  or  swollen  glands  in  which  the  coccus  may  be 
found. 

Sjonptoms. — The  incubation  lasts  from  a  few  hours  to  three  to  eleven 
days.  Prodromes  are  vague,  as  malaise,  headache  or  coryza.  The 
onset  may  be  gradual  or  sudden,  sometimes  with  a  chill  and  usually  with 
fever.  The  course  is  attended  by  fever  and  brain  irritation;  an  almost 
constant  triad  of  s^Tnptom5,  headache,  rigid  neck  and  hyperesthesia; 
vomiting,  mental,  motor  and  sensory  symptoms,  and  in  fatal  cases  death 
results  from  paralysis,  convulsions  or  coma. 


CEREBROSPINAL  FEVER 


91 


1.  General  Nerv^ous  Symptoms. — (a)  Headache  is  very  rarely  absent 
except  in  very  young  children.  It  is  early,  most  severe  and  generalized. 
It  is  constant,  with  exacerbations,  and  in  children  provokes  the  short 
plaintive,  clear  meningeal  cry,  cri  hydrencephaliqtie  (Coindet,  1817). 
The  headache  is  throbbing  or  lancinating,  even  under  narcotics,  and 
persists  even  after  delirium  and  coma  have  set  in.  Its  cause  may  be 
compression  of  the  dura,  inflammation  of  the  nerve  trunks,  or  ventricu- 
lar exudation,  (b)  Hyperesthesia  or  hyperalgesia  affects  the  special 
senses,  causing  intolerance  of  light  and  noise,  or  general  sensation — affect- 
ing the  arms  most,  the  trunk  less  and  the  legs  least.  It  is  rarely  absent, 
always  suggestive,  and  due  to  root  neuritis,  (e)  Rigidity  of  the  neck 
and  spine  is  caused  by  inflammation  of  the  nerve  roots.  The  head  is 
retracted,  sometimes  so  severely 
that  the  occiput  lies  between 
the  shoulders,  producing  dys- 
phagia and  decubitus;  marked 
opisthotonos  may  be  present. 
The  entire  body  may  be  lifted 
by  the  head.  The  most  com- 
mon attitude  is  the  lateral,  with 
the  head  retracted,  the  arms 
flexed  and  the  knees  drawn  up. 
Flexures  in  the  ankles,  knees 
and  hips  result  when  an  attempt 
is  made  to  flex  the  neck  (Brud- 
zinski's  "neck  sign").  Closely 
associated  and  caused  in  the 
same  way  is  severe  spinal  pain 
with  tenderness,  chiefly  in  the 
neck  and  loins.  It  may  radiate 
to  the  trunk  and  in  33  per  cent, 
of  cases  to  the  extremities,  (d) 
Contractures  of  the  limbs  are 
caused  by  root  inflammation, 
increased  pressure,  or  lesions  in 
the  pyramidal  tracts.  Kernig's 
sign  comes  under  this  head ;  when 

the  patient  sits  or  the  thighs  are  at  right  angles  with  the  trunk,  in  85  per 
cent,  of  all  meningitis  cases  it  is  impossible  to  extend  the  knees  (Fig.  11). 
The  legs  and  thighs  are  flexed  (flexor  contracture)  and  the  knees 
cannot  be  pressed  down  when  the  patient  is  sitting,  but  this  is  possi- 
ble when  he  is  lying.  It  indicates  involvement  of  the  spinal  meninges, 
pyramidal  tracts  or  posterior  sensory  roots.  It  lasts  well  into  convales- 
cence, whence,  as  Netter  states,  "a  retrospective  diagnosis  may  be  made." 
It  occurs  in  other  conditions,  but  in  infancy  is  generally  meningitic. 
(e)  Mental  symptoms  occur  early,  especially  in  children  and  include  unrest, 
insomnia,  delirium  sometimes  with  periods  of  normal  intelligence,  and  fol- 
lowed by  incomplete  coma.  (/)  Vomiting  in  the  initial  stage  is  due  to 
vagus  irritation ;  later  it  results  from  ventricular  hydrops  or  increased  cere- 


FiG.  11. — Kernig's  sign,  showing  retraction  of 
head  and  back  and  prominence  of  knees  in  the 
erect  posture,  i.  e.,  the  impossibility  of  extension 
of  knees.      (Dieulafoy.) 


92         ■  BACTERIAL  DISEASES 

brospinal  pressure.  It  is  of  the  cerebral  type,  i.  e.,  it  occurs  \Yithout  nausea 
or  relation  to  eating,  is  often  projectile  and  is  not  amenable  to  gastric 
therapy.  Vomiting  is  more  typical  and  common  in  children,  (g)  The 
puhe  at  first  is  increased,  perhaps  dispropottionately,  considering  the 
fever.  Sometimes  it  slows  later  because  of  brain  pressure,  but  ultimately 
it  is  fast  again.  It  may  be  irregular  in  rhythm  and  oscillating  in  rate 
from  84  to  1-4-i  within  a  minute.  Blood-pressure  increases  in  proportion 
as  the  disease  is  severe,  (h)  Resyiration  is  irregular  in  20  per  cent,  of 
cases;  Cheyne-Stokes  breathing  develops  toward  the  end  in  53  per  cent. 
(Conner).  Deep  breathing  with  apneic  pauses  and  undulatory  respira- 
tion (Biot's  breathing)  are  less  common  than  in  the  tuberculous  type. 
{{)  Conndsions  are  most  common  in  the  young,  but  are  ambiguous  from 
their  frequent  occurrence  in  other  diseases  of  childhood. 

2.  Focal  Xervous  Symptoms. — These  are  partly  irritative  and  partly 
paralytic,  (a)  The  cranial  nerves  are  most  involved  in  basal  localization, 
while  the  limbs  are  most  affected  in  that  of  the  convexity.  Optic  neuritis 
is  frequent,  if  the  disease  lasts  over  four  days.  The  disk  is  swollen  and 
its  margin  is  "washed";  hemorrhage  and  choking  are  uncommon.  (See 
Plate  IV,  Fig.  4.)  The  pupils  at  first  are  usually  small,  often  unequal, 
and  sometimes  variable.  Later  they  widen  spontaneously  or  on  move- 
ment of  the  rigid  neck  and  irritation  of  the  skm,  but  do  not  react  to 
light.  Ptosis,  diplopia,  nystagmus  and  strabismus  are  frequent  and  may 
vary  from  time  to  time.  Complete  paralysis  of  the  third  nerve  is  not 
common.  Involvement  of  the  fifth  nerve  is  unusual,  although  trismus, 
grinding  of  the  teeth  and  trigeminal  neuralgia  have  been  noted.  Involve- 
ment of  the  facial  nerve  ranks  next  to  that  of  the  third  nerve;  basal 
paralysis  is  usually  total;  cortical  palsy  is  of  the  cerebral  type,  and  its 
upper  third  escapes.  The  facial  expression  indicates  suft'ering,  the  brows 
are  slightly  elevated  and  the  forehead  is  corrugated.  The  auditory  nerve 
is  often  bathed  in  pus,  and  extension  may  induce  hemorrhagic  inflam- 
mation in  the  labyrinth.  The  tongue  on  protrusion  may  deviate  to  one 
side;  dysarthria  or  dysphagia  is  sometimes  seen.  (6)  Paralysis  of  the 
limbs  is  not  frequent.  Hemiplegia  is  rarely  complete,  occurs  with  or 
without  participation  of  the  tongue  and  face,  and  is  caused  by  involve- 
ment of  the  cortex  or  p^Tamidal  tracts.  It  is  frequently  accompanied 
by  rigidity  of  the  limbs  and  aphasia.  It  is  most  frequent  in  children 
and  may  be  temporary  or  permanent.  The  less  frequent  monoplegia 
most  often  concerns  the  face  or  arm.  Choreiform  or  athetotic  movements, 
twitchings  and  tremors  are  occasional.  Convulsions  are  frequently 
Jacksonian  in  t^'pe.  The  tendon  reflexes  may  be  increased  at  first  and 
are  often  decreased  or  abolished  late  in  the  disease.  The  skin  reflexes 
are  variable. 

3.  General  axd  Somatic  Sy^iptoms. — (a)  The  almost  invariable 
fever  is  usually  irregular  or  remittent,  follows  no  definite  cycle,  and  lysis 
is  usual  in  cases  which  reco^'er.  A  temperature  of  107°  may  be  registered 
before  death.  (&)  The  hlood  shows  leukocytosis,  which  is  early  and 
constant;  the  white  cells  may  mmiber  25,000  to  40,000;  the  lympho- 
cytes increase  during  convalescence;  the  meningococcus  is  found  in  25 
per  cent,  of  cases,     (c)  The  abdomen  is  often  retracted  and  scaphoid, 


PLATE  IV 


Retinal  Findings  in  the  More  Important  Diseases. 

1.  Retinitis  diabetica.  2.  Atrophy  (and  pigmentation)  of  retina  and  optic 
nerve.  3.  Choked  disk  in  brain  tumor.  4.  Optic  neuritis  in  meningitis.  5. 
MeduUated   nerve   fibers    (normal). 


CEREBROSPINAL  FEVER  93 

although  less  so  than  in  the  tuberculous  type;  it  is  due  to  retraction  of 
the  abdominal  walls  or  possibly  of  the  intestines  from  irritation  of  the 
vagus,  (d)  The  spleen  is  often  palpable,  (e)  The  urine  is  febrile,  albu- 
minous (33  per  cent.)  and  may  show  peptonuria,  hematuria  in  malignant 
cases,  and  rarely  glycosuria  or  polyuria.  (/)  Skin:  The  tdcJie  cerebrale 
has  no  differentiating  value,  for  it  occurs  in  many  other  conditions. 
Eruptions  are  more  common  in  epidemic  than  in  sporadic  cases.  Herpes 
viiTies  with  the  epidemic  (40  to  even  90  per  cent.) ;  it  is  most  frequent  on 
the  face,  but  may  develop  anywhere;  it  spreads  more  rapidly  than  in 
any  other  disease;  in  one  case  the  author  saw  it  extend  from  the  lip  to 
the  ear,  neck,  chest  and  shoulder.  Purpura  (" spotted  fever")  occurs  in 
severe  t\'pes. 

Clinical  Forms. — (a)  The  ordinary  acute  type  in  which  the  general 
nervous  symptoms  enumerated  are  followed  by  focal  nervous  s>-mptoms, 
somatic  symptoms,  death  in  coma,  or  slow  recovery;  (b)  the  foudroyant 
form,  with  violent  onset,  rapid  course  and  death  in  three  to  thirt.y-six 
hours,  with  apoplectic  symptoms,  purpura,  high  fever  and  early  coma; 
(«?)  the  abortive  form,  with  low  fever  and  symptoms  so  mild  that  the 
disease  is  recognized  only  during  an  epidemic;  and  (d)  Heubner's 
chronic  form,  which  lasts  two  to  six  months,  with  marasmus  and  recur- 
rent fever. 

Complications  and  Sequels. — Pneumonia,  tonsillitis,  pleurisy,  parotitis, 
endo-  and  pericarditis,  arthritis  and  nephritis  are  the  most  common. 
Pneumonia  is  usually  pneumococcic,  but  Councilman  found  the  menin- 
gococcus in  isolated  foci  in  the  lung.  The  arthritis  is  poly-  or  mono- 
articular, simple  or  suppurative,  and  may  heal  even  when  suppurati\'e; 
it  occurs  in  25  per  cent.  ]\Iental  alteration,  paralysis,  contractures, 
obstinate  headache,  optic  atrophy,  deafness  or  Meniere's  syndrome, 
chronic  hydrocephalus,  vomiting  and  convulsions  may  remain  after 
recovery.  In  a  Heidelberg  epidemic,  Moos  found  deaf-mutism  in  60 
per  cent.,  deafness  in  31  per  cent,  and  ataxia  in  50  per  cent,  of  th?  cases. 

Prognosis. — The  mortality  averages  37  per  cent.,  but  it  varies  with  the 
epidemic,  and  may  reach  75  per  cent.  Fifty  per  cent,  of  deaths  occur 
in  the  first  five  days.  Recovery  is  exceptional  after  deep  coma,  repeated 
convulsions,  high  fever  or  vagus  paralysis.  Obstinate  vomiting,  dis- 
turbed respiration,  sudden  drop  of  temperature  and  inanition  are  ominous 
signs. 

Diagnosis. — The  first  step  is  the  diagnosis  of  meningitis,  and  the  second, 
its  variety,  cause  and  localization. 

Cardinal  Sy:\iptoms. — (a)  The  early  triad  of  headache,  retracted  rigid 
neck  and  hyperesthesia  and  (b)  general  symptoms,  as  vomiting,  abdomi- 
nal retraction,  pulse  and  respiratory  changes,  fever  or  convulsions,  are 
important  in  their  grouping,  (c)  Lumbar  puncture  (Quincke,  1890)  is 
of  great  diagnostic  value.  Its  technique  is  as  follows:  The  patient  sits 
or  lies  on  the  side  with  the  knees  drawn  up  and  the  body  bent  as  far 
forward  as  spinal  rigidity  allows;  an  aspirating  needle  is  introduced  in 
the  median  line  in  children,  and  a  quarter  to  half  an  inch  to  one  side  in 
adults,  between  the  third  and  fourth  lumbar  vertebrae  and  is  pushed 
forward  toward  the  median  line  and  a  little  upward,  1.5  inches  deep  in 


94 


BACTERIAL  DISEASES 


children  and  1.5  to  2.5  inches  in  adults,  until  it  passes  into  the  canal; 
15  to  30  c.c.  should  be  withdrawn.  Results:  (i)  Normally  the  pressure 
with  the  patient  in  the  lateral  position,  equals  100  to  150  mm.  of  water 
and  the  escaping  fluid  only  trickles  out.  In  meningitis,  the  pressure  is 
greatly  increased  (200  to  700  mm.)  and  the  fluid  often  spurts  out.  (ii) 
The  normal  fluid  is  clear,  has  a  specific  gravity  of  1.007-09  and  contains 
little  albumin  (^  to  1  gm.  per  mille).  Though  the  fluid  may  be  clear  in  all 
forms  of  meningitis,  it  is  usually  clear  in  the  serous  form,  but  cloudy, 
flocculent  or  sometimes  bloody  in  other  forms;  in  the  tuberculous  variety 
it  is  usually  clear  or  slightly  yellow  with  a  whitish  clot  forming  on  stand- 
ing; in  the  epidemic  form,  it  may  be  turbid  or  clear,  with  a  yellowish 
clot;  in  the  purulent  type  it  is  opaque,  and  in  rare  cases  pure  pus.  The 
specific  gravity  is  about  1.010  in  the  serous,  1.011  in  the  tuberculous,  and 
1 .015  in  the  purulent  or  epidemic  type.  The  percentage  of  albumin  is  small 
in  the  serous,  2  per  mille  in  the  tuberculous,  and  3  or  even  9  gm.  per  mille 
in  the  suppurative  forms.  The  Nonne,  Noguchi  and  Ross-Jones  globulin 
tests  are  positive,  (iii)  Bacteriologically  in  the  purulent  type  the  strep- 
tococcus, staphylococcus,  pneumococcus,  typhoid  and  colon  bacilli  are 
found;  in  the  epidemic  variety,  the  meningococcus  was  positive  in  100 
per  cent,  in  the  last  New  York  epidemic;  in  the  tuberculous  type,  tu- 
bercle bacilli  exist  in  80  to  100  per  cent,  in  the  small  clot,  which  forms 
after  standing,  (iv)  The  cellular  morphology  is  a  valuable  aid.  In 
purulent  and  epidemic  forms  the  leukocytes  are  largely  polymorphonu- 
clear; in  the  tuberculous  form  the  lymphocytes  predominate  (see  Cyto- 
DiAGNOSis,  Pleurisy),  (d)  Local  signs  usually  follow  the  general  signs, 
and  are  more  important,  but  their  late  development  lessens  their  diag- 
nostic value. 

Diagnosis  of  the  Variety  {v.  ^.). — Cases  of  tuberculous  meningitis 
sometimes  increase  when  the  epidemic  form  prevails.  Sporadic  cases 
may  be  indistinguishable  from  primary  pneumococcic  meningitis,  save 
by  lumbar  puncture. 


EPIDEMIC  FORM. 

Onset:  Sudden,  with  few 
prodromes. 

Fever:  Fairly  high;  pulse 
more  rapid. 

Eruptions:  Herpes  and  pur- 
pura very  common. 

Leukocytosis:  Regular  and 
marked. 

Rigidity  of  neck:  Most 
frequent. 

Other  symptoms:  Pepto- 
nuria. 

Course :  Rapid  —  more  re- 
coveries. 

Lumbar  puncture:  Menin- 
gococcus; leukocytes, 
polymorphonuclear. 


TUBERCULOUS. 

Longer  prodromes;  family 
history;  other  evidences 
of  tuberculosis. 

Less;  in  versed  type  fre- 
quent. 

Rare. 

Exceptional. 

Spinal  symptoms  less  fre- 
quent. 
Choroidal  tubercles. 

Subacute,  slower,  fatal. 

Tubercle  bacilli;  mono- 
nuclear. 


SUPPURATIVE. 

Secondary  to  ear  disease, 
acute  infections,  pneu- 
monia, etc. 

Especially  high,  with  chills 
or  pyemia. 

Rare — ^polymorphous  septic 
rashes. 

Frequent. 

Sometimes  absent  (pneumo- 
coccic) . 
Peptonuria. 

More  acute,  very  rarely  re- 
cover. 
Pyogenic    cocci,    pneumo- 
coccus ;  polymorphonuclear. 


Diagnosis  of  Location. — (a)  Convexity  localization  is  characterized 
by  delirium,  Jacksonian  convulsions,  mono-  or  hemiplegia,  less  cranial 


CEREBROSPINAL  FEVER  95 

nerve  paralysis  and  less  optic  neuritis;  (6)  basal  localization,  by  more 
frequent  cranial  nerve  neuritis  and  optic  neuritis;  (c)  the  ventricular 
form  rarely  in\-olves  the  cranial  nerves. 

Differentiation. — 1.  From  Nervous  Toxemia. — Jenner  pointed  out 
that  toxemic  headache  ceases  when  delirium  begins  in  acute  infections. 
Meningitis  without  focal  symptoms  may  resemble  uremia  {q.  v.),  but 
the  albuminuric  retinitis,  cardiovascular  changes,  albuminuria  and 
cylindruria  are  usually  distinctive.  Acute  inflammation  of  the  labyrinth 
may  mimic  meningitis,  for  it  sometimes  produces  headache,  vomiting, 
fever,  convulsions,  stiff  neck  and  even  optic  neuritis;  if  labyrinthitis 
in\-olves  the  meninges,  the  facial  nerve  is  likely  to  be  affected.  Such 
conditions  resembling  meningitis  Dupre  called  meningismus,  and  Bou- 
chut  pseudomeningitis  (see  pages  34,  46,  47). 

2.  From  Brain  Disease. — See  syphilitic  and  tuberculous  meningitis, 
brain  abscess,  cerebral  hemorrhage  and  encephalitis. 

3.  From  Hysteria. — Hysteria  is  marked  by  psychical  alteration, 
limitation  of  the  field  of  vision,  anesthesia  and  other  stigmata.  Hys- 
terical strabismus  is  always  spastic  and  convergent,  and  is  often  asso- 
ciated with  small  pupils;  meningitic  strabismus  is  often  divergent  (always 
a  sign  of  organic  disease),  aiid  the  pupils  are  unequal. 

Treatment. — Prophylaxis;  the  nose  should  be  douched  with  a  weak 
resorcin  solution. 

Flexner's  and  Jobling's  Serum  has  given  70  per  cent,  of  recoveries 
in  1300  cases;  given  on  first  to  third  day  the  mortality  was  18  per 
cent.;  fourth  to  seventh,  27  per  cent.;  after  the  seventh  day,  37  per 
cent.  The  results  are  (a)  the  meningococci  become  more  intracel- 
lular, and  degenerate;  (b)  the  exudate  becomes  less  turbid  or  purulent; 
(c)  leukocytosis  decreases  rapidly;  and  (d)  complications  are  few  and 
recovery  is  usually  complete.  The  mortality  under  1  year  was  50  per 
cent.;  1-2  years,  31  per  cent.;  2-5  years,  28  per  cent.;  5-10  years,  15 
per  cent.;  10-20  years,  37  per  cent.  The  serum  is  bactericidal  rather 
than  antitoxic,  although  some  antibodies  exist  in  the  serum.  In  some 
failures,  the  parameningococcus  should  be  considered;  it  was  discovered 
by  Dopter  and  is  distinguished  by  the  fact  that  it  does  not  agglutinate 
in  antimeningococcus  serum.  Technique:  Lumbar  puncture  is  performed 
and  from  the  trickling  fluid,  cover  slips,  cultures  and  a  leukocyte  count 
are  made.  If  possible,  30  to  45  c.c.  are  withdrawn;  an  aspirating  syringe 
is  then  attached  and  injects  an  equal  amount  of  serum,  warmed  to  body 
temperature  by  standing  in  warm  water.  Injections  are  repeated  daily 
for  4  days,  and  if  improvement  follows,  injections  are  discontinued  for 
4  days,  and  then  repeated.  Now  and  then,  increased  intradural  pressure 
is  evidenced  by  disturbed,  even  stertorous  breathing,  cyanosis,  cold  sweats 
and  fall  of  blood-pressure.  Sophian,  who  has  given  1500  injections  with- 
out accident,  employs  a  gravity  method  rather  than  a  syringe,  which 
allows  of  more  ready  control  of  the  amount  of  serum  injected;  he  takes 
the  blood-pressure  during  the  injection.  Anaphylactic  death  has  been 
reported.  \Yhen  intraventricular  effusions  occur,  the  ventricles  should 
be  tapped  and  filled  with  the  serum. 

The  patient  should  be  kept  quiet  in  a  dark  room,  the  head  elevated 


96  BACTERIAL  DISEASES 

without  flexion,  an  ice-bag  applied  to  the  head  and  spine,  or  an  ice-pillow 
used.  Nutrition  is  maintained  by  feeding  with  the  nasal  tube  or  by- 
nutrient  enemata,  if  retraction  of  the  neck  causes  dysphagia.  The  bowels 
are  mildly  relaxed,  and  the  bladder  is  watched.  Vomiting  is  treated  as 
in  acute  gastritis  {q.  v.),  but  therapy  is  usually  unavailing,  for  the  cause 
is  cerebral  irritation;  of  drugs  the  bromides  are  in  general  most  service- 
able. Feeding  by  the  rectum,  sucking  of  ice,  and  the  remedies  indicated 
for  the  headache  give  the  greatest  relief.  Counter-irritation  by  blisters 
or  cautery  is  dangerous  because  the  skin  sloughs  readily.  Headache, 
restlessness  and  con^■Tllsions  necessitate  the  hypodermic  use  of  morphine 
or  the  tincture  of  deodorized  opium  by  mouth  with  atropine;  no  other 
analgesic  is  equally  potent.  Chloral  is  used  for  con^Tilsions  and  unrest. 
Warm  baths  are  considered  almost  specific  by  Xetter.  Stimulation 
is  indicated  when  the  heart  weakens.  Resorbents,  as  iodides  and  mercurial 
inunctions,  are  inefficacious  although  they  seem  to  modify  serous  menin- 
gitis. Crowe  recommends  urotroyin,  5ss-j  daily;  formalin  is  found  in 
the  spinal  fluid  30  minutes  after  ingestion. 


ACUTE    POLIOMYEUTIS. 

Definition. — An  acute  general  infection,  characterized  by  (i)  diffuse 
cerebrospinal  lesions,  especially  in  the  anterior  horns  (acute  anterior 
poliomyelitis),  with  sequential  acute,  flaccid  paralysis,  wasting  of  the 
muscles,  loss  of  reflexes,  reaction  of  degeneration  and  contractures; 
ill)  lymphoid  hyperplasia  in  the  lymph  glands,  spleen  and  intestine; 
and  (iiij  parenchymatous  changes  in  the  lungs,  liver  and  kidneys. 

History. — Infantile  paralysis,  acute  poliomyelitis,  atrophic  paralysis, 
was  first  described  clinically  by  Heine  (1840).  The  famous  contribution 
of  Charcot  and  Joffroy  (1870)  referred  the  trophic  relation  of  the  special 
cells  involved  to  the  atrophy  of  the  nerves  and  muscles  supplied  and 
stated  that  the  disease  was  due  to  primary  inflammation  of  the  cells 
themselves.  The  first  epidemic  in  America  occurred  in  Louisiana,  in 
1841.  Medin  described  it  definitely  as  an  infectious  disease,  the  epidemic 
character  of  which  was  fully  considered  by  Wickman  in  his  monograph. 
Among  recent  investigations  are  those  of  Landsteiner  and  Popper,  who 
inoculated  the  disease  into  rabbits,  followed  by  the  brilliant  work  of 
Flexner  and  Lewis,  Landsteiner  and  Levaditi,  etc.  In  the  L'nited  States, 
Boston  and  New  York  are  the  chief  centres,  probably  invaded  from 
Northeastern  Europe.  In  New  York  there  were  2500  cases  in  1907, 
and  in  1910  over  8000  in  the  United  States.  It  exists  epidemically 
and  sporadically.  In  some  statistics  it  constitutes  even  8  per  cent,  of 
the  diseases  of  childhood. 

Etiology. — I.  The  virus,  which  passes  the  finest  filters,  is  found  in  the 
brain  and  cord,  tonsils,  nasopharynx,  lymphatic  and  salivary  glands,  blood, 
cerebrospinal  fluid,  stomach  and  intestine.  Flexner  regards  the  naso- 
pharynx as  the  atrium  to  the  nervous  system  and  also  as  the  point  of  exit; 
its  ingress  is  along  the  lymph  channels,  around  the  filaments  of  the  olfactory 
nerves,  and  its  egress,  in  the  reverse-  direction,  along  the  same  paths. 


ACUTE  POLIOMYELITIS  97 

Miiller  holds  that,  as  in  rabies,  infection  progresses  along  the  nerve 
sheaths,  but  Flexner  maintains  that  it  occurs  by  the  cerebrospinal  fluid. 
The  virus  was  inoculated  into  monkeys,  and  from  one  to  another  through 
25  animals  successively.  Flexner  and  Noguchi  cultivated  the  virus;  it 
is  anaerobic;  small  bodies  are  found,  0.15-0.3  microns,  single,  double, 
in  chains  or  masses.  The  virus  is  extremely  resistant  to  external  influences, 
as  freezing  or  drying,  and  persists  in  the  nasopharynx  from  six  weeks  to 
six  months  after  the  disease,  in  monkeys,  and  after  it  had  disappeared 
from  the  brain  and  cord. 

II.  DissEMiXATiON. — ^The  nasal,  bronchial  and  intestinal  secretions, 
the  house-  and  stable-fly,  and  dust,  may  convey  the  disease. 

III.  Carriers. — In  epidemics  a  certain  percentage  of  cases  occur  of 
the  abortive  type,  in  which  few  symptoms  develop.  Frost  and  Anderson- 
proved  that  two-thirds  of  these  cases  were  actually  poliomyelitis,  by  the 
biological  test  (the  serum  of  one  who  has  had  the  disease,  injected  into 
monkeys,  protects  the  latter  from  inoculation).  This  may  explain  the 
apparent  immunity  of  children  in  households  in  which  the  frank  form  of 
the  disease  prevails;  they  may  have  a  light  infection,  overlooked  save 
for  the  presence  of  an  epidemic,  or  may  carry  the  virus  without  themselves 
contracting  the  disease. 

IV.  Secondary  Factors. — Sixty  per  cent,  of  cases  occur  in  the  first 
three  years,  and  87  per  cent,  in  the  first  ten  years,  and  80  per  cent,  of 
cases  occur  in  the  summer  months. 

'■  Pathology. — The  affection  is  called  poliomyelitis  (Kussmaul),  because 
it  is  an  inflammation  of  the  anterior  gray  matter,  supplied  by  the  central 
arteries,  branches  of  the  anterior  median  artery  of  the  anterior  longitu- 
dinal flssure.  A  given  vessel  branches  up  and  down,  supplying  a  cylin- 
drical vertical  area  of  two  inches  or  more,  the  usual  dimension  of  a  polio- 
myelitic  focus.  Recent  reports  place  equal  emphasis  on  changes  in  the 
central  vein  and  in  other  arteries.  The  cord  changes  are  always  accom- 
panied by  a  round-cell  infiltration  of  the  pia  mater  and  the  arach- 
noid, such  as  occurs  in  rabies  and  syphilis,  but  not  in  diseases  of  bacterial 
origin.  The  meningitis  is  most  marked  in  the  lumbar  and  sacral  regions 
of  the  cord,  next  in  the  cervical;  it  is  most  intense  over  the  anterior  sur- 
face, whence  it  follows  the  pia  into  the  depths  of  the  anterior  fossa, 
along  the  sheaths  of  the  vessels,  the  posterior  root  fibers  and  the  arach- 
noid covering  the  spinal  ganglia.  This  inflammation  of  the  pia,  arachnoid 
and  ganglia  is  responsible  for  the  irritative  symptoms  of  the  disease. 
The  inflammation  may  extend  back  of  the  anterior  horns  into  the  antero- 
lateral columns.  The  fresh  focus  is  rarely  seen,  since  death  is  unusual; 
to  the  naked  eye  it  is  red,  soft,  juts  above  the  cut  section  and  is  mostly 
confined  to  the  anterior  horn,  i.  e.,  the  beginning  of  the  lower  motor 
neurone.  Microscopically,  the  lesion  in  the  anterior  roots  is  inflammation 
in  and  about  the  vessels  above  named,  even  before  they  enter  the  cord; 
the  perivascular  spaces  are  full  of  round  cells  and  granule-cells;  there  is 
exudation  of  red  and  white  cells,  with  actual  hemorrhage  in  severe  cases ; 
the  ganglion  cefls  in  the  anterior  horn  suffer  secondary  changes;  their 
dendrites  may  shrink,  their  nuclei  disappear,  or  the  whole  cell  may  disin- 
tegrate, while  here  and  there  some  cells  escape.  The  cells  involved  depend 
7 


98  BACTERIAL   DISEASES 

solely  on  the  vessel  affected;  involvement  is  sometimes  bilateral  and  in 
severe  cases  is  distributed  through  several  segments,  especially  in  the 
lumbar  cord. 

An  inflammatory  edema  is  detected  throughout  the  cord,  macroscopi- 
cally,  by  the  moist  appearance  of  its  cut  surface;  it  explains  the  transitory 
nature  of  certain  s\Tnptoms.  As  easily  anticipated,  disease  of  the  trophic 
cells  of  the  lower  motor  neurone  must  be  followed  by  degeneration  of 
their  axis-cylinders,  nerve  roots,  peripheral  nerves  and  muscles  (which 
become  granular,  fatty  and  later  indurated).  In  old  cases  the  unaided 
eye  detects  shrinking  of  the  anterior  horns,  with  lack  of  differentiation 
between  the  gray  and  white  matter.  ^Microscopically,  the  formerly 
inflamed  vessels  are  thickened  and  pigmented;  groups  of  ganglion  cells 
■  have  disappeared  and  their  nerve  fibers  are  degenerated  or  wholly  wasted, 
which  led  Charcot  to  consider  the  process  essentially  in  the  ganglionic 
cells,  but  the  thicker  connective  tissue  is  rich  in  cells  and  stains  deeply 
with  carmine.  In  severe  cases,  identical  changes  are  found  in  the  medulla, 
pons,  centrum  ovale,  and  even  in  the  cortex  or  cerebellum.  Acute  polio- 
myelitis differs  from  acute  myelitis  and  disseminated  myelitis  only  in 
its  localization.  The  ^'isceral  pathology,  other  than  the  nervous,  consists 
of  lymphoid  h^'perplasia  of  the  lymph  glands,  spleen  and  intestinal  fol- 
licles (which  may  be  the  atrium  of  the  infection] ,  changes  similar  to  those 
of  typhoid;  the  kidneys  are  cloudy,  foci  of  necrosis  appear  in  the  liver, 
and  there  is  bronchitis  and  often  bronchopneumonia. 

Symptoms. — ^^Yickman's  classification  of  poliomyelitis  includes  eight 
types  as  follows: 

I.  The  Spinal  Type. — There  are  three  clinical  periods  after  an  incuba- 
tion of  5  to  10  days.  (1)  The  acute  stage.  (2)  The  diffuse  paralysis  when 
degeneration  appears  and  regeneration  begins.  (3)  The  stationary 
stage,  T^-ith  determination  of  the  paralysis  to  given  muscles. 

1.  AcTTE  Stage. — The  typical  onset  is  acute,  appearing  in  a  child 
previously  well,  Avith  fever  (75  per  cent.),  often  with  vomiting,  headache, 
somnolence  and  sometimes  with  convidsions  or  coma,  which  are  followed 
by  a  sudden  complete  and  flaccid  parcdysis  in  one  or  more  limbs;  it  cor- 
responds to  the  acute  inflammation  in  the  anterior  horn.  The  fever 
averages  101°,  may  reach  105°  or  more  and  lasts  about  twenty-four  hours. 
Convulsions  are  not  as  common  as  in  the  cerebral  type,  and  occur  mostly 
in  younger  subjects,  are  attributed  perhaps  to  teething,  once  thought 
the  cause  of  the  paralysis.  The  motor  paralysis  usually  reaches  its 
maximum  in  twenty-four  to  forty-eight  hours  and  is  not  progressive. 
In  many  cases  prodromata  exist,  as  tonsillitis  or  angina,  coryza,  bronchitis, 
swollen  joints,  malaise,  pain  in  the  back  and  limbs  or  diarrhea;  Miiller 
anticipates  poliomyelitis  in  a  general  infection  beginning  with  profuse 
sweats,  hyperesthesia  and  leukopenia;  tympanites  and  weakness  of  the 
abdominal  reflexes  and  abdominal  muscles  are  also  emphasized.  Varia- 
tions in  onset;  the  fever  may  last  one  or  two  weeks  before  the  paralysis 
develops,  it  may  last  a  few  hours  onl}^  or  may  be  absent.  The  paralysis 
may  develop  during  the  night;  sometimes  it  is  not  noticed  until,  for 
example,  the  child  fails  to  walk.  Convulsions  involve  principally  the 
extremities,  sometimes  as  clonic  muscular  contractions. 


ACUTE  POLIOMYELITIS  99 

2.  Stage  of  Degeneration. — The  localization  in  the  anterior  horn 
produces  paralysis,  disturbed  nutrition,  vasomotor  changes  and  loss  of 
reflexes,  (a)  The  ixiralysis  is  motor  only;  it  is  sudden,  complete,  flaccid 
and  non-progressive;  at  first  diffuse,  it  usually  regresses,  although 
incompletely,  leaving  some  permanent  paralysis.  General  localization: 
(i)  Paralysis,  most  frequently  of  one  leg,  then  (ii)  of  both  legs,  and  (iii) 
and  (iv)  of  all  four  limbs  or  of  one  arm  (with  equal  frequency),  (v)  of 
arm  and  leg  of  same  side  (spinal  hemiplegia),  (vi)  of  arm  with  opposite 
leg  (crossed  paralysis),  (vii)  of  three  limbs  and  least  often  (viii)  of  both 
arms.  The  back,  abdomen,  neck,  face  and  eye  may  be  involved  in  severe 
and  diffuse  foci.  As  to  its  special  localization,  the  leg  is  yaralyzecl  in 
75  per  cent,  of  cases;  in  one  form  the  lasting  paralysis  afi^ects  the  quadri- 
ceps femoris  with  the  adductors  (upper  lumbar  lesion),  but  the  sartorius 
is  not  involved;  another  form  involves  the  muscles  below  the  knee 
supplied  by  the  peroneal  nerve — the  tibialis  anticus,  extensor  digitorum 
communis,  ext.  longus  or  brevis,  ext.  hallucis  longus,  peronei  (lower 
lumbar  and  upper  sacral  lesion),  of  which  some  muscles  may  escape, 
as  the  tibialis  anticus.  If  both  legs  are  involved  the  paralysis  is  rarely 
symmetrical.  Poliomyelitis  usually  involves  several  segments  because 
of  the  arterial  distribution.  The  arm  is  paralyzed  in  25  per  cent., 
chiefly  in  the  form  of  the  combined  shoulder  paralysis  of  Remak, 
involving  the  deltoid  (sometimes  alone),  biceps,  brachialis,  supinator 
longus  with  the  supra-  and  infraspinatus  and  teretes  (lesion  in  upper 
cervical  enlargement,  fifth  to  sixth  segment);  in  some  cases  the  forearm 
type  may  be  seen,  with  involvement  of  the  flexors,  possibly  the  extensors, 
while  the  supinator  longus  often  escapes  (lower  cervical  lesion,  seventh 
and  eighth  segments) .  The  trunk  or  neck  muscles  usually  show  improve- 
ment in  this  stage,  (b)  As  to  disturbed  yiutrition,  the  muscles  and  nerves 
corresponding  to  the  level  of  the  poliomyelitis  rapidly  degenerate,  as 
shown  by  early  reaction  of  degeneration  and  muscular  atrophy.  The 
reaction  of  degeneration  consists  of  failure  of  the  nerve  and  muscles  to 
respond  to  the  faradic  current  and  usually  appears  in  one  or  two  weeks; 
it  also  includes  a  lack  of  response  of  the  nerve  to  the  galvanic  current 
and  finally  a  too  prompt  response  of  the  muscles  to  the  galvanic  current 
and  more  quickly  to  the  positive  than  to  the  negative  pble;  this  latter 
reaction  lasts  for  two,  three  or  six  months  and  then  gradually  disappears 
in  a  year  or  two.  Muscular  atrophy  is  more  clearly  seen  in  the  arm 
than  in  the  leg  or  trunks  where  adipose  deposit  may  obscure  it.  Fibrillary 
contractions  are  frequent.  The  wasted  flaccid  member  hangs  and  swings 
in  a  lifeless  fashion,  (c)  Vasomotor  paralysis  causes  the  low  temperature 
(1°  to  even  10°  below  normal)  and  the  livid,  clammy  skin,  {d)  The  skin 
and  tendon  reflexes  are  abolished  in  the  limb  at  first;  the  skin  reflexes 
usually  return  later.  The  sphincters  are  almost  always  intact  and  sen- 
sation is  very  rarely  affected.    Trophic  changes  are  almost  unknown. 

3.  vStationary,  Chronic,  Residual  Stage. — This  stage  is  marked 
(a)  by  accentuation  of  muscular  atrophy,  connective  and  sometimes 
adipose  tissue  replacing  the  contractile  substance,  especially  in  the  legs. 
{b)  The  bones  become  flexible,  friable,  arrested  in  development  and  there- 
fore shorter;    the  bone  cortex  wastes  and  its  medulla  becomes  more 


100  BACTERIAL  DISEASES 

spongy;  scoliosis  may  result,  (c)  There  may  be  pronounced  vasomotor 
lividity.  (d)  In  the  joints,  nodules  may  appear  as  in  cerebral  hemi- 
plegia; the  joint  structures  are  relaxed  and  the  "flail  joint"  may  develop 
with  luxation  or  subluxation,  (e)  Contractures  are  due  principally  to 
the  mechanical  influence  of  the  unopposed  antagonist  muscles  on  the 
posture  of  the  joint;  if  all  the  muscles  are  paralyzed  they  sometimes 
result  from  static  causes,  as  from  standing  or  attempting  to  walk; 
the  arm,  shoulder,  wrist  and  fingers  are  flexed  and  the  elbow  usually 
escapes  involvement.  In  the  leg,  deformity  (pes  equinovarus)  is  more 
common  than  in  the  arm. 

II.  The  Ascending  or  Descendijig  Type. — This  variety,  more  often 
ascending  than  descending,  may  exactly  mimic  Landry's  paralysis. 
In  one  epidemic  (1905),  among  159  poHomyelitis  deaths,  28  per  cent, 
were  of  this  form. 

III.  Bulbar  or  Pontine  Type. — Perivascular  exudation  may  crowd 
closely  around  these  vital  nuclei,  without  injury  to  them,  yet  in  all  fatal 
cases  they  are  affected;  death  is  caused  by  disease  of  the  respiratory 
centre.  The  third,  fourth,  fifth,  sixth  and  seventh  nerves  are  often 
affected. 

IV.  Encephalitic  Type. — This  is  identical  with  Striimpell's  polio- 
encephalitis (see  Infantile  Cerebral  Paralysis).  Convulsions  may 
antedate  paralysis  by  days;  hemiplegia,  epilepsy  and  mental  deficiency 
may  be  its  legacy. 

V.  Ataxic  Type. — Involvement  of  the  tract  between  the  dentate 
nucleus  of  the  cerebellum  and  the  contralateral  red  nucleus  may  occasion 
a  coarse  intention  tremor,  some  paresis  and  rigidity  and  increased 
muscular  tonus. 

VI.  Polyneuritic  Type. — While  the  sporadic  forms  are  often  painless, 
the  epidemic  forms  are  often  exquisitely  painful,  not  merely  during  the 
acute  phase  but  for  weeks  afterward. 

VII.  Meningitic  Type. — ^Without  spinal  puncture,  differentiation  may 
be  impracticable,  because  of  the  rigidity  of  the  neck,  Kernig's  sign, 
twitchings,  convulsions,  and  herpetic,  petechial  or  other  rashes. 

VIII.  Abortive  Types. — Positively  proved  to  be  poliomyelitic  by  inocu- 
lations (v.  s.),  many  or  most  cases  would  be  mistaken,  in  the  absence 
of  an  epidemic.  The  subforms  are  (a)  those  evidencing  only  fever  or 
toxemia;  (h)  those  with  symptoms  of  meningitis  or  meningismus;  (c) 
the  pseudo-influenzal  (pains  and  hyperesthesia);  and  (d)  gastro-enteric 
symptoms  as  diarrhea,  which  in  some  epidemics  are  the  first  symptoms, 
even  in  90  per  cent,  of  cases. 

Diagnosis. — The  initial  vomiting,'  fever  and  convulsions  are  usually 
misinterpreted  until  the  diffuse  motor  paralysis  appears  and  conse- 
quently the  physician  is  unjustly  blamed  for  what  no  one  can  anticipate. 
The  rapid  atrophy,  reaction  of  degeneration  and  loss  of  reflexes  are 
positive  diagnostics. 

Differentiation. — (a)  The  various  forms  of  muscular  atroiohy  in  chil- 
dren are  gradual  in  onset,  progressive,  symmetrical  and  often  familial. 
The  atrophy  precedes  and  exceeds  paralysis  and  there  is  no  arrest  in 
development.     The  neural  progressive  muscular  atrophy  of  Hoffmann 


ACUTE  POLIOMYELITIS  101 

IS  progressive,  familial  and  involves  sensation,  (b)  Multiple  neuritis 
(q.  r.)  has  several  distinctive  features.  Poliomyelitis  is  due  to  a  local 
inflammation,  is  unilateral  and  spinal  in  type — or  if  bilateral,  it  is  asym- 
metrical. jMultiple  neuritis  is  hematogenous  and  toxic,  and  therefore 
affects  the  spinal,  and  often  the  cranial  nerves  symmetrically  and  bi- 
laterally and  usually  involves  the  arms  and  legs;  ataxia,  sensory  dis- 
turbance and  local  tenderness  over  the  nerve  trunks  are  common; 
its  onset  is  more  subacute,  the  reaction  of  degeneration  less  intense 
and  the  issue  more  favorable,  (c)  The  cerebral  palsies  of  children 
iq.  V.)  never  produce  marked  degenerative  atrophy  or  loss  of  faradic 
irritability.  The  hemiplegic  form  involves  the  face  and  the  paraplegic 
form  is  spastic.  Disturbance  of  the  intellect,  convulsions  and  hemichorea 
are  common,  (d)  Myelitis  also  begins  acutely,  but  usually  in  older  sub- 
jects. Poliomyelitis  may  be  confused  only  when  it  is  bilateral,  located 
in  the  cervical  or  lumbar  enlargement,  when  sensory  changes  occur 
(2  per  cent.)  or  the  sphincters  are  involved,  producing  a  flaccid  atrophic 
paralysis  of  an  arm  and  a  transitory  spastic  paresis  of  the  leg.  Bed-sores 
so  common  in  myelitis,  are  almost  unknown  in  poliomyelitis,  (e)  Painful 
affections  causing  immobility  of  a  joint,  hip-joint  disease.  Parrot's  syphil- 
itic pseudoparalysis  and  infantile  scurvy  but  superficially  resemble  polio- 
myelitis. (/)  Meningitis  shows  its  appropriate  microorganism  (tubercle 
bacillus,  meningococcus,  etc.).  Lumbar  puncture  of  the  poliomyelitic 
shows  a  clear,  possibly  slightly  opalescent  fluid,  under  increased  pressure, 
exhibiting  a  mononucleosis,  a  slight  fibrinous  clot  and  positive  globulin 
reactions. 

Prognosis. — (1)  Regarding  life;  there  is  little  danger  after  the  fever 
subsides;  life  is  rarely  threatened  from  extension  to  the  medulla  ob- 
longata. In  epidemics  the  mortality  may  reach  15  to  33  per  cent.,  but 
averages  7  per  cent.  (2)  Regarding  recovery,  improvement  is  the  rule 
and  recovery  is  due  to  the  recession  of  the  congestion  and  edema;  in 
some  epidemics  abortive  cases  number  33  to  50  per  cent.  (Trethowan,  5298 
cases,  1912).  A  localized  initial  paralysis  may  show  little  improvement, 
or  an  extensive  initial  paralysis  may  diminish  greatly.  A  definite  prog- 
nosis cannot  be  made  for  two  weeks  and  then  only  by  the  electrical 
examination.  Muscles  which  show  no  reaction  of  degeneration  after 
fourteen  days  will  probably  recover;  those  showing  slight  loss  of  faradic 
irritability  will  recover  in  great  part;  after  six  weeks  only  those  muscles 
are  paralyzed  which  will  remain  paralyzed ;  if  there  is  no  recovery  in  three 
months  there  will  be  none  or  it  will  be  slight. 

Treatment. — In  pjrophylaxis ,  isolation  should  be  practised,  and  carriers 
should  be  quarantined.  The  nose  and  throat  require  special  care  in 
those  ill  of  the  disease,  in  carriers  and  in  those  exposed  to  infection; 
two  parts  water  to  one  of  hydrogen  peroxide,  and  urotropin  are  advised 
{v.  i.).  In  the  acute  stage  rest,  a  light  diet,  laxatives  and  diaphoretics  are 
indicated.  After  administration  of  urotropin.  Gushing  found  formalde- 
hyde in  the  spinal  fluid;  Starr  recommends  urotropin,  gr.  v,  every  four 
hours;  Flexner  and  Lewis  found  that  urotropin  given  to  monkeys,  in- 
oculated with  the  virus,  prolongs  the  incubation  and  often  prevents 
paralysis.    After  the  fever  the  patient  should  be  kept  in  bed  for  weeks; 


102  BACTERIAL   DISEASES 

immobilizing  the  liml)  lessens  spinal  irritability.  Electricity  is  contra- 
indicated.  As  the  paralysis  recedes  a  fuller  diet  and  careful  passive 
movements  are  beneficial.  Hot  baths  are  quieting  and  repeated  lumbar 
punctures  apparently  are  beneficial.  In  the  chronic  stationary  stage, 
with  its  inevitable  and  permanent  paralysis,  fresh  air  and  liberal  nourish- 
ment are  important.  Strychnine  is  valuable  because  of  its  general  tonic 
action  and  its  effect  on  the  motor  side  of  the  cord.  It  is  given  for  three 
weeks  after  the  paralysis  becomes  stationary.  Full  doses  may  induce 
muscular  spasm,  pain  and  irritating  paresthesia,  and  of  late  its  use  is 
far  less  popular.  Electricity  cannot  restore  destroyed  tissue,  but  it 
hastens  recovery  in  partial  lesions;  if  applied  to  the  spine  it  is  useless, 
but  the  constant  stream  to  the  muscles  and  the  faradic  current  to  the 
skin  are  helpful.  Contractures  and  deformities  due  to  neglect  may  be 
modified  by  gymnastic  movements,  massage  and  orthopedic  apparatus. 
The  child  should  be  kept  in  bed  for  a  long  period.  In  some  cases  teno- 
tomy, arthrodesis  and  tendon  transplantation  (by  attaching  the  tendons 
of  sound  muscles  to  those  of  paralyzed  muscles)  and  nerve  transplan- 
tation are  indicated. 


INFLUENZA  'LA  GRIPPE). 

Definition. — A  specific  infection,  caused  by  the  Bacillus  influenzae,  and 
characterized  by  its  protean  symptomatology  and  particular  affinity  for 
the  respiratory  tract. 

Varieties. — (Ij  Influenza  A'era,  pandemic,  endemic  or  epidemic,  due  to 
Pfeiff'er's  bacillus.  (2)  Influenza  notha  s.  nostras,  pseudogrippe,  catarrhal 
fever,  of  A'ariable  bacteriology. 

Pandemics  originate  in  Asiatic  Prussia.  Xo  other  pandemic  is  so  widely 
or  rapidly  distributed  as  influenza,  which  is  due  to  the  enormous  virulence 
of  the  virus;  to  the  universal  susceptibility;  and  to  the  fact  that  many 
moderately  sick  individuals  frequent  public  places.  Epidemics  usually 
follow  pandemics;  they  occur  every  few  years  whereas  pandemics  are 
separated  by  decades.  The  first  epidemic  occurred  in  1173  and  the 
first  pandemic  in  1510. 

Etiology. — Most  cases  occur  between  the  twentieth  and  fortieth  years. 
The  immunity  conferred  by  one  attack  is  less  enduring  and  absolute 
than  in  other  infections.  The  organism  discovered  by  Pfeifl'er  (1S91-2) 
is  the  smallest  bacillus  cultivated.  Its  ends  are  rounded  and  it  resembles 
a  diplococcus  when  two  bacilli  lie  end  to  end.  It  has  no  capsule,  is  non- 
motile,  it  lies  free  in  the  sputum  in  the  early  stages  and  later  within  the 
leukocytes,  but  often  disappears  early  from  the  sputum.  The  bacilli 
lie  in  lines  "like  schools  of  fish."  It  is  best  stained  by  Gram's  method  and 
then  ten  minutes'  staining  with  carbol  fuchsin;  if  pneumococci  and  strepto- 
cocci are  present,  they  are  stained  deep  purple,  and  the  influenza  organism 
red.  The  bacillus  is  aerobic,  short-lived  and  very  susceptible  to  drying. 
It  grows  characteristically  on  blood  serum  as  closely  compressed  yet 
discrete  colonies,  clear  as  water  and  almost  microscopic  in  size;  it  is 
easily  overgrown  by  saprophytes.    The  germ  has  also  been  found  in  rare 


INFLUENZA  103 

instances  in  the  blood,  cerebrospinal  fluid,  gall-bladder,  joints,  pneumonic 
and  encephalitic  foci,  peritoneum  (puerperal  sepsis)  and  other  parts, 
and  possesses  rather  marked  pyogenic  characters.  Its  atrium  is  probably 
respiratory. 

Symptoms. — There  is  scarcely  another  acute  infection  with  such 
varied  symptoms,  sequels  and  complications. 

After  a  short  incubation  of  one  to  three  days,  the  grippe  begins  suddenly 
with  chill  and  fever,  headache,  general  pains,  respiratory  catarrh  and 
intense  nervous  and  sometimes  digestive  symptoms. 

Types. — In  the  simple  toxemic  type  there  are  coryza,  moderate  soreness 
of  the  throat,  possibly  some  cough  and  toxemia,  evidenced  by  fever, 
depression,  and  pains  in  the  head,  back  and  limbs.  In  the  severer  toxemic 
forms,  these  symptoms  obtain,  but  the  patient  suffers  profound  depression 
both  with  the  fever,  and  after  it.  The  intensely  respiratory  variety 
(75  per  cent,  of  all  influenzas)  is  attended  by  fever  and  toxemia,  the 
bronchitis  is  severe,  perhaps  intractable  and  not  uncommonly  followed 
by  pneumonia.  The  g astro-intestinal  grippe  is  attended  by  gastric 
intolerance  and  diarrhea.  Of  the  septicopyemic  type,  only  seven  in- 
stances are  reported. 

The  duration  is  one  to  three  days  and  the  diagnosis  is  usually  easy 
without  the  detection  of  the  bacillus.  Recurrences  are  frequent;  most 
frequently,  an  initial  respiratory  catarrh  is  seen  with  nervous  mani- 
festations in  the  recrudescence  but  the  order  may  be  reversed.  In  rare 
instances  influenza  may  cause  chronic  symptoms.  Convalescence  is 
marked  by  great  nervous  depression,  neuralgias,  possibly  cardiovascular 
atonicity,  and  tardy  return  of  vigor. 

Special  Symptoms. — 1.  Fever. — The  rise  is  usually  sudden  to  103° 
or  104°.  It  is  entirely  atypical.  Remittent  fever  is  more  common  than 
continuous  fever,  which  may  suggest  typhoid.  It  is  occasionally  inter- 
mittent, resembling  malaria.  Hyperpyrexia  is  observed  particularly 
in  encephalitis.  Certain  nervous  forms  are  afebrile.  The  fever  runs 
one  to  four  days,  or  longer  as  a  result  of  complications. 

2.  Nervous  System. — The  nervous  system  is  second  in  importance 
only  to  the  respiratory  tract.  The  most  frequent  disturbances  are 
functional  and  psychical.  Headache  is  observed  in  nearly  all  cases,  and 
often  is  very  severe.  Influenza  comatosa  results  from  very  acute  intoxi- 
cation, which  also  may  cause  epileptiform  seizures,  or  severe  delirium. 
The  postinfluenzal  psychoses,  due  to  toxemic  exliaustion,  are  observed 
eight  times  as  frequently  as  in  any  other  acute  disease,  and  most  cases 
are  seen  in  the  young.  They  usually  follow  the  attack  and  chiefly  are 
of  the  hypochondriacal  type.  Suicides  in  Paris  increased  25  per  cent, 
during  the  last  pandemic.  In  encephalitis  grippalis,  acute  foci  of  inflam- 
mation, usually  discrete  and  multiple,  occur  in  the  gray  substance  of  the 
cortex  or  ganglia  and  vary  in  size  from  the  "flea-bite"  spots  of  inflam- 
matory hemorrhage  with  surrounding  softening  to  the  size  of  a  cherry 
or  pigeon's  egg — due  to  embolism  by  the  Bacillus  influenzae  (Pfuhl  and 
Nauwerk).  ^lono-  and  hemiplegia  or  sudden  apoplectiform  onset  may 
mark  the  process,  or  there  may  be  dift'use  cerebral  symptoms  without 
definite  focal  localization.     Encephalitis  is  usually  fatal.     Meningitis 


104  BACTERIAL  DISEASES 

grippalis  generally  develops  early,  the  virus  reaching  the  brain  by  the 
blood  stream  or  through  the  basis  cranii.  Slawyk  first  found  the  organism 
in  the  cerebrospinal  fluid.  Nearly  all  are  under  ten  years  of  age;  of 
Flexner's  58  cases  (1911),  all  but  six  died.  Transverse  myelitis  has 
been  observed.  Neuritis  is  usually  postinfluenzal;  neuralgia  affects 
most  often  the  fifth,  sciatic  and  intercostal  nerves. 

3,  The  eespiratory  tract  is  the  atrium  of  the  bacillus  and  is  in- 
volved in  75  per  cent,  of  cases;  coryza  is  seen  in  70  per  cent,  of  cases,. 
angina  in  .33  per  cent,  and  tonsillitis  in  60  per  cent.  Laryngitis  (10  per 
cent.)  occurs  with  hoarseness.  Tracheitis  (65  per  cent.)  causes  pain, 
tenderness  and  severe  paroxysmal  cough,  induced  by  irritation  at  the 
tracheal  bifurcation. 

Bronchitis  is  diffuse  or  more  characteristically  occurs  over  one  lung 
or  lobe.  At  autopsy  are  found  great  congestion,  hemorrhage,  round-cell 
infiltration  into  the  mucosa,  and  thrombosis  of  the  smaller  vessels,  which 
causes  necrosis  of  the  mucosa.  The  sputum  is  characteristically  num- 
mular and  greenish-yellow.  It  is  often  blood-stained,  viscid  and  contains 
the  bacillus.  Rales  abound  near  the  liver  and  lingual  lobe.  We  may 
observe  dyspnea  without  physical  findings.  Cyanosis  is  inauspicious 
in  the  young,  aged  and  decrepit.  Acute  bronchiectasis  is  not  uncommon, 
but  usually  escapes  clinical  recognition. 

Influenzal  yneumonia  (in  6  per  cent,  of  cases)  is  the  most  important 
complication.  Pfeiffer's  bacillus  is  its  most  frequent  cause,  alone  or 
combined  with  the  pneumococcus,  streptococcus  and  staphylococcus. 
Influenzal  pneumonia,  strictly  speaking,  shows  no  fibrinous  exudation 
or  granulations,  but  is  catarrhal,  with  infiltration  of  cells  about  the 
bronchi  as  discrete  foci.  Clinically,  the  pneumonia  is  atypical  and  begins 
without  a  chill,  but  with  insidious  increase  of  the  prior  cough  and  dyspnea. 
It  usually  develops  during  or  after  the  influenzal  attack,  although  pneu- 
monia may  be  the  first  sign  of  influenza.  Its  symptoms  are  more  pro- 
nounced than  its  physical  signs,  and  the  disproportionate  cyanosis  and 
dyspnea  sometimes  suggest  miliary  tuberculosis.  Foci  of  dulness  may  be 
found  but  distinct  bronchial  breathing  is  rare;  bronchophony  is  a  much 
more  reliable  symptom.  There  may  be  oligopnea  (slow  breathing) 
with  difficult,  prolonged  expiration.  The  heart  is  often  weak  and  a  peculiar 
redness  of  the  face  and  head,  profuse  sweats  at  the  beginning,  and  char- 
acteristic paroxysmal  coughing  are  symptoms  not  seen  in  ordinary 
pneumonia.  The  foci  are  bilateral  or  multiple  in  60  per  cent,  of  cases 
and  the  apices  are  involved  frequently.  The  sputum  is  purulent  or  bloody.. 
Issues:  (1)  solution  by  lysis;  (2)  death  from  early  edema  pulmonum; 
the  patient  may  die  later,  with  early  gray  hepatization;  the  mortality 
is  20  to  30  per  cent.;  (3)  chronic  influenza-pneumonia,  with  hectic 
fever  and  suppuration,  simulating  tuberculosis;  during  a  grippe  epidemic 
an  increased  mortality  from  tuberculosis  is  noticed;  (4)  abscess  or 
gangrene  of  the  lung.  A  grippe  epidemic  may  double  the  number  of 
lobar  pneumonia  cases;  when  it  complicates  grippe,  it  is  less  completely 
lobar  and  granular. 

Primary  pleurisy  occurs  in  27  per  cent,  of  the  fatal  cases  of  influenza; 
its  symptoms  are  frequently  severe  and  protracted. 


INFLUENZA  105 

4.  Circulation. — The  heart-muscle  is  directly  injured,  especially 
affecting  the  lesser  circulation.  Weakness  or  syncope  may  occur  dur- 
ing convalescence,  especially  from  preexisting  arteriosclerotic  changes. 
The  pulse  is  labile,  often  arrhythmic  or  dicrotic;  it  may  be  rapid  and  out 
of  proportion  to  the  fever;  cyanosis,  dyspnea  and  bronchiolitis  are 
frequent  in  such  cases.  A  slow  pulse  occurs  in  50  per  cent,  of  the  severer 
types.  Acute  endocarditis  sometimes  follows  abscess  of  the  lung;  in 
three  cases  the  influenza  bacillus  was  found.  Acute  phlebitis  is  seen 
mostly  in  severe  cases  with  cardiac  weakness,  most  frequently  in  the 
upper  extremities.  Arteritis  is  rare,  occurs  mostly  in  the  popliteal 
vessels,  and  may  end  in  gangrene.  Leukocytosis  occurs  in  a  third  of  the 
cases  Hemorrhages  into  the  skin  and  mucous  membranes  indicate 
severe  intoxication. 

5.  Alimentary  Tract. — Digestive  symptoms  are  not  important. 
The  coated  tongue  is  rarely  typhoidal.  Vomiting  (34  per  cent.)  is  some- 
times persistent  (grippe  hyperesthesia  of  the  stomach).  Constipation 
is  more  frequent  than  diarrhea.  There  are  the  usual  febrile  degenerative 
changes  in  the  liver.  Icterus  is  rare  (2  per  cent.).  The  spleen  is  enlarged 
in  15  per  cent,  of  cases. 

6.  Genito-urinary  Tract. — Albuminuria  may  result  from  toxemia 
(10  per  cent.).  Altered  red  blood  cells  in  the  urine  are  rather  frequent. 
Acute  glomerulonephritis  occurs  in  1  per  cent,  of  cases.  The  diazo 
reaction  and  indicanuria  are  noted  frequently. 

7.  Skin,  Muscles,  Joints. — Urticaria,  herpes  (5  per  cent.),  miliaria, 
erythematous,  scarlatiniform  or  morbilliform  eruptions  or  purpura  may 
be  noted  (16  per  cent.).  Polysynovitis,  pyarthrosis,  bone  involvement 
and  myositis  are  not  common.  Eye  involvement  (7  per  cent.),  con- 
junctivitis, keratitis,  herpes  and  otitis  media  (35  per  cent.),  usually 
purulent  and  often  hemorrhagic,  are  due  to  the  pyogenic  cocci,  pneu- 
mococci  and  the  influenza  bacillus. 

Diagnosis. — During  an  epidemic  the  diagnosis  is  simple.  Respiratory 
catarrh,  headache,  pains  in  the  joints  and  back,  nervous  depression 
and  tardy  convalescence  are  significant.  The  diagnosis  of  the  toxic, 
nervous  and  alimentary  forms  is  more  difficult  and  many  errors  may  be 
made.  The  importance  of  bacteriological  diagnosis  has  been  over-rated, 
but  positive  results  are  decisive. 

Differentiation.- — A  clinical  picture,  identical  with  the  grippe,  may  be 
due  to  pneumococcemia,  without  hepatization.  A  peculiar  streptococcus 
causing  influenzal  symptoms,  is  reported  by  Miiller,  Seligmann  and 
Richardson  in  septic  sore  throat. 

Typhoid  fever  may  be  considered  when  severe  influenza  begins  with 
step-like  rise  of  the  fever  and  tympany,  enteritis,  intestinal  hemorrhage, 
swelling  of  the  spleen  and  roseolse;  at  autopsy,  swelling  and  even  ulcera- 
tion of  the  stomach  mucosa  and  Peyer's  patches  occur.  However, 
the  existence  of  an  epidemic  and  early  catarrhal  symptoms  indicate 
influenza. 

Simple  coryza  and  bronchitis  are  distinguished  by  the  sudden  rise 
of  fever  in  influenza,  its  nervous  manifestations,  bacteriology,  pains 
in  the  head,  splenic  tumor  and  exanthems.    Lord  found  the  bacillus  of 


106  BACTERIAL  DISEASES 

Pfeiffer  in  30  per  cent,  of  bronchitis  cases  in  Boston,  in  which  there 
was  no  suspicion  of  influenza. 

Measles. — The  early  respiratory  catarrh  and  the  measles-hke  eruptions 
in  influenza  may  cause  confusion,  but  the  measles  fever-curve,  rising 
after  the  prodromes,  with  the  exanthem  and  Kophk's  spots,  determine 
the  diagnosis  on  the  third  or  fourth  day. 

Miliary  tuberculosis  is  suggested  only  in  severe  respiratory  types. 
Meningitis,  apoplexy,  acute  psychoses  and  acute  poisoning  are  rarely 
simulated  by  influenza. 

Prognosis. — (1)  The  morbidity  is  enormous  (50  to  75  per  cent,  of  the 
population,  pandemic  of  1889-90).  (2)  The  mortality  is  0.6  to  1  per 
cent.  Influenza  increases  the  number  of  deaths  from  pneumonia  and 
tuberculosis,  especially  in  the  weak  and  aged.  In  some  cases  the  course 
is  chronic,  the  bacillus  being  found  in  the  sputum  for  months,  especially 
in  the  remarkably  susceptible  tuberculous  subject. 

Treatment. — There  is  scarcely  any  prophylaxis  excei^t  avoiding  crowds. 
Isolation  should  be  practised  in  asylums,  hospitals  and  prisons.  Gargles 
and  nasal  douches  possibly  prevent  infection  and  are  indicated  in  grippe 
patients.  There  is  7io  specific  treatment.  Influenza  must  be  treated  as  a 
serious  disease,  and  complications  avoided  by  rest  in  bed  and  a  restricted 
diet. 

1.  Pain. — ^At  the  onset,  Dover's  powder  and  acetphenetidin,  aa  grains 
X,  are  given  for  pain  (phenacetin  is  superior  to  acetanilide  and  is  less 
depressing).  These  measures  failing,  the  salicj'lates  (or  acetylsalicylic 
acid,  aspirin)  are  used  as  in  rheumatism.   Cold  baths  are  poorly  tolerated. 

2.  Catarrhal  Symptoms. — For  conjunctivitis,  boric  acid  solution  is 
excellent;  for  coryza  {q.  v.)  douches  with  Dobell's  solution,  tincture 
of  belladonna  and  of  aconite  in  two-  and  one-drop  doses,  respectively, 
every  half-hour  for  six  doses,  and  the  alkaloid  cocaine,  gr.  j  to  albolene 
§j,  should  be  used  locally;  for  pharyngitis,  silver  nitrate  (20  per  cent.); 
for  tonsillitis,  nitrate  of  silver  is  introduced  into  the  follicles  which  are 
first  opened;  for  bronchitis  {q.  v.),  heroine  or  morphine  is  indicated; 
for  enteritis,  bismuth  and  paregoric,  aa  3jj  are  given  after  each  bowel 
movement. 

3.  Nervous  syjViptoms  are  somewhat  relieved  by  warm  baths.  Neu- 
ralgia indicates  acetphenetidin,  camphor,  iron  and  arsenic.  Headache 
is  treated  as  in  typhoid.  Flexner  and  Wollstein  prepared  a  serum  against 
experimental  influenzal  meningitis. 

4.  Heart. — Strychnine  may  be  indicated. 

5.  Convalescence  concerns  chronic  tuberculosis  and  bronchitis. 


PERTUSSIS  (WHOOPING-COUGH). 

Definition. — ^A  specific  infection,  characterized  by  a  cyclic  course  and 
a  severe  convulsive  cough,  which  ends  in  a  whoop.  Cullen's  definition 
was  "Morbus  contagiosus,  tussis  convulsiva  strangulans  cum  inspiratione 
sonora  iterata,  saepe  vomitus." 

History. — Pertussis  was  described  by  Ballonius  (1578). 


PERTUSSIS  107 

Etiology. — (a)  Age:  It  usually  occurs  in  children  and  is  most  frequent 
at  the  fourth  year.  It  is  extremely  infrequent  after  the  twentieth  year. 
(b)  Sex:  Sixty-six  per  cent,  of  cases  occur  in  girls,  (c)  Most  cases  occur 
in  March  and  April. 

In  1906  Bordet  and  Gengou  obtained  in  pure  culture  a  small,  short 
bacillus,  with  rounded  ends.  It  stains  feebly  and  shows  polar  granules 
with  carbol  methylene  blue.  It  occurs  in  the  sputum  unmixed  with  other 
organisms  at  the  onset,  in  the  catarrhal  stage  and  for  a  few  days  after  the 
whoop  appears.  As  the  disease  progresses,  other  organisms,  especially 
the  influenza  bacillus,  overgrow  it.  It  has  been  cultivated  from  the 
blood  and  lungs.  The  blood  in  convalescent  cases  rather  feebly  ag- 
glutinates the  organism.  Specific  antibodies  have  been  demonstrated 
in  the  serum.  Mallory  and  Horner  find  the  bacillus  characteristically 
between  the  cilia  of  the  trachea  and  bronchi.  It  interferes  mechanically 
with  the  movements  of  the  cilia,  preventing  the  normal  removal  of 
secretion.  One  attack  confers  almost  absolute  immunity.  Incubation 
lasts  from  two  to  eight  days. 

Symptoms. — 1.  The  stadium  catarrhale  is  characterized  by  headache, 
photophobia,  conjunctivitis,  coryza,  angina  and  a  cough  which  becomes 
dryer  and  harder  toward  the  end  of  this  stage.  In  a  few  cases  there  is 
moderate  fever.    This  stage  averages  one  week,  or  less  during  an  epidemic. 

2.  The  stadium  spasmodicum  dates  from  the  first  "whoop."  The  fever 
ceases,  aside  from  complications.  The  seizures  are  paroxysmal,  con- 
vulsive and  accompanied  by  dyspnea  and  vomiting.  The  child  is  well 
except  for  the  paroxysm,  which  has  for  an  aura,  tickling  in  the  larynx, 
thoracic  constriction,  vertigo  or  a  creeping  sensation,  when  the  child 
braces  himself  and  terrified,  runs  for  support.  Then  the  explosion  comes 
in  the  form  of  three  to  ten  or  more  short  expiratory  coughs  following  in 
rapid  succession  until  the  breath  is  lost,  when  the  "whooj)"  is  heard 
as  a  deep,  singing  or  whistling  inspiration.  Then  thin  tenacious  mucus 
is  expectorated  and  vomiting  constitutes  the  crisis  of  the  paroxysm. 
In  severe  cases  there  may  be  apnea  and  cyanosis.  One  to  two  minutes 
elapse  between  expiration  and  inspiration,  and  inspiratory  and  ex- 
piratory spasms  or  generalized  convulsions  may  develop.  The  eyes  are 
injected,  the  nose  runs,  the  jugular  veins  are  large  and  the  skin  is  clammy. 
Involuntary  evacuations  occur;  the  pulse  is  small;  ecchymoses  sometimes 
occur  in  the  conjunctivae,  sclerse,  neck  or  face.  After  the  attack,  con- 
sciousness returns,  respiration  is  fast,  and  there  is  fatigue,  stupor,  sweating 
and  pain  in  the  abdominal  or  other  muscles  from  the  strain  of  coughing. 
The  attacks  occur  especially  toward  morning.  The  attacks  average 
twenty  daily.  In  the  free  interval  there  may  be  euphoria  or  great  de- 
pression, gastric  disturbance,  inanition  or  diarrhea.  A  marked  leuko- 
cytosis is  observed  early  in  the  disease;  lymphocytosis  occurs  in  85 
per  cent,  of  cases. 

3.  The  stadium  decrementi  follows,  but  this  stage  is  longer  in  pro- 
portion as  the  case  is  mild.  From  its  complications  (v.  i.)  it  is  the 
most  dangerous  stage. 

Com-se. — The  incubation  lasts  one  week;  the  catarrhal  stage  one  to 
two,  the  spasmodic,  three  to  six,  and  the  decline,  three  weeks. 


108  BACTERIAL  DISEASES 

Complications. — 1.  Ixcrease  or  Extexsiox  of  the  Usual  Sy:viptoms. 
— Catarrhal  inflammation  is  common  in  the  initial  stage — stomatitis, 
laryngitis,  diarrhea  (10  per  cent.)  and  otitis  media  (10  per  cent.).  Bron- 
chitis (bronchiolitis)  is  not  common  in  the  spasmodic  stage.  It  may 
occur  with  fever,  a  pulse  of  120  to  150,  respirations  of  30  to  50,  many 
rales,  cyanosis  and  atelectasis.  Bronchopneumonia  is  the  most  frequent 
and  severe  complication,  occurring  particularly  in  rhachitic  children 
between  the  third  and  fifth  years,  most  often  in  the  convulsive  stage. 
The  onset  is  gradual  with  fever  of  100°  to  102°,  pulse  of  130  to  160, 
respirations  of  30  to  SO,  with  cyanosis  and  dyspnea.  The  mortality 
may  reach  25  per  cent,  and  an  almost  absolutely  bad  prognosis  must  be 
given  in  the  very  young.  Sometimes  the  pneumonia  greatly  lessens  or 
entirely  abolishes  the  spasms.  Lobar  pneumonia,  exudative  pleurisy, 
endocarditis,  pericarditis,  meningitis  and  nephritis  are  very  infrequent. 
Spasm  of  the  glottis  in  nervous  or  scrofulous  children  is  largely  nocturnal 
in  incidence,  and  may  cause  death  from  asphyxia  even  in  the  lightest 
cases.  Convulsions  of  the  carpopedal  type,  especially  in  nervous  chil- 
dren, are  most  frequent  at  the  height  of  the  apnea.  The  eyes  are  rolled 
upward  and  outward,  the  pupils  are  dilated  and  coma  follows. 

2.  Mech.ixical  Complicatioxs. —  Hemorrhages  may  occur  into  the 
skin,  conjunctivae,  nose,  ears  and  throat.  Valentine  summarized  83 
instances  of  paralysis  from  cerebral  hemorrhage.  Extravasation  of  blood 
into  the  retina,  lungs,  stomach  and  intestine  is  rare.  There  may  be 
edema  of  the  eye-lids,  rupture  of  the  tympanum  ot  frenulum  of  the  tongue, 
the  ulceration  of  which  is  almost  constant.  Vomiting  occurs  regularly, 
as  a  mechanical  crisis  to  the  paroxj^sm.  Other  mechanical  complications 
are  cardiac  dilatation,  pulmonary  emphysema  (less  often  interstitial  than 
alveolar;,  bronchiectasis,  pneumothorax,  involuntary  evacuations,  pro- 
lapse of  the  rectum  or  uterus,  aneurysm,  muscular  rupture,  hernias 
and  rib  fracture. 

3.  Toxemia. — Marked  toxemia  is  rare.  Parenchymatous  degenerations 
are  found  in  the  fatal  cases.     Nephritis  is  not  common. 

Sequels. — The  hysterical  coughing  which  sometimes  follows  pertussis 
may  very  closely  resemble  it.  Tuberculosis  may  involve  the  lungs  or 
lymph  glands,  especially  after  pertussis  with  measles,  both  of  which 
infections  predispose  to  tuberculosis.  Preexisting  tuberculosis  renders 
the  prognosis  of  whooping-cough  very  unfavorable.  The  heart-muscle 
may  suffer  permanent  weakness. 

Diagnosis. — Diagnosis  is  made  by  (1)  the  definite  stages  of  the  disease; 
(2)  the  presence  of  an  epidemic;  (3)  the  characteristic  convulsive  seizures; 
(4)  the  sublingual  ulceration,  swollen  eyelids,  facial  edema,  petechise 
and  tender  areas  in  the  larynx;  (5)  pressing  the  tongue  back  with  a 
spoon  often  elicits  a  characteristic  attack  of  coughing.  The  stridor 
may  be  absent  in  nurslings  and  adults.  The  diagnosis  may  be  difficult 
between  paroxysms  in  the  early  or  late  stages.  Intercurrent  diseases, 
like  pneumonia  or  measles,  may  render  pertussis  atypical. 

Differentiation. — In  croup  there  are  fever,  aphonia,  metallic  inspiration, 
lividity  and  constancy  of  the  symptoms.  False  croup  (laryngismus  strid- 
ulus) beginning  with  acute  catarrhal  laryngotracheitis,  occurs  at  night 


PERTUSSIS  109 

in  healthy  children.  Simsmodic  cough  from  diseased  bronchial  glands 
very  closely  resembles  pertussis.  Barthez  and  Sannee  give  the  following 
differentiation: 

WhOOPIXG-CDUGH vs. ENL-iRGED    Gl.\NT)S. 

1.  Contagious,  epidemic.  1.  Isolated,  not  contagiotis. 

2.  Three  periods,  second  paroxysmal.  2.  No  distinct  periods. 

3.  Paroxysmal  cough  vnXh.  whoop,   vomit-         3.   Paroxj-sms,   Tvithout  the  whoop,   expec- 

ing  and  viscid  expectoration.  toration  or  vomiting. 

4.  Respiratory  sounds  normal.  4.  Signs     of     enlarged     glands     sometimes 

present. 

5.  Respiration  normal  in  interval;  apyrexia         5.  Asthma  in  some  cases,  febrile  movements, 

if  simple.  sweats,  wasting,  etc. 

6.  Voice  natural.  6.  Sometimes  a  change  in  voice. 

7.  Acute.  7.   Chronic. 

Spasmus  glottidis  in  nervous  children  at  dentition,  in  rhachitis  and 
tetany,  is  a  sudden  spasmodic  closure  of  the  glottis  without  prodromes, 
but  with  dyspnea,  cyanosis  and  convulsions.  Asthma  yeriodicum  (Millar's 
asthma)  relates  to  thymic  disease.  Hysterical  "  after-pertvssis"  presents 
no  catarrhal  symptoms,  fever,  vomiting,  sublingual  ulceration,  edema 
of  the  face,  petechia  or  a  tender  point  in  the  larynx,  and  other  stigmata 
of  hysteria  (q.  v.)  are  present. 

Prognosis. — In  the  United  States  10,000  deaths  occur  each  year  from 
pertussis,  and  its  death-rate  almost  equals  that  of  scarlatina  (per  100,000, 
diphtheria  21.4,  measles  12.3,  scarlatina  11.6,  and  pertussis  11.4).  The 
mortality  averages  3  per  cent.,  but  in  certain  epidemics  reaches  15  per 
cent.  The  longer  the  time  of  development  of  the  convulsive  stage,  the 
better  is  the  prognosis,  and  the  clearer  are  the  intervals  between  par- 
oxysms. The  outlook  is  more  unfavorable  in  the  poor,  nurslings  and 
children  under  five  years,  especially  in  colored  children.  The  mortality 
of  cases  in  the  first  year  is  about  27  per  cent.;  in  the  second  year,  14; 
from  the  second  to  the  fifth  year,  3;  from  the  fifth  to  fifteenth  year, 
1.8  (Hagenbach);  90  per  cent,  of  pertussis  deaths  occur  between  one 
and  two  years  of  age.  According  to  Trousseau,  more  than  forty  attacks 
in  one  day  indicate  a  grave  prognosis  and  over  60  attacks  indicate 
a  fatal  outcome;  the  writer  has  seen  recovery  with  over  100  paroxyms 
daily.  Coincident  measles,  pneumonia  or  early  bronchitis,  weak  heart, 
continued  emesis,  glottis  spasm,  eclampsia,  skin  emphysema,  hemorrhages, 
asphyxia  and  tuberculosis  cloud  the  prognosis. 

Treatment. — 1.  Prophylaxis. — Isolation  is  indicated,  particularly  in 
tuberculous  children.  It  is  never  advisable  to  expose  a  child  to  an 
epidemic.  The  greatest  danger  of  infection  exists  during  the  catarrhal 
stage.  The  sputum,  clothes,  etc.,  should  be  cared  for  on  antiseptic 
principles.  It  was  thought  that  vaccination  mitigated  or  aborted  per- 
tussis, but  in  eleven  personal  unvaccinated  cases,  vaccinia  was  ineffectual. 

2.  ]\Iedicatiox. — There  is  no  specific,  as  proved  by  the  multitude 
of  vaunted  remedies.  All  drugs  should  be  employed  cautiously.  Quinine 
is  the  foremost  remedy  (1|  times  as  many  grains  per  diem  as  the  child 
is  years  old;  to  children  under  two  years,  ^  grain  for  each  month). 
Children  seldom  object  to  its  taste, 


no  BACTERIAL   DISEASES 

'Bf — Extr.  belladoniiEe ?      .      .      .      .      gr.  iss 

Quininse  sulph gr.  ^-iij 

Sacchari  albi gr.  xxx 

M.  et  di^"ide  in  piilv.  no.  x. 

S. — One  powder,  three  times  daUj-  (.Widerhofer's  formula^. 

Camphor  may  be  indicated  as  a  stimulant  in  asthenia  and  bronchitis, 
I  grain  at  a  dose.  Coal  tars  should  not  be  exliibited.  Bromine  moderates 
the  course  of  the  disease;  bromoform  should  be  kept  bottled  in  the  dark — 
dose  one  to  five  minims. 

The  catarrh  may  be  treated  with  expectorants,  alkaline  drinks,  a  steam- 
ing kettle  under  a  tent  constructed  over  the  bed,  benzoic  and  tannic 
acids  (aa  gr.  ij,  t.  i.  d.). 

For  the  paroxysm  there  is  no  specific.  Belladonna  is  given,  one-sixth 
grain  of  the  extract,  to  a  child  of  six  to  eight  months,  until  flushing  is 
observed;  symptomatically  it  is  also  useful  for  the  clammy,  cool  skin 
and  collapse;  though  children  tolerate  belladonna  well,  great  care  must 
be  exercised  in  very  young  children.  The  same  caution  applies  to  ipecac, 
chloral  and  opium. 

Chloroform  inhalations  are  dangerous.  Codeine  is  less  eft'ective  than 
morphine.  Chloroform  is  advantageous  in  dry  coughs  (twice  as  many  drops 
as  the  child  is  years  old,  in  one  dram  of  warm  water).  Adrenalin, TTLj-iij, 
may  relieve  spasmodic  cough. 

I^ — Morphinae  hydrochloridi gr.  i 

Sodii  bromidi 3ss 

Chlorali  hydrati gr.  xvj 

AquEe  chlorofonni ad.  gjss 

Misce,  fiat  mistura. 

S. — One  to  three  teaspoonfuls  for  a  dose,  according  to  age. 

I^ — Sodii  benzoatis gr.  bixij 

Sodii  bicarbonatis gr.  xhdij 

AquEB  chlorofonni oJ 

AquEe  anisi ad.  §iij 

Misce,  fiat  mistura. 

S. — One  to  four  teaspoonfuls,  according  to  age,  even,-  few  hours. 

Digitalis  is  used  for  right-heart  dilatation.  Intubation  for  the  spasm 
of  the  glottis  may  induce  ulceration  from  the  long-continued  pressure. 
Bronchopneumonia   (q.  v.). 

3.  Hygiene  .\2sd  Diet. — A  warm  climate  modifies  the  course  and  is 
prophylactic  against  tuberculosis.  The  attacks  are  often  lessened  by 
removal  to  the  country.  Irritants,  as  beef-tea,  stimulants,  dry  bread, 
cookies  and  overfeeding,  provoke  coughing  and  vomiting.  Food  should 
be  given  at  frequent  intervals  in  concentrated  form — gruels,  milk  with 
lime-water,  zwieback  in  milk,  eggs,  meat-juice,  etc.  Older  patients 
tolerate  more  solid  food.     Rectal  feeding   is   sometimes   advantageous. 

4.  Vaccixes  axd  Seeotherapy. — In  reports,  bacterins  are  claimed 
to  shorten  the  course  of  the  disease  twelve  to  twenty-one  days,  but 
vaccines  and  serotherapy  are  still  on  probation. 


CHOLERA   ASIATIC  A  111 


CHOLERA  ASIATICA. 


Definition. — An  infection  caused  by  the  comma  bacillus  and  char- 
acterized by  vomiting,  severe  purging,  cardiac  failure  and  suppression 
of  urine. 

History. — The  name  has  been  used  since  the  time  of  Hippocrates, 
Galen  and  Celsus,  but  apparently  not  for  Asiatic  cholera.  Asiatic 
cholera  existed  before  Christ.  Its  first  European  invasion  was  in  1817, 
from  which  time  our  knowledge  dates.  Cholera  visited  America  in  1832- 
1835,  1836,  1848,  1849,  1854,  1865,  1867  and  1873.  Isolated  cases  have 
ocf'airred  since. 

Bacteriology. — Koch,  studying  cholera  in  Egypt  and  India  in  1883- 
1884,  discovered  the  comma  haciUus  in  the  feces  during  life  and  in  the 
bowel  at  autopsy.  It  is  1  to  1.5/x  long  and  half  as  wide;  smaller  than  the 
tubercle  bacillus,  but  more  plump  and  curved  and  is  motile  and  flagellated. 
Gaffky  (1887)  first  obtained  pure  growths.  In  cultures  its  form  varies, 
being  sometimes  S-shaped,  and  thread-  or  spirillum-like.  Pure  cultures 
are  grown  from  the  stools.  After  several  days  it  may  be  found  in  the 
bowel  wall,  though  rarely  in  the  stomach,  vomitus,  blood  or  viscera. 
It  disappears  from  the  movements  after  six  to  eleven  days. 

In  its  dissemination,  cholera  resembles  typhoid,  i.  e.,  infection  is  in- 
direct. Koch  maintained  that  cholera  was  conveyed  by  imter  con- 
tamination. He  found  the  cholera  vibrios  in  a  water-tank  in  Calcutta 
from  which  infection  was  clearly  traced.  Attendance  on  cholera  patients 
is  not  dangerous  if  the  hands  are  kept  clean.  The  germ  is  very  susceptible 
to  boiling,  antiseptics  and  drying.  There  is  little  risk  of  aerial  dissemina- 
tion except  by  flies.  The  acid  of  the  stomach  protects  the  individual, 
and  animals  are  infected  experimentally  only  when  the  gastric  acidity 
is  neutralized  and  peristalsis  is  arrested  by  opium.  Pettenkofer  objected 
to  Koch's  teaching  and  even  swallowed  pure  cultures,  luckily  escaping 
infection.  Nevertheless,  the  terrible  Hamburg  epidemic  (1892-1894) 
amounted,  as  Koch  said,  to  a  demonstration  of  almost  laboratory  exact- 
ness. The  disease  developed  "explosively."  On  August  16  there  was 
1  case;  by  August  27  there  were  1000  deaths,  and  September  3,  there 
were  10,000  cases  and  4300  deaths.  The  total  mortality  was  over  8300. 
The  Hamburg  drinking  water  came  unfiltered  from  the  Elbe  River, 
which  was  then  at  a  low  level.  The  germ  was  found  in  this  supply. 
Altona  and  Wandsbeck,  parts  of  Hamburg,  had  a  supply  of  good  water 
and  escaped.  The  germ  is  difficult  to  find  in  water  because  it  is  so  easily 
overgrown  by  saprophytes. 

Infection  by  ice,  milk,  lettuce,  flies,  the  washing  of  infected  linen  or 
in  the  laboratory  is  less  common.  In  India,  hundreds  of  thousands 
of  pilgrims  drink  the  "holy  water"  of  the  Ganges,  in  which  they  also 
bathe  and  defecate.  Similar  infections  occur  in  the  pilgrimages  to  Mecca. 
In  former  years,  caravans  carried  infection  from  India  through  Persia 
and  Afghanistan  to  Russia,  which  was  the  route  of  dissemination  in  1892. 
Ships  from  the  Orient  are  extremely  dangerous.  Carriers:  In  Manila 
8  per  cent,  of  374  healthy  individuals  were  vibrio  carriers.  In  the 
Italian  epidemic  of  1911,  their  officials  detected  41  carriers  about  to 


112  BACTERIAL  DISEASES 

embark  for  this  country,  and  at  New  York  the  quarantine  of  62  sick 
with  the  disease  and  also  carriers  averted  an  epidemic  and  its  attendant 
panic. 

Decreased  physiological  resistance,  alcohoHsm,  purgation,  dyspepsia, 
overexertion,  poor  hygienic  conditions  and  debilitating  diseases  are 
predisposing  factors.  Counting  the  mortality  in  a  cholera-stricken  com- 
munity for  a  few  years,  the  total  death-rate  is  not  increased,  which 
indicates  that  weakly  persons  succumb  to  cholera  and  that  later,  epi- 
demics of  other  diseases  have  fewer  victims. 

Epidemics  end  with  a  lessening  mortality;  their  ending  and  lessened 
mortality  are  explained  by  the  decreasing  virulence  of  the  germ.  Warm 
weather  increases  and  frost  usually  checks  epidemics;  nevertheless, 
Russia's  severest  epidemic  occurred  in  the  winter. 

Symptoms. — After  an  incubation  of  two  or  three  days,  the  disease 
develops;  several  stages  are  described,  which  also  correspond  to  clinical 
types  of  varying  virulence. 

1.  Prodromal  Diarrhea. — The  thin  stools  contain  the  comma 
bacillus,  are  voided  without  pain  and  sometimes  produce  only  moderate 
malaise.  The  trouble  may  cease  here,  when  we  speak  of  cholera  diarrhea, 
or  it  may  pass  into  the  choleraic  stage. 

2.  Choleraic  Stage. — The  stools,  at  first  yellow  and  voided  fre- 
quenth",  become  colorless  because  the  bile  pigment  is  diluted  and  de- 
creased, and  become  thin — the  ominous  "rice-water"  stools.  The  stools 
may  number  twenty  or  thirty,  aggregating  a  pint  to  five  quarts  daily. 
They  have  a  fetid,  not  a  fecal  odor,  and  contain  fiocculi  of  comma  bacilli, 
leukocytes,  epithelial  cells,  detritus  and  a  few  red  cells.  There  is  often 
gurgling,  although  little  gas  is  voided.  The  fluid  thus  lost  to  the  circula- 
tion, causes  some  of  the  following  symptoms:  The  abdomen  is  flat, 
usually  neither  tender  nor  painful,  and  fluid  may  be  percussed  in  the 
bowels.  Vomiting  is  frequent,  painless,  although  exhausting,  thin  and 
profuse,  even  to  three  quarts  daily;  sometimes  Koch's  bacillus  is  found. 
The  skin  shows  the  lack  of  fluid;  it  becomes  shrunken,  wrinkled  and  when 
pinched,  its  folds  disappear  but  slowly.  The  nose  becomes  small  and 
pointed,  and  the  malar  bones  jut  out  prominently;  the  extremities, 
nose  and  ears  become  cold  and  cyanotic,  and  grayish-blue  rings  develop 
beneath  the  sunken  eyes  {fades  cholerica).  If  pleurisy  or  dropsy  is 
present,  it  is  rapidly  absorbed.  The  saliva  and  urine  decrease  or  disappear. 
The  loss  of  fluid  occasions  distressing  thirst  and  muscle  cramps,  especially 
in  the  calves  and  other  muscles,  which  are  found  dry  at  autopsy.  The 
immense  transudation  into  the  bowel  concentrates  the  blood,  whose  red 
cells  may  total  six  to  eight  millions  and  the  serum  has  a  specific  gravity 
of  1.040,  even  1.070  (1.028  being  the  normal) ,  "^ /The  heart  tones  become 
weak  and  the  pulse  rises  to  100,  because  the  body  cannot  lose  10  per  cent, 
of  its  fluid  without  injury.  The  heart  has  not  enough  blood  upon  which 
to  contract  and  the  blood  is  viscid;  the  heart  also  degenerates  from 
absorption  of  soluble  toxins  from  the  bacilli.  The  difficulty  in  oxygenation 
increases  the  respirations  to  thirty  or  forty,  and  occasions  precordial  and 
epigastric  anxiety.  The  vox  cholerica.  is  due  to  the  dry  larynx  and  weak 
muscles,     The  refiexes  are  decreased  or  abolished,  the  pupils  tardy; 


CHOLERA  ASIATIC  A  113 

the  sensoriiim  is  normal,  although  exliaustion  and  apathy  are  usual. 
The  urine  contains  albumin  and  hyaline  casts.  While  the  extremities 
are  colder  by  5°  to  10°  or  more,  the  patient  feels  hot,  and  the  rectal  tem- 
perature may  be  102°  or  higher.  The  loss  of  weight  is  great  (even  1 
per  cent,  hourly).  In  some  cases  the  patient  dies  before  diarrhea  develops 
{cholera  sicca).  Recovery  is  possible,  even  with  these  ominous  symptoms; 
the  diarrhea  and  algidity  may  lessen,  the  heart  may  improve  and  ery- 
thematous, roseolous  and  urticarial  rashes  may  develop;  indican,  pre- 
viously absent  from  the  urine,  may  reappear;  the  urea  and  ethereal 
sulphates  are  increased.  The  later  symptoms  probably  result  from 
acidosis  or  absorption  of  toxins  from  the  intestine  (the  so-called  cholera 
typhoid). 

3.  Stage  of  Collapse. — This  stage  is  characterized  by  asphyxia 
(literally,  without  pulse),  algidity  or  collapse.  The  heart  tones  are  inaud- 
ible, the  pulse  imperceptible,  the  arteries  empty.  In  the  days  of  vene- 
section the  blood  would  not  drain  from  the  incised  veins,  and  at  autopsy 
little  or  no  blood  escapes  from  the  vessels.  The  skin  is  lead-colored, 
cyanotic,  even  purple.  There  is  dyspnea,  the  expired  air  is  cool,  the 
voice  gone,  the  mouth  dry,  the  conjunctivae  opaque,  and  the  lids  are 
parted,  yet  the  mind  is  clear.  The  evacuations  cease.  Pericardial  or 
pleural  rubs  may  be  heard,  due  to  the  great  viscidity  found  in  all  the 
serosse  at  necropsy.  Very  few  patients  with  cholera-typhoid  recover; 
most  die  within  a  few  hours,  or  a  day.  After  death  the  muscles  contract, 
to  the  great  terror  of  observers;  the  face  is  distorted,  the  fingers  flexed 
and  the  legs  drawn  up.  At  autopsy  the  small  intestines  are  injected, 
jBlled  with  rice-water  contents,  their  epithelium  and  villi  are  desqua- 
mated. Comma  bacilli  are  found  in  the  stools  and  intestinal  wall. 
The  muscles  are  dry  and  the  kidneys  show  a  pale  cortex  with  great 
cortical  degeneration,  especially  in  the  convoluted  tubules,  from 
toxemia. 

Complications. — Due  to  the  pyogenic  cocci,  diphtheroid  changes  may 
be  found  in  the  bowel,  uterus,  vagina  and  throat.  Small  hemorrhages 
from  mucous  or  serous  surfaces  may  occur.  Pneumonia  (20  per  cent, 
of  fatal  cases),  pleurisy  or  lung  infarct;  skin,  parotid  or  other  suppura- 
tions; icterus,  bronchitis,  venous  thrombosis  or  postfebrile  psychoses, 
are  uncommon.  Griesinger's  "cholera-typhoid"  is  the  most  frequent 
sequel  (25  per  cent,  of  cases);  acidosis,  nervous  complications  and 
uremia  are  far  less  common  causes  than  toxemia  operating  on  the  ex- 
hausted and  anemic  brain. 

Diagnosis. — ^The  first  cases  occasion  the  most  difficulty,  especially  if 
they  are  light.  Robust  individuals  may  not  react  to  the  germs  found 
in  their  stools;  simple  diarrhea  may  result  in  other  cases,  and  a  mild 
depression  only  may  mark  cholerine.  On  the  other  hand,  aged  or  weakly 
persons  may  succumb  before  its  characteristic  stages  develop.  In  sus- 
picious cases,  laboratory  measures  are  necessary  for  diagnosis.  The 
pseudocholera  vibrios  in  the  Elbe,  Seine  or  Danube  Canal  (Vienna)  are 
differentiated  with  difficulty. 

Cholera  nostras  produces  a  similar,  though  less  severe  picture.  In 
some  few  cases  the  Finckler-Prior  bacillus  is  found,  but  in  the  majority 


114  BACTERIAL   DISEASES 

other  microbes  are  present,  such  as  the  colon  bacilkis,  and  less  often  the 
streptococcus,  staphylococcus  and  a  bacillus  like  the  Bacillus  subtilis; 
vibrios,  proteus  and  pyocyaneus  forms;  the  dysentery  bacillus;  Gartner's 
Bacillus  enteritidis;  in  meat,  the  paratyphoid  and  anaerobic  forms; 
and  in  mollusks,  Zieber's  Bacillus  piscicidus  agilis.  Cholera  nostras 
bears  the  same  relation  to  cholera  x\siatica  as  varicella  does  to  variola 
or  German  measles  to  measles. 

Arsenical  poisoning,  peritonitis,  and  intussusception,  without  bacter- 
iological confirmation  may  closely  resemble  cholera. 

Prognosis. — Cholera  ranks  next  after  the  plague  in  death-rate,  and 
averages  60  per  cent.,  and  sometimes  80  per  cent.;  100,000  to  700,000 
die  yearly  in  India.  About  45  per  cent,  of  deaths  occur  in  the  first  twenty- 
four  hours  and  17  per  cent,  in  forty-eight  hours,  whence  the  prognosis 
is  more  favorable  after  the  second  day;  when  the  stage  of  collapse  is 
reached  85  per  cent.  die. 

Treatment. — 1.  Peophylaxis. — Isolation  of  early  cases,  disinfection 
of  the  stools,  soiled  linen,  etc.,  and  special  attention  to  light  cases  and 
any  suspicious  diarrhea  are  most  important.  In  convalescence  the  stools 
may  remain  infective  for  seven  weeks.  Despite  the  sudden  outbreaks 
in  Germany  in  1892-1894,  sanitary  measiu-es  kept  the  total  of  deaths 
at  10,000,  while  in  Russia  800,000  died  in  the  same  period.  Individual 
prophylaxis  concerns  the  maintenance  of  physiological  resistance;  moder- 
ation in  eating;  boiling  of  drinking  water  and  milk;  care  in  regard  to 
ice;  avoidance  of  green  fruits  and  vegetables,  and  contamination  of  food 
by  flies.  In  quarantine,  the  stools  of  all  aboard  suspected  vessels  should 
be  examined,  to  detect  carriers.  In  one  series  the  prophylactic  serum 
of  Ferran  and  HafYkine  reduced  the  morbidity  two-thirds  and  the  mor- 
tality one-half. 

2.  DiAKRHEA. — Absolute  rest  in  bed,  an  initial  cleansing  of  the  bowels 
with  calomel  and  castor  oil;  thin  gruels;  red  wine,  aromatics,  tea  and 
full  doses  of  bismuth,  and  morphine,  hypodermically,  should  be  given. 
Intestinal  antiseptics  are  inert.  The  diarrhea,  except  the  early  move- 
ments, is  not  easily  stopped,  because  absorption  is  arrested.  Cantani 
advised  that  1  or  2  quarts  of  1  per  cent,  tannic  acid  solution  be 
given  slowly  by  rectum  in  the  hope  that  it  would  reach  the  small 
intestine. 

3.  Vomiting. — ^^-'omiting  is  intractable.  Fluids  should  not  be  with- 
held. The  stomach  may  be  washed  with  normal  salt  solution.  Hot 
wine,  champagne,  and  hypodermics  of  morphine  are  indicated. 

4.  Heart. — Failing  heart  action  and  renal  secretion  are  sometimes 
helped  by  a  warm  bath.  Hypodermoclysis  and  intravenous  transfusions 
were  studied  during  the  Hamburg  epidemic  and  their  employment  often 
greatly  benefited  the  heart  and  the  general  condition. 

5.  IMuscular  cramps  are  helped  by  warm  baths,  friction,  local  heat, 
saline  infusions  and  morphine  hypodermically.  In  convalescence,  great 
care  is  necessary  lest  the  diarrhea  return.  Other  symptoms  and  sequels 
are  treated  expectantly. 


THE  PLAGUE  115 


THE  PLAGUE. 


Definition. — The  pest,  or  bubonic  plague,  is  a  specific  acute  infection 
caused  by  the  Bacilkis  pestis  and  characterized  by  a  pronounced  typhoid 
state,  fever,  buboes  and  carbuncles,  very  frequently  by  pesticemia,  and 
by  extremely  high  mortality. 

History. — The  first  clear  account  dates  from  the  times  of  Trajan, 
in  the  second  century,  and  of  Justinian,  in  the  year  542.  In  the  four- 
teenth century  the  "black  death"  swept  over  Europe  with  a  mortality 
of  25,000,000  (one-quarter  of  the  world's  population).  It  reappeared 
in  the  sixteenth  and  seventeenth  centuries,  but  in  the  eighteenth  century 
it  withdrew  southeast  and  disappeared  from  Europe  until  the  small 
Russian  epidemic  in  1878-1879.  Egypt  was  the  early  focus  for  African 
epidemics,  and  European  epidemics  started  from  Syria,  the  leading 
Asiatic  focus  for  thirteen  epidemics  (1773-1843).  The  present  Oriental 
focus,  is  Thibet,  whence  India  and  China  have  been  invaded  thirty 
times  between  1823  and  1897.  Uganda  is  considered  a  permanent 
plague  home  by  Koch;  plague  is  endemic  in  Asia  near  Mecca,  in  Mesopo- 
tamia and  in  Siberia.  In  1899-1900,  New  York,  San  Francisco,  Cape 
Town,  South  America  and  Australia  were  visited;  in  1906  England, 
and  in  1912  Cuba  and  Porto  Rico;  4500  died  in  Manchuria  in  1910-11. 
Plague  appeared  in  New  Orleans  in  1914. 

Etiology. — The  Bacillus  pestis  was  found  by  Yersin  in  1894,  and 
independently  by  Kitasato.  Its  ends  are  rounded  and  stain  deeply; 
its  sides  are  somewhat  convex;  it  measures  1^  to  If  by  ^  to  f  ^t  and  is 
encapsulated.  It  is  polymorphous,  and  appears  as  rods  or  diplo-bacilli. 
Atypical  forms  are  ovoid,  annular,  chain-,  thread-,  or  branch-like; 
involution  forms  are  the  pyriform,  biscuit,  comma-shaped,  or  sperma- 
tozoid.  It  contains  no  spores  or  flagella.  It  is  found  in  all  organs,  in  the 
sputum,  the  urine  and  feces,  and  in  the  bubo  and  carbuncles.  Its 
cultures  are  typical  and  superficial,  and  have  bulging,  wall-like  edges. 
It  stains  with  ordinary  stains,  but  not  by  Gram's  method. 

Atrium. — It  may  enter  (1)  by  the  skin,  through  invisible  wounds, 
scratches  or  the  intact  integument.  Postmortem  and  laboratory  inocula- 
tion is  possible,  as  in  the  unfortunate  case  of  Miiller,  of  Vienna,  while 
writing  his  well-known  monograph.  Flies,  fleas,  bed-bugs,  etc.,  may 
inoculate  the  disease.  (2)  The  mucosae,  conjunctivae,  nose,  tonsils,  anus 
and  external  genitalia,  may  be  primarily  infected,  especially  the  nose 
and  throat  in  children.  (3)  The  bacillus  may  cause  primary  plague 
pneumonia. 

Contagion  may  be  direct  or  indirect,  {a)  Direct:  Dissemination  of 
plague  pneumonia  by  the  sputum  is  most  dangerous  {v.  Fliigge's  experi- 
ments in  tuberculosis).  The  pest  spreads  rapidly  only  when  it  is  of  the 
pneumonic  type.  The  bacilli  escape  from  ruptured  carbuncles  or  buboes. 
The  urine,  the  feces  and  the  milk  of  nursing  women  are  also  dangerous. 
Direct  contagion  may  result  from  autopsies  or  operations.  (&)  Indirect: 
This  may  result  from  fomites,  or  bites  of  animals  or  insects  containing 
the  germ.    Epidemics  among  rats  precede  human  epidemics.     In  Canton 


116  BACTERIAL  DISEASES 

35,000  dead  rats  were  found  in  one  district.  The  disease  also  exists 
among  apes,  cats,  mice,  ground-squirrels,  which  latter  made  California 
a  permanent  pest  focus,  and  marmots  (Manchurian  epidemic).  Infection 
by  rat-fleas  is  clearly  proved.  Flies  may  convey  infection  from  the 
urine  or  feces  of  infected  rats.    The  bacillus  produces  mrulent  toxins. 

Symptoms. — There  are  two  factors  in  the  clinical  picture:  (a)  The 
local  changes,  as  the  primary  localization  (bubo  or  pneumonia),  and 
(6)  the  successive  septicemia  (pesticemia)  and  toxenaia.  The  average 
incubation  is  five  days.  Usually  the  onset  is  very  acute,  with  marked 
headache,  intense  vertigo,  severe  rigor,  sudden  ffever,  vomiting  and, 
in  children  convulsions.  There  is  early  glandular  fain,  profound  pros- 
tration, and  an  early  typhoid  state.  T\\e  fever  reaches  104°  on  the  second 
day,  is  continuous  or  remittent,  in  convalescing  cases  falls  by  lysis 
(fifth  to  seventh  day),  or  may  remain  high  until  death.  Crisis  is  seen 
in  light  cases  only.  The  skin  is  hot  and  dry  or  covered  with  sweat  as 
death  approaches.  Skin  hemorrhages,  due  to  embolism  by  the  Bacillus 
pestis  are  frequent  before  death.      Herpes  never  develops. 

1.  Local  Lesion. — This  is  the  bubo.  The  lymph  glands  are  more 
important  than  in  any  other  infection.  The  clinical  forms  of  the  plague 
are  (a)  the  bubonic  type  (77.7  per  cent.);  (6)  the  septicemic  type  (14  per 
cent.);  (t)  the  pulmonary  type  (4.3  per  cent.);  {d)  the  carbuncle  type 
(2.5  per  cent.);  (e)  mixed  infection  (1  per  cent.);  and  (/)  the  ambulatory 
type  (pestis  minor,  0.5  per  cent.),  which  is  considered  by  Scheube  as  not 
plague  but  "climatic  bubo."  In  all  except  the  pulmonary  type,  the  bubo 
is  found  very  early  (95  per  cent.) ;  it  occurs  in  the  external  lymph  glands 
in  the  region  of  the  atrium;  it  is  large,  very  painful  and  tender,  and  is 
attended  by  great  periadenitis,  edema,  heniorrhage  and  vesiculation  of 
the  skin.  Its  size  and  rapid  growth  are  due  in  part  to  lymph-medullary 
swelling,  but  chiefly  to  hemorrhage,  which  may  spread  along  the  nerves 
or  vessels,  into  which  it  may  break,  disseminating  the  bacilli.  The  glands 
may  fuse  into  a  brawny  mass,  as  large  as  an  egg  or  a  man's  fist;  they 
and  the  surrounding  tissues  contain  enormous  numbers  of  bacilli.  The 
location  is  inguinal  (70  per  cent.),  axillary  (20  per  cent.)  and  cervical 
(10  per  cent.).  The  inguinal  and  axillary  adenitis  is  more  common  in 
males;  cervical  adenitis  results  in  children  from  infection  of  nose  and 
throat  by  dirty  fingers;  the  popliteal  and  epitrochlear  glands,  curiously, 
are  involved  in  but  1  or  2  per  cent.  Strangely,  too,  the  lymph  vessels 
are  usually  unaffected.  From  the  primary  bubo  the  contiguous  glands 
are  involved,  e.  g.,  after  the  infection  of  the  inguinal  glands,  the  iliac, 
aortic,  mediastinal,  subpectoral,  infra-  and  supraclavicular  or  cervical 
glands  may  be  involved,  i.  e.,  infection  occurs  in  the  direction  of  the 
lymph  current.  On  the  fourth  to  the  sixth  day  necrosis  occurs,  and  on 
the  eighth  or  ninth  day  suppuration  develops,  resulting  more  often 
from  the  Bacillus  pestis  alone  (66  per  cent.)  than  mixed  infection  (33 
per  cent.).  The  primary  bubo  is  often  inconspicuous  and  its  size  has  no 
bearing  on  the  intensity  of  the  disease,  yet  subjects  with  marked  peri- 
adenitis rarely  recover.  The  bacilli  in  the  blood  have  a  remarkable 
affinity  for  lymphatic  structures;  these  hematogenous  buboes  are  smaller, 
less  tender,   painful,   edematous   and   hemorrhagic,   than  the  primary 


THE  PLAGUE  117 

bubo.  The  mesenteric  glands,  the  pharyngeal  follicles,  stomach,  intestine 
and  lung  contain  bacilli  in  large  numbers.  Carbuncles  result  chiefl}^ 
from  pesticemia  and  occur  in  10  to  15  per  cent,  of  cases,  often  near  the 
primary  bubo;  the  crowning  serous  vesicle  ruptures,  discharges  bacilli 
and  leaves  an  ulcer,  whose  floor  is  bluish-red  from  hemorrhage  or  yellow 
from  swarms  of  bacilli.  A  dark  crust  then  forms.  There  is  great  per- 
ipheral infiltration  and  the  whole  limb  may  become  edematous.  These 
lesions  indicate  that  the  pesticemia  is  an  integral  part  of  the  disease. 
The  blood  shows  polymorphonuclear  leukocytosis.  The  spleen  is  enlarged 
threefold.  Its  cut  surface  is  finely  granular  and  slightly  glistening. 
It  is  infiltrated  with  white  cells  and  bacilli,  found  in  innumerable  foci 
of  minute  necrosis.    It  is  usually  palpable  on  the  first  or  second  day. 

2.  Nervous  System. — There  are  few  anatomical  changes  except 
meningeal  hemorrhages  and  brain  edema.  Clinically  the  toxemic  "ty- 
phoid" symptoms  are  prominent — early  headache,  marked  prostration 
and  vertigo,  causing  a  drunken,  cerebellar  gait.  The  delirium  is  most 
often  dull,  dreamy  and  docile.  Twitching,  rigidity  of  the  neck  and 
increased  pulse  and  respiration,  polyphagia  or  polydipsia,  may  suggest 
meningitis.  Conjunctival  hyperemia,  sometimes  with  ecchymoses,  is  so 
frequent  that  Yamagiwa  made  it  a  cardinal  symptom. 

3.  Circulation. — Circulatory  and  nervous  changes  measure  the 
intensity  of  infection  and  forecast  the  prognosis.  There  are  few  cardiac 
poisons  as  intense  as  the  plague  toxin  which  operates  on  the  medulla 
and  its  vagus  nucleus.  Early  the  pulse  is  full  and  dicrotic,  with  a  rate 
of  80  to  90.  Later,  it  increases  to  120  to  150;  the  heart  tones  become 
muffled;  tachypnea,  dyspnea  and  all  the  signs  of  acute  cardiac  insuf- 
ficiency develop.  At  autopsy  the  heart  is  lax,  the  right  ventricle  dilated, 
the  myocardium  cloudy,  and  the  serous  investments  ecchymotic. 

4.  Respiratory  Tract. — The  plague  pnevmonia  is  of  two  varieties: 
(fl)  The  primary,  in  which  the  lung  is  the  atrium  (or  analogue  of  the 
primary  bubo) — the  "black  death"  of  the  middle  ages.  It  became 
well  known  in  the  Indo-Chinese  epidemic  of  1896-1897,  when  Childe 
found  the  Bacillus  pestis  in  the  lung.  The  bacillus,  if  inhaled,  causes 
confluent  lobar  pneumonia  and  salient  lymphatic  involvement.  The 
bacilli  exist  in  hordes  in  the  lung  and  sputum,  and  may  cause  hematog- 
enous buboes  and  carbuncles.  The  diagnosis  is  positive  only  from  the 
sputum,  cyanosis,  dyspnea,  hemoptysis,  pleuritic  pains,  signs  of  con- 
solidation, adynamia,  splenic  tumor  and  collapse.  Death  occurs  in  97 
per  cent,  of  cases,  (b)  Secondary  pneumonia  is  (i)  embolic,  as  multiple 
small  foci  and  difficult  to  diagnosticate  without  bacilli  in  the  sputum. 
(ii)  Aspiration  pneumonia  in  the  lower  lobes  follows  bubonic  disease 
of  the  tonsil,  pharynx  or  bronchi  and  is  almost  invariably  fatal 

5.  Digestive  Tract. — A  moist,  then  dry  tongue,  hemorrhage  from 
the  mouth,  and  involvement  of  the  tonsils  or  pharynx  are  common. 
There  may  be  ecchymoses  and  erosions  in  the  stomach  and  intestines; 
l)ubonic  changes  in  the  lymph  structures  were  found  in  20  per  cent,  of 
Wilm's  cases,  and  mesenteric  adenitis  in  60  per  cent.  Vomiting  is  fre- 
quent, meteorism  and  diarrhea  occasional.  The  liver  is  swollen  from 
degeneration  or  stasis. 


118  BACTERIAL  DISEASES 

6.  Gexito-ueixary  Tra.ct. — The  urine  is  decreased,  and  moderate 
albuminuria  is  very  common.  Xephritis  is  frequent.  xAiiatomically, 
degeneration,  minute  areas  of  focal  necrosis  and  glomerular  hemorrhage 
from  capillary  embolism  of  the  bacilli  are  common.  Bacilluria  occurs 
in  about  30  per  cent,  of  the  cases.  The  bacilli  have  been  found  in  the 
aborted  fetus. 

Diagnosis. — The  cardinal  signs  are  fever,  buboes,  pesticemia  and 
positive  blood  cultures,  inoculation  and  agglutination  (not  well  marked 
until  the  second  week  of  infection,  and  best  developed  in  convalescence; 
negative  results  do  not  exclude  plague). 

Prognosis. — ^A  patient,  stricken  in  the  morning,  may  die  before  night. 
If  the  patient  outlives  a  week,  the  chances  of  recovery  are  good.  Ominous 
symptoms  are  marked  nervous  and  cardiac  toxemia,  digestive  disorders, 
hemorrhages,  cervical  buboes,  tonsillar  involvement  and  pneumonia. 
The  death-rate  is  often  80  and  sometimes  95  per  cent.  In  Toidon  (1721), 
77  per  cent,  of  the  population  had  the  plague  and  62  per  cent,  died — 
higher  percentages  than  in  any  other  epidemic  disease.  Nearly  1,000,000 
die  yearly  in  India. 

Treatment. — 1.  Prophylaxis. — The  plague  patient  should  be  isolated 
and  carefully  covered  with  netting.  Infected  houses  should  be  isolated, 
unroofed  to  admit  the  sun  and  fumigated  to  kill  insects  and  rats.  Vigorous 
attacks  should  be  made  on  rats  and  ground-squirrels.  Ships  should 
be  held  in  quarantine  until  the  rats  in  their  holds  are  killed,  the  bilge- 
water  disinfected,  and  all  clothing  fumigated.  The  sputum  may  be  infec- 
tive for  three  months  and  the  urine  for  six  weeks.  The  strictest  pre- 
cautions are  imperative  in  those  coming  into  close  contact  -udth  the 
disease;  besides  ordinary  antisepsis,  goggles  and  masks  should  be  worn. 
Inoculation  with  dead  cultures  and  with  serum  from  immunized  animals 
and  from  convalescent  patients  is  a  measure  assured  of  success. 

2.  Symptoal^tic  Treatmext. — Buboes  and  carbuncles  are  most 
efficaciously  treated  with  weak  sublimate  dressings.  Surgical  extir- 
pation disseminates  infection,  and  injection  of  carbolic  acid  into  the 
buboes  does  not  stay  the  septicemia.  Digitalis,  alcohol  and  hydrotherapy 
are  employed  as  in  other  toxemias.  Bichloride  of  mercury  is  well  toler- 
ated and  was  suggested  by  the  observation  that  syphilitics  under  mer- 
curial treatment  withstood  infection. 

DYSENTERY. 

Definition. — An  acute  contagious  disease,  caused  chiefly  by  the  Ameba 
dysenterise  and  Shiga's  Bacillus  dysenterise;  attended  anatomically  by 
bowel  inflammation  and  characterized  clinically  by  colic,  tenesmus  and 
mucobloody  passages. 

History. — The  name  dates  from  Hippocrates  (480  B.C.),  and  the  affec- 
tion is  clearly  mentioned  in  the  oldest  medical  script,  the  Papyrus  Ebers 
(1550  B.C.),  and  in  the  Veda.  It  has  been  the  scourge  of  armies  from 
the  times  of  the  Greco-Persian  wars.  In  our  Civil  war  there  were  287,522 
cases  among  the  Northern  troops.  Among  the  English  soldiers  in  India 
30  per  cent,  of  the  deaths  were  due  to  dysentery.     It  prevailed  in  the 


i 


DYSENTERY  119 

recent  South  African  and  Spanish-American  wars,  but  was  practically 
absent  among  the  Japanese  forces  (1904-1905).  Essentially  a  disease 
of  the  tropics  and  subtropics,  it  is  frequently  observed  in  temperate 
zones,  especially  in  prisons  and  in  asylums.  Lack  of  hygiene,  overcrowd- 
ing, eating  of  spoiled  food  or  fruits  and  impure  water  are  predisposing  causes. 

Shiga's  Bacillary  Form  of  Dysentery. — The  Bacillus  dysenterioe  was 
described  by  Shiga  (1897),  who  found  it  in  the  intestinal  wall;  the 
bacillus  and  its  toxins,  when  inoculated,  produce  intestinal  hemorrhage. 
There  is  a  specific  agglutination,  increasing  in  intensity  under  observa- 
tion and  most  marked  in  convalescents;  the  serum  of  the  immunized 
cases  is  of  prophylactic  and  therapeutic  value.  Actual  inoculations  of 
man  produce  dysentery,  as  in  Strong's  inoculation  of  a  criminal  under 
sentence  of  death,  as  well  as  in  accidental  laboratory  infections.  The 
bacillus  resembles  the  colon  and  typhoid  bacilli  in  form,  though  less 
motile  than  the  latter,  and  flagellated;  it  is  a  facultative  anaerobe,  con- 
tains no  spores,  stains  readily  but  not  by  Gram's  method,  and  grows  on 
all  media. ^  It  is  suggested  that  the  Shiga  type  be  called  dysentery  and 
the  Flexner-Harris  type  paradysentery,  but  the  general  term  bacillary 
dysentery  probably  will  prevail.  The  bacilli  are  less  abundant  in  the 
early  diarrheal  stools  than  in  the  later  mucobloody  stools;  when  the 
dejecta  become  purulent  (last  stage)  the  bacillus  disappears.  It  is  found 
in  the  mesenteric  glands,  but  rarely  in  the  blood,  spleen  or  liver.  Infec- 
tion is  probably  carried  by  contaminated  drinking  water,  milk  and  flies. 
Healthy  bacilli-carriers  and  convalescents  may  convey  infection.  Flexner, 
Barker,  Strong,  Musgrave  and  Craig  found  this  type  in  the  Philippines; 
Kruse  found  it  in  Germany,  Flexner,  Goodliffe  and  others  in  America 
(1901).  Duval,  Bassett,  Wollstein  and  other  clinicians  discovered  it  in 
infantile  types.    Epidemics  have  existed  for  centuries  in  Japan. 

Symptoms. — After  an  incuhation  of  two  to  eight  days,  there  is  a  sudden 
onset  with  fever,  reaching  100°  to  102°  (even  104°),  colic  and  diarrhea. 
The  simple  diarrheal  stools  soon  show  mucus,  and  then  bloody  mucus  or 
pure  blood,  voided  with  severe  rectal  tenesmus.  The  passages  are  small, 
numbering  twenty  to  sixty  or  even  one  hundred  a  day,  and  contain 
Shiga's  bacillus.  The  urine  is  scanty.  In  mild  cases  the  symptoms 
abate  in  two  to  three  weeks,  and  the  stools  become  purulent  and  contain 
few  bacilli. 

The  symptoms  arise  from  local  inflammation  and  from  systemic  toxemic 
reaction  to  solution  of  the  bacilli  themselves  in  the  tissues;  especially 
when  lesions  occur  in  the  lower  small  intestine,  the  absorptive  power 
of  which  is  great,  a  typhoidal  condition  results,  with  coated  tongue, 
nervous  toxemia,  weak  pulse,  and  frequently  death  in  the  first  week. 
Shiga   names   this    form    enterodysentery,    as   distinguished   from   the 

'  In  gelatin  it  grows  with  deep,  pin-point  cultures,  is  brownish-yellow  without  lique- 
faction, and  has  well-marked  borders;  it  develops  best  in  glucose  agar  (grayish  growth 
along  the  puncture,  without  fermentation),  or  in  litmus  milk  (some  slight  acidification, 
followed  by  alkalinization  and  a  brownish  color).  There  are  three  strains  of  the  bacillus: 
(1)  The  Shiga  type,  which  attacks  glucose  but  not  other  sugars;  (2)  Flexner-Harris  type, 
which  attacks  glucose,  mannite  and  dextrine  but  not  lactose,  and  forms  more  acid;  (3) 
Hiss-Russell  type,  which  attacks  glucose  and  mannite  but  not  lactose  or  dextrine.  The 
blood  of  a  dysentery  subject  will  agglutinate  all  types,  but  particularly  the  second. 


120  BACTERIAL  DISEASES 

ordinary  type,  colodysentery.  If  the  stools  become  gangrenous  the 
outlook  is  hopeless.  Ecchymoses  on  the  chest,  epigastrium  and  inner 
surface  of  the  limbs  are  quite  frequent.  Emaciation  is  marked  in  acute 
and  chronic  forms. 

The  symptoms  are  explained  by  the  anatomical  findings:  The  bacilli 
lodge  largely  in  the  small  folds  and  large  flexures  of  the  colon  and  sigmoid. 
The  intensely  hyperemic  mucosa  shows  various  grades  of  inflammation — 
catarrhal,  hemorrhagic,  diphtheritic,  necrotic  or  ulcerative.  The  rugse 
and  the  entire  mucosa  are  edematous,  thickened  and  show  coagulation 
necrosis,  fibrinous  exudation  and  cellular  infiltration;  the  submucosa 
is  infiltrated;  the  muscularis  is  sometimes  infiltrated  and  the  serosa  is 
ecchymotic  and  freshly  fibrinous.  In  marked  cases  the  necrotic  areas 
become  ulcers,  in  or  between  the  follicles;  they  have  a  flat  base,  occupy 
chiefly  the  folds,  usually  reach  only  the  muscularis  mucosae,  and  in  severe 
cases  impart  a  sieve-like  aspect.  The  swelling  may  obliterate  the  lumen 
of  the  intestine.  Cocci  and  colon  bacilli  infest  the  upper  but  never  the 
lower  layers,  where  we  find  the  Bacillus  dysenterise  in  and  around  the 
glands.  In  the  virulent  cases  the  gut  becomes  gangrenous.  Stenosis 
may  follow  cicatrization  of  the  ulcers. 

Diagnosis. — Local  rectal  disease  (syphilis,  cancer  or  papilloma)  may 
possibly  confuse.  In  contradistinction  to  amebic  dysentery,  it  is  generally 
acute;  toxemic  symptoms  and  hemorrhages  are  common,  from  involve- 
ment of  the  small  intestine;  the  ulcers  are  flat,  on  the  folds  of  the  intes- 
tine and  never  undermined;  liver  abscess  never  occurs.  Amebic  dysen- 
tery is  characteristically  subacute  or  chronic;  the  small  intestine  less 
frequently  suffers;  liver  abscess  is  common  (20  to  33  per  cent.),  and 
necrosis  begins  in  the  submucosa  and  produces  ulcers  with  undermined 
edges.  Agglutination,  similar  to  the  Widal  reaction  in  typhoid,  occurs 
in  dilutions  of  1  to  20  (even  1  to  100  or  1000).  It  gradually  increases  as 
the  disease  progresses,  as  Forster  noted  in  typhoid  fever — a  good  prog- 
nostic. It  is  seen  in  the  second  week  and  most  clearly  in  convalescence, 
and  therefore  late  for  diagnostic  purposes. 

Prognosis. — The  prognosis  is  more  favorable  in  involvement  of  the 
rectum  and  sigmoid  flexure  than  when  the  upper  colon  or  cecum  is  affected. 
The  outlook  is  grave  in  patients  under  five  or  over  fifty  years  of  age. 
Intoxication  is  a  bad  prognostic.  The  effect  of  serotherapy  is  another 
factor  {v.  i.).  The  mortality  is  high,  particularly  in  Japan,  ranging  from 
20  to  25  per  cent.  No  immunity  is  conferred.  A  second  attack  was 
observed  in  2.7  per  cent.,  and  a  third  in  0.3  per  cent,  in  Ogata's  collection 
of  25,279  cases. 

Amebic  Dysentery. — Lambl  (1859)  and  Losch  (1876)  discovered  an 
ameba  in  the  bowel  movements.  Kartulis,  in  Egypt,  found  the  ameba 
in  over  500  cases  and  in  the  secondary  liver  abscess;  (a)  it  was  constant 
in  certain  forms  of  dysentery,  in  the  ulcers,  feces  and  liver  abscesses;  (6) 
it  was  inoculable  in  cats;  (c)  negative  results  were  obtained  with  the 
ameba  found  in  normal  feces.  The  home  of  amebic  dysentery  is  the 
tropics,  especially  in  Egypt,  India,  Formosa,  China,  Arabia  and  Italy. 
Sporadic  cases  occur  in  the  temperate  zone,  especially  in  Germany  and 
America,  where  it  is  the  most  frequent  form.    The  author  has  seen  sixteen 


DYSENTERY 


121 


cases,  clearly  acquired  in  Chicago.  In  the  Philippines  it  constituted  67 
to  80  per  cent,  of  Strong's  series.  The  ameba  is  found  in  the  pus,  glairy 
mucus  or  blood-tinged  mucus  of  the  evacuations;  introducing  a  rectal 
tube,  the  fecal  matter  in  its  eyelets  shows  the  ameba.  It  is  round  in  the 
quiescent  stage  or  irregular  from  protrusion  of  pseudopodia,  when  the 
slide  is  slightly  warmed;  for  diagnosis  it  must  be  motile.  It  is  uni- 
cellular, and  measures  10  to  50/x.  Schaudinn  distinguishes  the  innocuous 
Entameba  coli  from  the  pathogenic  Entameba  histolytica  (Ameba  dysen- 
terife),  which  is  larger,  has  a  highly  refractile  hyaline  ectoplasm  (more 
clearly  differentiated  from  the  endoplasm),  contains  more  vacuoles, 
has  a  sharper  nucleus  (5  to  7^),  and  more  frequent  red-cell  inclusions. 
Encysted  amebse  are  resistant,  dangerous  forms,  resembling  the  gametes 
of  malaria  (Musgrave  and  Clegg).  It  stains  readily  by  the  Wright- 
Romanowsky  method  and  in  tissues  best  with  thionin.  Wooley  and  Mus- 
grave obtained  it  in  pure  cultujes.  The  ameba  probably  enters  in  the 
food  or  drink.  Unhygienic  condi- 
tions favor  infection.  Amebic  dysen- 
tery is  probably  perpetuated  by 
"carriers,"  who  have  had  the  disease 
or  carry  the  parasites  without  react- 
ing to  them.  Intestinal  amebiasis 
(Musgrave)  occurs  largely  in  males 
in  the  third  or  fourth  decade. 

Symptoms. — The  symptoms  of  acute 
amebic  dysentery  begin  abruptly 
with  much  the  same  picture  as  in 
Shiga's  type,  although  the  fever  is 
lower  and  rarely  lasts  over  two  or 
three  days.  The  movements  are  pul- 
taceous,  fluid  and  yellow  at  first  and 
later,  mucous  and  bloody.  Some- 
times in  one  movement  feces  are  voided  first,  followed  by  mucus  and 
blood,  or  blood-tinged  fluid  containing  amebse,  glairy  clumps  like  swollen 
sago  or  frog  spawn,  pus  cells  and  detritus.  The  stools  may  be  chocolate- 
colored,  or  masses  of  necrotic  tissue  are  voided.  The  stools  number  5 
to  20  or  more  daily;  their  odor  is  fetid  when  feces  are  present;  they  are 
odorless  when  only  blood  or  mucus  is  present;  and  are  stinking  when 
gangrene  occurs.  The  repeated  and  painful  movements  cause  straining, 
sweating  and  sometimes  syncope.  Colic  and  borborygmus  are  present; 
pain  is  referred  to  the  navel;  tenderness  is  marked  over  the  sigmoid, 
colon  and  frequently  over  the  cecum,  and  tenesmus  and  a  burning  anal 
pain  mark  involvement  of  the  lower  bowel,  though  less  than  in  Shiga's 
type.  The  rectum  may  prolapse  and  vesical  strangury  appear.  The 
abdomen  is  sometimes  distended.  Very  light  cases  show  only  catarrhal 
movements,  but  blood,  pus,  membrane  or  shreds  indicate  necrosis  and 
ulceration;  strong  men  may  be  ill  for  months  or  even  die  before  the 
malady  is  suspected.  Constipation  was  noted  by  Musgrave  in  50  patients, 
the  autopsy  showing  incipient  ulceration  or  extensive  destruction  of  the 
colon  mucosa;  abdominal  aching,  flatulency,  loss  of  weight  and  sweating 


Fig.  12. — Amebse  (Hallopeau). 


122  BACTERIAL  DISEASES 

characterized  these  cases.  Severe  cases  may  begin  with  chills,  fever  of 
103°  or  104°,  vomiting,  herpes  and  symptoms  like  those  of  cholera; 
e.  g.,  20  to  100  movements  daily,  leg  cramps,  scanty  urine,  failing  pulse 
and  rapid  emaciation.  Peracute  cases,  with  chill,  high  fever,  great  abdomi- 
nal pain,  collapse,  and  even  sudden  death,  exceptionally  result  from  rapid 
necrosis  or  gangrene.  The  average  course  is  one  and  a  half  to  three 
weeks.  Perforative  peritonitis  (in  19  per  cent.),  or  exhausting  hemor- 
rhages sometimes  occur.  Neglected  cases  easily  become  severe  or 
chronic;    spontaneous  recovery  is  uncommon. 

Chronic  amebic  dysentery  results  from  the  acute  form  or  is  subchronic 
from  the  beginning.  The  symptoms  are  the  same  but  less  intense. 
Some  patients  maintain  their  weight  and  suffer  only  from  recurrent 
diarrhea  every  few  weeks,  or  from  irregular  moderate  intestinal  derange- 
ment. In  the  average  case  the  tongue  is  lacquered  and  red,  the  abdomen 
is  somewhat  distended  and  tender  and  the  lower  colon  and  sigmoid  are 
palpable  as  a  thick  cord.  The  outcome  is  (1)  recovery  after  two  to  four 
months;  severe  infections  generally  leave  intestinal  cicatrices  or  chronic 
catarrh;  after  a  year's  illness  recovery  is  seldom  complete;  (2)  recurrent 
attacks  for  months  or  years,  constipation  alternating  with  diarrhea;  (3) 
complications,  such  as  liver  abscess  {q.  v.)  in  20  to  33  per  cent.  Strong 
reports  10  cases  of  profuse  fatal  enterorrhagia  coincident  with  liver 
abscess.  Perforative  peritonitis,  brain  or  splenic  abscess,  arthritis, 
myelitis,  neuritis  and  less  frequently,  endocarditis  or  chronic  nephritis 
are  other  complications;  (4)  gradually  increasing  anemia,  marked  or 
extreme  emaciation  and  death  from  exhaustion. 

Pathology. — The  early  changes  in  the  mucosa  are  catarrh,  inflammatory 
injection,  swelling  and  hemorrhage,  mostly  in  the  large  intestine.  The 
essential  change  is  in  the  submucosa  (John  Hunter,  Councilman  and 
Lafleur).  The  amebse  enter  by  the  tubular  glands  or  sometimes  the 
bloodvessels,  and  reach  the  submucosa  where  they  cause  fibrinous  exuda- 
tion and  cellular  accumulations  which  are  not  leukocytes,  but  connective- 
tissue  cells.  These  foci  undergo  coagulation  necrosis  and  the  mucosa 
which  at  first  covers  the  small  submucous  cavities,  afterward  sloughs,  and 
exposes  the  primary  grayish-yellow  necrosis.  When  the  necrotic  tissue 
sloughs  out,  the  dysenteric  ulcers  are  more  apparent.  They  lie  in  the 
whole  of  the  large  intestine  (50  per  cent,  of  cases) ;  in  the  colon  descendens 
and  sigmoid  (25  per  cent.);  in  the  cecum,  with  ascending  or  descending 
colon,  or  in  the  rectum  (25  per  cent.);  in  the  rectum  alone  (20  per  cent.); 
in  the  cecum  alone  (5  per  cent.);  in  the  appendix  (7  per  cent.);  ileum 
(3.5  per  cent.)  and  the  entire  bowel  (80  per  cent.).  The  deep  ulceration 
exceeds  the  superficial  ulceration,  and  early  ulcers  may,  by  fistulous 
tracts,  tunnel  the  apparently  healthy  mucous  membrane;  their  edges 
are  undermined.  The  ulcers  may  be  round  or  serpiginous  and  are  usually 
discrete.  They  may  penetrate  to  the  muscularis  or  perforate  the  serosa, 
causing  diffuse  or  localized  peritonitis.  The  lymphatic  structures  of  the 
bowel  are  less  affected  than  in  Shiga's  type.  Secondary  changes  include 
streptococcic  diphtheroid  deposits,  diffuse  sloughing  of  entire  blocks 
of  the  intestinal  wall  and  gangrene.  In  chronic  cases  the  muscularis 
frequently  thickens  and  narrows  the  lumen.     Healing  ulcers  produce 


DYSENTERY  123 

pigmented  stellate  scars  which  sometimes  cause  stenosis.  Amebse  may 
enter  the  mesenteric  bloodvessels,  by  which  they  reach  the  portal  circula- 
tion (pylephlebitis;  liver  abscess).  The  liver  shoivs  toxemic  focal  necroses, 
and,  in  a  large  percentage,  abscesses;  the  solitary,  large  abscess  generally 
develops  in  the  right  lobe  near  the  diaphragm  or  colon.  The  multiple 
small  abscesses  are  also  superficial.  In  both  types  there  is  central  necrosis, 
the  contents  are  yellow,  green  or  chocolate-colored,  contain  fat  droplets, 
liver  detritus  and  the  amebse  on  the  abscess  walls.  In  older  cases  there 
is  a  firm  connectivcrtissue  capsule,  but  round-cell  infiltration  is  as  infre- 
quent as  in  the  intestine.  Amebse  may  be  found  in  the  sputum  when  the 
abscess  ruptures  into  the  lung.  The  mortality  averages  6  per  cent.;  7 
per  cent,  of  deaths  in  Cairo  are  dysenteric. 

Indeterminate  Dysenteries. — Of  these  forms,  some  are  primary  and 
others  secondary  infections  (colon  bacillus,  proteus,  pyocyaneus,  pneumo-, 
strepto-  and  staphylococcus).  Varieties:  (a)  Catarrhal  dysentery,  in 
which  the  mucosa  is  injected,  cloudy  and  infiltrated;  the  solitary  follicles 
are  swollen  and  become  round,  deep  and  small  ulcers — the  "acute  fol- 
licular colitis"  seen  especially  in  childl-en.  The  symptoms  are  mild  pain 
and  mucobloody  evacuations.  (6)  The  croupous  or  diphtheroid  dysen- 
tery represents  a  severer  stage  or  degree.  The  epithelium  necroses,  the 
submucosa  is  infiltrated,  and  there  are  membranous  deposits  on  the  rugae 
over  slight  superficial  ulcerations,  or  there  may  be  deeper,  wider  ulcers 
with  great  thickening  of  all  the  intestinal  layers.  This  may  occur  (i) 
as  a  primary  infection,  with  dysenteric  symptoms,  marked  typhoidal 
symptoms,  fever  and  chill,  and  frequently  with  a  fatal  outcome;  or  (ii) 
as  a  secondary  incident  in  pneumonia  particularly,  typhoid,  scarlatina, 
diphtheria,  syphilis,  cardiac  affections,  cachectic  conditions,  mercurial 
or  other  poisonings,  uremia,  etc.;  there  may  be  symptoms  of  clinical 
latency,  (c)  Gangrenous  dysentery  results  in  enormous  swelling,  soften- 
ing, and  sloughing  of  dark,  gangrenous  shreds,  and  sometimes  in  tubular 
sloughs  of  the  larger  part  of  the  intestinal  circumference.  Perforation 
sometimes  occurs.  In  the  Cochin-China  endemic  form,  enlarged  glands, 
splenic  tumor  and  intumescence  of  the  liver  are  found.  Coprostasis, 
foreign  bodies  and  parasites  are  promoting  factors,  e.  g.,  the  cercomonas, 
Trichocephalus  dispar,  Anguillula  stercoralis  or  Distoma  hematobium, 
causing  dysentery,  bloody  urine  and  strangury,  hypertrophy  of  the 
mucosa  and  ulceration. 

Treatment  of  all  Forms. — 1.  Specific  Teeatment. — Shiga's  bactericidal 
and  antitoxic  serum  reduces  the  mortality  from  35  to  9  per  cent.,  and 
shortens  the  course;  in  mild  cases  5iiss  are  injected  once;  in  medium 
cases  5iiss  twice,  and  in  severe  cases  5v  daily  for  three  days.  The  best 
results  attend  early  injection.  As  Shiga  states,  specific  treatment  is 
more  potent  in  reducing  the  mortality  of  the  disease  than  in  its  prophyl- 
axis. Shiga's  serum  does  not  help  the  Flexner-Harris  type,  nor  conversely. 
Vaccines  are  uncertain,  but  apparently  have  checked  institutional  out- 
breaks. 

2.  Prophylaxis. — Drinking  water  should  be  boiled,  and  fruits  and 
vegetables  should  be  cooked.  In  the  tropics,  sudden  variations  of  tem- 
perature are  to  be  avoided.     "Carriers"  require  consideration. 


124  BACTERIAL  DISEASES 

3.  Diet. — Acute  and  chronic  cases  must  be  kept  in  bed.  Boiled  milk, 
raw  or  slightly  cooked  eggs,  or  the  whites  of  eggs  beaten  with  water  are 
given  to  relieve  colic  and  tenesmus.  Lactose  may  benefit  (Kendall). 
Broths  and  cold  drinks  excite  peristalsis.  Some  lemonade  is  permissible. 
In  convalescent,  acute  or  in  chronic  cases,  solids  should  be  given  late, 
commencing  with  well-cooked,  tender  meat  and  starches,  and  avoiding 
vegetables  and  fruit  until  convalescence  is  absolutely  established. 

4.  Eliminative  Treatment. — Sodium  sulphate  is  given  in  early 
cases  to  cleanse  the  bowel  and  to  minimize  the  danger  of  ascent  of  the 
virus  from  the  lower  intestine  (3j  every  two  hours  until  the  bowel  is 
emptied).  Aromatic  sulphuric  acid,  TTlxx  p.  c,  is  sometimes  given  after 
the  saline  treatment.  Castor  oil  or  calomel,  in  frequent  and  small  doses, 
is  of  little  use  except  in  the  early  stages. 

5.  Antisepsis. — Beta-naphtol  and  phenylis  salicylas,  aa  gr.  x,  q.  i.  d., 
probably  do  not  reach  the  larger  intestine. 

6.  Ipecac  was  introduced  from  Brazil,  by  Piso,  in  1648,  and  is  con- 
sidered almost  specific  in  India  and  Brazil.  It  reduced  the  mortality  from 
11  to  5  per  cent,  in  Frayer's  series;  food  is  withheld  for  five  hours,  and 
then  a  hypodermic  of  morphine,  or  opium  by  mouth,  is  administered 
to  quiet  the  stomach  and  lessen  nausea;  15  grains  of  powdered  ipecac 
are  administered  every  hour  for  two  or  three  doses.  If  the  first  dose  is 
vomited,  the  opium  and  ipecac  are  given  again.  Given  in  salol-  or  kera- 
tin-coated pills,  ipecac  passes  the  stomach  and  does  not  induce  vomiting, 
whence  morphine  or  opium  can  be  omitted.  Vedder's  experiments  and 
Roger's  clinical  results  have  revived  the  use  of  ipecac  in  the  form  of 
emetin  hydrochloride,  given  once  or  twice  daily,  by  mouth  or  hypodermic- 
ally  (gr.  I  in  30  drops  of  water;  ^  gr.  equals  5j  of  ipecac). 

7.  Pain. — Opium  quiets  the  patient,  enforces  rest  and  decreases 
tenesmus  and  peristalsis.  It  is  given  most  efficaciously  by  rectum  in  a 
suppository,  or  by  enema,  mixing  Tr.  opii  deodorat.  Hflxx  with  an  ounce 
of  starch  water. 

8.  Local  Measures. — Bismuth  by  mouth  is  local  in  its  action;  doses 
of  5j-ij  are  necessary,  and  even  two  ounces  daily  are  given.  It  may 
cake  in  the  ulcers;  bismuth  poisoning  (from  liberated  nitrous  oxide  or 
arsenical  contamination)  is  avoided  by  using  the  subcarbonate.  Lavage 
is  difficult  because  of  the  tenesmus,  and  is  not  without  danger  in  copious 
irrigations.  The  rectal  tube  must  be  introduced  carefully  as  the  rectum 
is  very  sensitive,  first  using  cocaine,  opium  or  iodoform  (5-grain) 
suppository. 

I^ — Ac.  tannici gr.  xv 

Exti.  opii gr.  iv 

Extr.  belladonnse gr.  j 

Olei  theobromatis q.  s. 

M.  et  ft.  suppos.  no.  iv. 

Bellei  employs  as  an  antiseptic  and  anesthetic  douche,  carbolic  acid 
TTlxx,  tannin  5  j,  marshmallow  root  §  ij  to  a  quart  of  warm  water.  Thj^mol 
is  Musgrave's  main  reliance.  Among  the  other  solutions  of  value  are 
quinine,  of  which  Strong  advises  two  quarts  of  a  1  to  3000  solution,  the 
bag  being  three  to  four  feet  higher  than  the  bed  and  the  flow  being  slow. 


MALTA   FEVER  125 

A  weak  peroxide  solution  for  the  amebic  variety  is  recommended  by 
Harris;  all  enemata  should  be  warm.  Strong  silver  solutions  (1  to  500 
or  less)  cause  great  pain,  and  weak  dilutions  are  inert;  silver,  however, 
is  most  suitable  for  chronic  cases. 

9.  Turpentine  Emulsion  may  be  used  for  tympanites,  and  Leiter's 
coil  with  opium  may  be  used  for  hemorrhage. 

10.  Colostomy. — In  chronic  cases  colostomy  has  been  advocated, 
and  recently,  wide-open  cecostomy  (A.  B.  Herrick). 

MALTA   FEVER. 

Definition. — A  specific  infection,  caused  by  the  Micrococcus  melitensis, 
somewhat  resembling  typhoid,  but  characterized  by  a  longer  course, 
by  recurrent  fever,  severe  sweats,  splenic  tumor,  constipation,  orchitis, 
and  rheumatoid  or  neuralgic  pains. 

History. — It  was  first  described  as  a  separate  disease  by  Marston 
(1858).  Marston,  Bruce  and  Hughes,  English  army  surgeons,  are  the 
largest  contributors  to  our  knowledge  of  Malta  fever.  Its  distribution 
is  well  covered  by  its  names — Mediterranean,  Rock  or  Gibraltar  fever, 
Malta  fever,  Neapolitan  or  Levant  fever.  It  is  also  seen  on  the  Danube, 
Red  Sea,  Bosphorus;  in  China,  India,  the  Philippines;  in  the  Canaries, 
Azores  and  Antilles;  in  Venezuela  (Caracas  fever),  Brazil  and  South 
Africa.  About  a  dozen  cases  have  come  to  this  country;  H.  H.  Smith 
reports  one  from  Boston  and  Gentry  and  Ferenbaugh  7  cases  in  Texas. 

Etiology. — -The  Micrococcus  melitensis  (Bruce,  1887)  is  round  or  oval, 
measures  0.3/^,  often  occurs  in  chains,  is  non-motile  and  stains  with 
methylene  blue  or  gentian  violet,  but  not  by  Gram's  method.  Cultures 
on  slightly  acid  beef-water,  peptone  and  agar,  grow  characteristically  as 
small  pearl-like  spots;  these  after  a  few  weeks  become  yellowish-brown. 
The  bacillus  is  found  in  the  blood,  milk,  feces  and  urine  (even  two  years 
after  recovery),  and  in  the  liver  and  spleen.  Inoculated  apes  show  a 
typical  clinical  course  and  postmortem  findings.  The  disease  prevails 
chiefly  between  the  sixth  and  thirtieth  years,  in  the  hot,  dry  weather 
from  May  to  mid-October,  and  in  old  unhygienic  buildings.  The  atrium 
is  the  lungs  (dust),  or  alimentary  tract  (food  or  water).  In  Strong's 
laboratory  infection,  the  conjunctiva  was  the  point  of  entrance.  It  is 
not  directly  contagious.  Mosquitoes  and  goats  convey  infection;  the 
organism  is  found  in  the  blood  of  goats  in  50  per  cent,  and  in  their  milk 
in  20  per  cent.  In  the  Texas  cases  infection  came  from  goats,  34  per 
cent,  of  which  gave  a  positive  agglutination  test  {v.  i.);  in  1905  the 
Government  imported  Malta  goats,  in  which  the  micrococcus  was 
found. 

Symptoms. — Septicemic  symptoms  appear  after  an  incubation  of  six 
'to  ten  days.  Some  symptoms  so  resemble  those  of  typhoid  and  malaria 
that  the  three  diseases  were  formerly  confounded.  The  fever  rises  grad- 
ually to  104°  or  105°.  The  face  is  red,  there  are  chilly  sensations,  frontal 
headache,  depression,  and  pains  in  the  back  and  legs.  The  tongue  is 
coated,  at  first  moist,  and  then  dry  and  fissured.  The  tonsils  are  fre- 
quently swollen,  and  the  pharynx  is  red  or  ulcerated.    Anorexia,  nausea, 


126  BACTERIAL  DISEASES 

epigastric  pain  and  tenderness  and  constipation,  are  the  rule;  vomiting, 
icterus,  meteorism  and  diarrhea,  -^ith  dark,  malodorous,  mucous  and 
even  bloody  stools  are  sometimes  seen.  Bruce  denies  that  there  are  any 
anatomical  findings  in  the  intestines.  There  is  considerable  bronchitis 
and  the  sputum  is  often  streaked  \^'ith  blood.  Dyspnea  is  quite  frequent. 
The  pulse-rate,  at  first  between  80  and  90,  becomes  faster  later.  Severe, 
repeated  sweats  occur,  usually  after  midnight,  accompanied  by  sudamina 
{jebris  sudoralis).  An  acute  splenic  tumor  and  hepatic  intumescence 
are  due  to  degeneration  and  infiltration  by  round  cells. 

After  one  to  three  weeks,  the  continuous  fever  remits,  and  convales- 
cence is  apparently  established;  but  the  symptoms  again  return,  fre- 
quently several  times.  The  fever  curve  shows  waves  accompanying  each 
relapse  (literally  "undulant  fever";.  The  patient  becomes  emaciated 
and  palhd.  There  is  no  leukocytosis  and  micrococci  are  found  in  the 
blood  in  60  per  cent,  of  cases. 

Complications. — Pseudorheumatism  (in  50  per  cent,  of  cases)  is  accom- 
panied by  redness,  swelling  and  pain  in  the  joints  and  sometimes  in  the 
bursse,  periosteum  and  fibrous  tissues.  Xeuralgias  are  common.  Orchitis 
and  epidid\Tnitis  are  usually  painless,  unilateral  and  ephemeral.  Occa- 
sionally polyneuritis  or  psychoses  are  sequels. 

Erythematous  or  hemorrhagic  skin  eruptions  occur  in  the  relapses, 
sometimes  accompanied  by  hemorrhages  from  the  nose,  tongue,  gums 
or  lungs;  desquamation  and  falling  of  the  hair  or  a  reddish  or  violet 
circumscribed  edema  of  the  feet  and  ankles  are  common.  In  convales- 
cence, tuberculosis  not  infrequently  develops. 

Course  and  Prognosis. — The  majority  of  cases  relapse  after  three  weeks. 
The  average  duration  of  the  disease  is  120  days;  Bruce  records  a  case 
which  lasted  over  two  years;  Melland  found  that  50  per  cent,  of  cases 
in  the  Canary  Islands  lasted  from  two  to  three  weeks,  and  in  only  10 
per  cent,  did  the  protracted  undulating  type  occur.  Hughes  described 
three  t\"pes:  (a)  The  undulant,  the  most  common  type;  (h)  the  malig- 
nant, which  ends  in  death  in  one  to  three  weeks  from  weak  heart  or 
hyperpyrexia  C110°  or  111°);  and  (c)  the  intermittent,  which  lasts  for 
months.  The  death-rate  in  the  last  century  was  over  3  per  cent.,  but  it 
is  now  under  1  per  cent.    One  attack  usually  confers  immunity. 

Diagnosis. — The  differentiation  from  t^^^hoid  is  often  difficult.  In 
]\Ialta  fever  the  roseolse,  diazo  reaction,  Widal  and  the  bacillemia  are 
absent.  The  course  is  longer,  the  sweats  more  severe  and  the  joints 
inflamed;  orchitis  and  neuralgias  develop.  A  positive  diagnosis  can  be 
made  by  the  use  of  Wright's  serum  reaction  (1897),  after  the  fifth  day; 
agglutination  is  obtained  "^dth  li^'ing  or  dead  cultures;  the  dilution  of 
the  blood  is  1  to  50,  and  the  time  limit,  one  hour.  The  severe  bronchitis, 
fever  and  sweats  may  simulate  tuberculosis  and  the  older  writers  spoke 
of  Malta  fever  as  ''^Mediterranean  phthisis."  The  bronchi  are  intensely 
h\'peremic  and  the  sputum  is  frequently  blood-tinged.  Malaria,  ulcera- 
tive endocarditis,  liver  abscess,  etc.,  are  differentiated  by  the  agglutina- 
tion test. 

Treatment. — Among  English  troops  quartered  at  Malta,  2229  cases 
developed  (1898-1904;,  with  77  deaths;  in  the  fleet  there  was  an  equal 


ANTHRAX  127 

number.  Avoidance  of  goat  milk  reduced  the  morbidity  to  7  cases 
(1907).  There  is  no  specific  treatment.  Quinine  and  arsenic  are 
ineffectual.  Headache  and  backache  are  relieved  by  acetanilide  and 
morphine;  insomnia  by  bromides,  chloral  and  hyoscine;  diarrhea  by 
tt*.  ferri  chlor.;  pseudorheumatism  by  heat,  wool  investment,  tr.  iodi, 
locally,  and  by  salicylates,  internally;  orchitis,  by  local  heat  and  suspen- 
sory elevation.  The  general  therapy  is  the  same  as  in  typhoid.  Dalton 
advocates  a  solid  diet.    In  convalescence  a  change  of  climate  is  necessary. 

ANTHRAX. 

Anthrax  is  one  of  the  zoonoses  (diseases  acquired  from  animals),  which 
also  include  glanders,  foot-and-mouth  disease,  vaccinia  and  hydrophobia. 
Anthrax  is  also  called  splenic  fever,  pustula  maligna  and  carbunculus 
contagiosus. 

Definition. — An  acute  infection  caused  by  the  Bacillus  anthracis,  and 
usually  communicated  to  man  from  the  herbivora. 

History. — Over  a  century  ago  Morand  and  Fournier  distinguished 
between  the  simple  carbuncle  and  anthrax.  The  bacilli  were  seen  by 
Pollander  (1855)  and  Branell  (1858),  but  Davaine  (1864-1873)  noted 
that  the  organisms  were  bacteria.  It  remained  for  Koch  with  his  epoch- 
making  technique  to  find  the  spores  and  absolutely  differentiate  the  disease. 

Bacteriology. — The  anthrax  bacillus  is  the  largest  pathogenic  microbe 
(3  to  10  by  1  to  1.5^t).  In  growths  it  occurs  singly  or  in  chains.  The 
ends  are  slightly  rounded,  and  the  chains  resemble  the  phalanges  of  the 
finger,  the  organisms  lying  end  to  end.  They  are  non-motile,  transparent, 
and  stain  by  Gram's  method.  At  high  temperatures  they  grow  in  long, 
thread-like,  winding,  segmented  filaments.  Spores  are  absent  in  the 
cadaver  and  in  the  living  tissues ;  in  the  living  tissues  the  bacilli  multiply 
by  fission.  In  attenuated  cultures,  one  spore  develops  for  each  bacillus; 
these  become  bacilli  which  are  extremely  resistant  to  drying  and  heat. 

The  bacillus  is  an  obligate  aerobe.  Stab  cultures  of  agar  are  character- 
istic; a  white,  milky  yet  transparent  and  band-like  growth  develops 
horizontally  in  blood  serum,  and  grows  downward  at  an  acute  angle, 
so  that  in  three  days  it  resembles  a  quill  with  a  feathered  upper  end. 
Gro-^i:hs  on  gelatin  have  a  thick,  wooly  covering;  the  gelatin  liquefies  after 
a  few  days,  and  a  white,  granular  sediment  falls  to  the  bottom  of  the  tube. 

Anthrax  is  endemic  and  epidemic  in  Europe  and  Asia.  There  are 
persistent  foci  in  Saxony,  parts  of  Bavaria  and  in  Frankfort;  in  the 
provinces  of  Burgundy  and  Auvergne;  Hungary;  Russia,  principally 
in  Siberia  (the  "Siberian  plague") ;  in  China,  India  and  in  South  America. 
x\nthrax  is  rare  in  America,  though  small  epidemics  have  appeared  in 
Delaware  and  Pennsylvania.  From  Russia,  infection  may  be  dissem- 
inated by  horse's  hair  and  from  Asia  by  mohair  (Angora  goats).  Among 
animals,  the  herbivora  are  most  often  affected,  especially  sheep  and 
cattle,  and  in  Russia,  horses.  Omnivora  are  more  susceptible  than 
carnivora.  Mice,  guinea-pigs,  rabbits,  dogs  and  fowl  rarely  acquire 
the  disease.  Transmission  of  the  spores  by  means  of  water,  earth-worms, 
snails,  flies  and  fleas  is  possible. 


128"  BACTERIAL  DISEASES 

Of  Koranyi's  cases,  65  per  cent,  were  attributed  to  sheep  and  35  per 
cent,  to  cattle;  Bourgois  considers  that  the  greatest  percentage  comes 
from  cattle,  the  next  largest  from  sheep,  and  least  from  horses. 

I.  External  Anthrax. — External  anthrax  is  by  far  the  more  common  type. 
The  atrium  is  an  abrasion  of  the  skin,  possibly  through  intact  hair-fol- 
licles. Koch  observed  that  sheep  were  infected  by  fly-bites  on  the  exposed 
skin  of  the  neck.  Shepherds,  coachmen  and  those  who  attend  diseased 
animals;  butchers,  tanners,  wool-sorters  and  persons  who  handle  diseased 
hides  or  meat;  and  saddlers,  rag-pickers  and  gardeners  are  most  likely 
to  acquire  the  disease.  Jacobi  records  infection  from  a  hypodermic  needle, 
first  used  on  a  patient  with  anthrax.  The  spores  are  more  virulent  than 
the  bacilli. 

Site  of  the  Pustula  Maligna. — In  Koch's  series  51  per  cent,  developed 
on  the  head  and  face,  38  per  cent,  on  the  upper  extremities,  2  per  cent, 
on  the  lower,  5  per  cent,  on  the  neck,  and  4  per  cent,  on  the  trunk,  that 
is,  exposed  parts  are  the  usual  seat  of  primary  infection.  The  lesion  is 
usually  single,  but  several  pustules  may  develop,  possibly  from  inocula- 
tion by  the  finger-nails  in  scratching. 

Symptoms. — Incubation  lasts  two  or  three  days.  The  initial  small 
red  prominence  resembles  an  insect-bite.  It  itches  and  in  twelve  hours 
develops  a  small  vesicle,  which  becomes  purulent  if  ruptured  and  dries 
with  scab  formation,  and  a  dark,  central,  leathery  slough,  caused  by  strep- 
tococcic infection,  and  is  surrounded  by  dense  round-cell,  and  often  hemor- 
rhagic infiltration.  This  in  turn  is  surrounded  by  edema  of  the  connec- 
tive tissue,  in  the  deeper  lymph  vessels  of  which  the  Bacillus  anthracis 
abounds.  If  the  pustule  extends,  a  circle  or  even  concentric  circles  of 
new  vesicles  appear,  which  fuse  and  increase  the  infiltration.  The  eyes 
may  be  closed  or  the  lips  may  be  so  swollen  that  the  jaws  cannot  be 
opened.  Demarcation  now  occurs,  followed  by  sloughing,  granulation 
tissue  and  cicatrization;  or  general  infection  develops,  and  the  adjacent 
lymph  vessels  and  glands  become  infected,  soft  and  hemorrhagic — 
usually  on  the  fourth  to  sixth  day.  Anthrax  toxemia  and  bacillemia  are 
marked  by  headache,  backache,  pain  in  the  limbs,  chilliness,  leukocy- 
tosis, continuous  or  remittent  fever,  soft  pulse,  rapid  breathing,  vomiting 
of  mucus  or  blood,  colic,  diarrhea  and  collapse.  Hemorrhages  or  even 
gangrene  may  develop  around  the  carbuncle.  Bacilli  have  been  found 
in  the  cerebrospinal  fluid  by  lumbar  puncture.  The  mind  is  usually 
clear,  although  delirium,  convulsions  or  coma  may  develop,  and  death 
ma}^  occur  on  the  seventh  to  ninth  day  with  an  antemortem  fall  of  tem- 
perature. In  fatal  cases  there  is  only  slight  rigor  mortis  but  rapid  decom- 
position, dark  fluid  blood,  swelling  of  the  lymphadenoid  tissues  (glands, 
intestine  and  sometimes  the  spleen).  In  the  liver,  kidneys,  spleen,  heart, 
lungs,  brain  and  meninges,  hemorrhages  and  swelling  may  be  found; 
bacilli  are  seen  less  in  the  large  vessels  than  in  the  capillaries.  Bourgois 
describes  another  cutaneous  form,  most  often  on  the  body,  in  which 
there  is  great  edema  (charhon  blanc,  anthrax  edema),  but  no  pustule  or 
carbuncle. 

Diagnosis. — Simple  carbuncle  resembles  anthrax,  in  that  it  is  also  hard, 
has  a  prominent  central  necrosis,  is  surrounded  by  edema  and  sometimes 


ANTHRAX  129 

is  vesiculated;  it  usually  causes  great  pain,  and  has  numerous  openings 
which  discharge  ordinary  pus.  The  anthrax  carbuncle  may  be  differen- 
tiated by  the  bacilli,  depression  of  the  necrotic  centre,  the  corona  of 
vesicles,  more  rapid  evolution,  greater  edema,  remarkable  freedom 
from  pain,  and  lack  of  odor.  Glanders  may  be  distinguished  by  involve- 
ment of  the  mucosae,  painful  nodes  without  eschars,  and  ulcerations 
which  discharge  the  Bacillus  mallei.  Cultures  from  the  pustule  or  blood 
disclose  the  anthrax  bacilli. 

Prognosis. — The  prognosis  is  more  favorable  in  children,  in  cases  with 
local  symptoms  only,  and  those  with  simple  carbuncle  without  edema. 
Even  patients  with  bacillemia  may  recover.  In  Koch's  collection,  68 
per  cent,  recovered.  Nasarow's  figures  show  26  per  cent,  mortality  when 
anthrax  occurs  in  the  head  and  face,  23  per  cent,  when  it  occurs  in  the 
trunk,  19  per  cent,  in  the  neck,  14  per  cent,  in  the  upper,  and  5  per  cent, 
in  the  lower  extremity. 

Treatment. — Prophylaxis. — Infected  animals  should  be  cremated 
entirely.  Industrial  hair  (especially  when  blood-stained),  wool  and  hides 
should  be  thoroughly  disinfected.  Toussaint  (1880)  and  later,  Pasteur, 
Chauveau  and  Colbert  used  attenuated  cultures  to  immunize  animals. 
In  France  (1882-1893),  1,788,677  sheep  were  thus  inoculated,  with  a 
resulting  mortality  of  0.9  per  cent.;  and  200,962  cattle  were  inoculated, 
with  a  0.3  per  cent,  mortality. 

Active  Treatment. — ^Wounds  in  those  exposed  to  infection  should 
be  promptly  washed  with  strong  sublimate  solution.  Cauterization 
with  the  live  cautery,  carbolic  or  nitric  acid  or  caustic  potash;  surgical 
excision  through  sound  tissue;  and  injections  of  iodine  or  corrosive 
sublimate  have  been  recommended,  but  equally  good  results  are  obtained 
by  elevation,  the  use  of  mercurial  paste,  and  expectant  treatment,  which 
at  least  avoids  dissemination  of  the  parasite  through  sound  tissues.  In 
1073  cases  treated  with  Mendez's  serum,  the  mortality  was  but  4  per 
cent.    Salvarsan  is  recommended. 

II.  Internal  Anthrax. — Internal  anthrax  is  less  frequent. 

1.  Alimentary  Form. — In  mycosis  intestinalis,  first  described  by  Wahl 
and  Recklinghausen,  bacilli  may  enter  through  cuts  in  the  mouth  and 
throat,  but  usually  directly  invade  the  intestines  and  stomach,  which 
are  most  frequently  infected  by  spores  in  milk  or  water.  The  gastric 
juice  kills  the  bacilli  but  not  the  spores,  yet  peasants  often  eat  the- pickled 
meat  of  diseased  animals  without  being  infected.  In  Wurzen,  Saxony, 
there  were  206  cases  of  intestinal  anthrax  in  1877. 

Symptoms. — The  onset  is  usually  abrupt,  with  fever  and  vomiting  of 
mucus  or  blood,  followed  by  pain  in  the  bowels,  serous  and  afterward 
bloody  movements,  meteorism,  dyspnea,  weak  pulse,  and  by  collapse, 
as  seen  in  anthrax  generalization  in  the  cutaneous  form.  Secondary 
carbuncles,  or  more  often  hemorrhages  into  the  skin  of  the  neck  and  the 
abdomen,  may  develop.  The  course  is  severe;  death  results  in  five  or 
six  days,  although  recovery  is  possible. 

Diagnosis. — Bacilli  in  the  stools  and  blood  determine  the  diagnosis. 
Changes  like  the  cutaneous  carbuncle  consist  of  localized  induration 
with  central  sloughing,  opposite  the  mesenteric  attachment  and  accom- 
y 


130  BACTERIAL  DISEASES 

panied  by  surrounding  hemorrhage  and  edema  in  the  mucosa,  and 
swelling  of  the  solitary  follicles,  Peyer's  patches,  mesenteric  glands  and 
omentum  and  retroperitoneal  tissue.  The  bacillus  is  found  in  these 
lymphadenoid  structures  in  large  numbers  and  sometimes  in  the  chyle 
vessels  and  portal  bloodvessels.  The  greatest  changes  most  frequently 
occur  in  the  upper  small  intestine,  sometimes  in  the  stomach  or  ileum, 
seldom  in  the  colon  and  most  rarely  in  the  rectum.  Thirty  or  forty  foci 
may  be  seen  in  the  small  gut,  but  the  lesions  in  the  stomach  or  rectum 
are  fewer  and  more  discrete.  Secondary  embolism  of  the  intestinal 
arteries  from  anthrax  of  the  skin  seldom  cause  hemorrhagic  stools.  Sero- 
hemorrhagic fluid  may  be  found  in  the  peritoneal  cavity.  Treatment 
by  ipecac,  calomel  and  bichloride  of  mercury  is  without  effect. 

2.  Respiratory  Form. — The  respiratory  form  was  described  by  Bell 
(1879),  in  England,  as  the  "wool-sorters'  disease;"  and  by  Eppinger 
(1894)  in  Austria,  as  the  "rag-sorters'  disease."  Infection  may,  on  rare 
occasions,  occur  in  the  nose,  larynx,  tonsils  or  bronchi.  The  bacilli  are 
capable  of  entering  the  uninjured  bronchioles  and  alveoli.  Wool-sorters' 
disease  results  especially  from  infection  by  hides  imported  from  Russia 
and  Brazil,  and,  in  1897,  anthrax  developed  in  this  country  from  hides 
of  Chinese  origin. 

Symptoms.— The  affection  begins  suddenly  with  chill,  high  fever, 
tachypnea,  dyspnea  and  bronchitic  and  irregular  pneumonic  findings; 
the  viscid  or  hemorrhagic  sputum  in  some  instances  contains  the  pathog- 
nomonic bacilli.  The  later  symptoms  are  cyanosis  caused  by  diffuse 
mediastinal  infiltration;  serous  pleurisy,  weak  heart,  vomiting,  terminal 
collapse  and  antemortem  fall  of  temperature.  Icterus,  hematuria  and 
anthrax  endocarditis  have  been  observed.  The  sensorium  is  clear  to  the 
end  in  most  fatal  cases;  convulsions  and  coma  are  due  to  meningeal 
hemorrhage.  The  patient  may  die  on  the  second  or  third  day.  The 
mortality  in  rag-sorters'  disease  is  50  to  87  per  cent.,  and  rather  lower 
in  wool-sorters'  disease.  The  bacilli  enter  the  alveoli,  wherein  they  pro- 
duce alveolar  desquamation  and  cellulofibrinous  exudation — the  analogue 
of  the  carbuncle — and  much  serohemorrhagic  exudate,  comparable  to 
the  skin  edema.  Where  there  is  much  cellular  exudate,  recovery  may 
result  from  demarcation;  where  there  is  much  serous  infiltration  the 
bacilli  are  abundant  and  the  lymph  vessels  infect  the  mediastinum, 
peribronchial  glands  and  pleurae,  which  may  hold  cjuarts  of  anthrax- 
infected  serohemorrhagic  exudate. 

Treatment. — The  therapy  is  wholly  supportive. 

3.  Anthrax  Septicemia. — Anthrax  bacillemia  (septicemia!  is  a  rare,  fatal 
form,  in  which  no  atrium  can  be  found. 

GLANDERS. 

Definition. — An  acute  or  chronic  contagion,  mainly  acquired  from 
horses,  caused  by  the  Bacillus  mallei,  and  characterized  by  nodules  and 
ulcers,  chiefly  in  the  nose  and  skin. 

Etiology. — Glanders  and  farcy  were  known  to  Aristotle  and  Hippo- 
crates.    The  Bacillus  mallei  was  discovered  by  Loeffler  and  Schuetz 


t 


GLANDERS  131 

(1882),  and  independently  by  Bouchard,  Capitau  and  Charrin,  which 
identified  glanders  and  farcy  as  one  disease.  Weichselbaum  (1885) 
first  found  the  bacillus  in  human  infection.  It  closely  resembles  the 
tubercle  bacillus  morphologically,  but  is  shorter  and  thicker  and  measures 
2  to  5  by  0.4  to  LB/jl;  it  is  straight  or  slightly  bent;  its  ends  are  some- 
what rounded;  it  is  usually  single,  and  not  motile.  It  stains  with  the 
alkaline  anilines,  easily  in  cultures  but  with  more  difficulty  in  sections, 
and  the  bacillus  tinges  unevenly,  with  lighter  areas,  resembling  spores. 
It  is  a  facultative  aerobe  and  its  most  characteristic  growth  is  on  potato, 
on  which  a  thin  light  yellow  film  develops  in  two  days,  soon  becomes 
amber-colored  and  in  eight  days  assumes  a  weakly  red  tinge  with  some- 
what greenish-blue  borders.  The  atrium  is  usually  the  skin,  through 
which  the  bacillus  enters  by  some  small,  perhaps  microscopic  lesion;  or 
by  horse-bites;  infection  may  take  place  through  the  intact  mucosa  of 
the  nose  and  air-passages,  the  conjunctiva,  or  very  rarely,  the  digestive 
tract.  Man  is  usually  infected  by  chronically  diseased  horses;  man-to- 
man infection  is  far  less  frequent.  The  bacillus  is  found  in  the  nasal 
nodes  (glanders);  in  the  skin  nodes  (farcy);  in  the  lymph  vessels  and 
glands  (in  which  its  virulence  is.  greatest) ;  in  the  excretions  and  blood 
current,  where  it  occurs  more  frequently  in  man  than  in  animals. 

The  bacillus  soon  dies  in  pus,  but  may  endure  for  three  or  four  weeks 
in  the  viscera  of  cadavers;  it  is  rapidly  killed  by  sunlight.  Babes  (1890) 
and  Kalming  (1891)  isolated  a  toxin,  and  Kalming,  during  his  researches, 
succumbed  to  acute  glanders.  Hellmann  (1891)  isolated  mallein  and 
Babes  (1892)  morvine,  both  of  which  are  successfully  injected  for  diag- 
nosis and  immunization.  The  horse,  ass  and  mule  are  the  most  susceptible 
animals  and  from  them  other  animals  may  be  inoculated.  In  some 
localities  half  the  horses  have  latent  glanders  (Babes).  Infection  is 
carried  by  the  nasal  or  cutaneous  discharge,  whence  glanders  and  farcy 
are  chiefly  observed  in  stable-boys,  coachmen,  farmers  and  veterinary 
surgeons.    In  1909,  Robin  collected  156  human  infections. 

Symptoms,  Pathology  and  Course. — These  are  considered  under  two 
topics:  (J)  Farcy,  the  cutaneous  type  and  (B)  glanders,  the  nasal 
type.    In  most  cases  the  types  are  not  wholly  distinct. 

(A)  Farcy. — 1.  Acute  Form. — The  incubation  is  three  to  five  days, 
attended  by  depression,  nausea,  headache  and  pains.  The  infected 
skin  shows  infiltration,  which  may  heal  only  to  break  out  anew.  Lym- 
phangitis and  lymphadenitis  are  less  marked  than  in  the  horse.  Subcu- 
taneous and  cutaneous  nodes  or  areas  of  diffuse  infiltration  develop. 
These  lymphangitic  farcy-buds  or  areas  are  infective  granulomata,  com- 
posed of  epithelioid,  lymphoid  and  white  cells,  and  contain  the  bacilli, 
which  are  free,  rarely  intracellular  and  most  abundant  in  the  centre 
of  the  nodes.  Early  sections  are  succulent  and  show  central  necrosis, 
w  liich  is  followed  by  suppuration  and  ulceration.  The  ulcers  are  painful, 
deep  and  crater-like,  with  sharply  cut,  everted  borders  and  speckled 
bases;  they  have  a  thin,  puriform,  hemorrhagic  or  ichorous  discharge 
and  they  often  fuse.  Thrombophlebitis,  diffuse  phlegmons  or  gangrene 
may  develop.  The  initial  fever  may  resemble  the  ladder-like  ascent  of 
typhoid,  yet  chills,  polyarthritis  and  large  muscular  abscesses  are  fre- 


132  BACTERIAL  DISEASES 

quent.  In  some  cases  a  successively  macular,  papular  and  pustular 
skin  eruption  resembles  that  of  smallpox  except  that  it  is  rarely  umbili- 
cated;  it  may  be  scant  and  scattered,  very  diffuse  or  even  confluent; 
and  it  may  affect  the  mouth,  throat  and  conjunctivae.  The  patient 
is  often  delirious,  the  pulse  becomes  rapid  and  small  and  fresh  skin 
nodes  develop,  with  ulceration  or  perhaps  gangrene.  The  urine  shows 
albumin,  casts,  or  the  diazo  reaction,  the  frequent  movements  are  offen- 
sive, and  death  occurs  in  two  weeks  from  exhaustion  or  lung  inflammation. 

2.  Chronic  farcy  shows  the  same  changes,  but  they  are  gradual  in 
onset,  slow  in  progression  and  unaccompanied  by  essential  inflammatory 
reaction  or  lymphatic  invasion.  For  the  first  month  or  two  there  are 
pains  in  the  limbs  and  joints,  and  then  indolent  swellings  appear  in  the 
extremities  and  in  the  periarticular  tissues,  which  ulcerate.  The  ulcers 
may  cicatrize,  but  break  out  again  after  months,  resembling  lupus, 
which  heals  on  one  side  and  advances  on  another.  Muscular  abscesses 
may  appear,  most  often  in  the  pectoralis,  biceps,  brachialis  and  gas- 
trocnemius. The  course  lasts  for  months  or  years  (2-11).  Recovery 
occurs  in  50  per  cent,  of  the  cases,  or  death  results  from  exhaustion  and 
acute  dissemination.  In  horses  the  greatly  swollen  lymph  vessels  and 
glands  appear  as  sausage-shaped  masses,  whence  the  term  "farcy"  was 
used  by  Vegetius.  In  horses  the  skin  eruptions  and  orchitis  are  more 
frequent  than  in  man. 

(B)  Glanders. — 1.  The  acute  nasal  form  begins  in  the  nose  after  an 
incubation  of  three  days.  Miliary  nodules  develop,  which  are  elevated, 
yellowish-white  in  the  centre,  the  size  of  a  pea,  surrounded  by  a  pale 
red  zone  and  ulcerate.  New  nodes  form  on  the  edges  of  the  ulcers,  which 
break  down,  fuse  with  them,  and  discharge  a  thin,  puriform,  dirty, 
sanguinolent  fluid.  Diphtheroid  deposits  or  crusts  form.  Ulceration 
may  erode  the  bone  or  cartilage  and  perforate  the  septum.  The  nose 
is  swollen  and  eroded  externally.  The  process  reaches  the  mouth  by 
lymphangitis  or  thrombophlebitis.  The  palate  may  perforate;  the 
tongue,  gums  or  tonsils  are  invaded;  the  angular  lymphatic,  parotid 
and  submaxillary  glands  are  swollen,  and  the  larynx,  and  finally  the 
lungs  are  infected.  The  leukocytes  are  increased.  Beregin  found  micro- 
scopic nodes  in  the  liver,  kidney,  spleen  and  brain;  in  the  lungs  they 
resemble  miliary  tubercles,  or  pneumonia  malleosa  may  develop,  accom- 
panied by  hemorrhage,  abscess  formation,  gangrene,  a  distressing  cough 
and  raspberry,  mucopurulent  sputum.  Secondary  suppuration  in  the 
bones,  muscles,  joints  or  skin  complete  the  pyemic  picture.  The  course 
is  that  of  acute  farcy,  though  more  rapid,  and  death  occurs  in  two  weeks. 

2.  Chronic  Nasal  Form. — This  is  simflar  to  acute  glanders  except 
in  its  chronicity.  It  is  less  frequent,  and  when  nasal  involvement  is 
slight  it  may  resemble  pulmonary  tuberculosis,  chronic  coryza,  pyemia 
or  osteomyelitis.  The  malady  may  "slumber,"  to  be  aroused  later  by 
trauma  or  symbiosis  with  the  staphylococcus.  Death  occurs  from  exhaus- 
tion or  generalization  by  lymphangitis  or  thrombophlebitis.  In  Robin's 
series  6  per  cent,  recovered. 

Diagnosis  of  Glanders  and  Farcy. — Typhoid,  pyemia,  variola,  syphilis, 
lupus,  tuberculosis  and  anthrax  may  cause  confusion,  but  the  history 


TETANUS  133 

and  bacteriology  determine  the  diagnosis.  In  thick  smears,  the  chromatic 
bodies  in  the  bacilh  may  simulate  staphylococci  (Zeit).  The  cultural 
findings  are  proved  by  intraperitoneal  inoculation  of  a  male  guinea-pig, 
in  which  orchitis  develops  rapidly  (Strauss's  reaction,  1886).  Injections 
of  mallein  differentiate  in  90  per  cent,  of  cases,  producing  fever  of  three 
degrees  or  more.  The  bacilli  are  agglutinated  by  the  serum  of  normal 
horses  in  a  dilution  of  1  to  200,  and  of  those  subject  to  glanders  in  a 
dilution  of  1  to  1000. 

Treatment. — The  prophylaxis  of  glanders  is  like  that  of  anthrax — 
isolation  of  diseased,  and  cremation  of  dead  animals,  and  strong  antisep- 
tics in  wounds  of  persons  exposed  to  infection.  Skin  ulcers  are  curetted 
and  bandaged  antiseptically,  and  if  they  are  obstinate,  touched  with 
the  live  cautery.  Infection  of  the  nose  demands  carbolic  douches,  zinc 
chloride  paste  or  iodoform.  Arsenic,  mercurial  inunctions,  quinine  and 
alcohol  are  recommended.  Injections  of  mallein  and  large  doses  of 
potassium  iodide  are  recommended.  Among  others.  Cramp  records  a 
recovery  under  vaccines. 

TETANUS. 

Definition. — Tetanus,  or  lock-jaw,  is  an  acute  infection  caused  by  the 
tetanus  bacillus  and  characterized  by  greatly  increased  reflexes,  muscular 
rigidity  and  tonic  spasms.  Tetanus  is  literally  stretching.  It  is  described 
in  Hippocrates's  aphorisms. 

Etiology. — In  1884,  Carle,  Rosenbach  and  Rattone  produced  the  dis- 
ease b}'  inoculations  of  pus,  and  in  the  same  year,  Nicholaier  discovered 
the  tetanus  hacillus,  of  w^hich  Kitasato  (1889)  first  obtained  pure  cultures 
from  w^ounds  and  from  earth.  The  bacillus  measures  3  to  5  by  f  to  |/i 
and  is  enlarged  at  one  end,  in  which  there  is  a  spore,  thus  having  a  pin- 
head  or  drum-stick  shape.  It  becomes  thread-like  in  cultures.  It  stains 
readily  by  Gram's  method,  and  is  delicately  flagellated  and  motile. 
It  is  anaerobic  and  cultures  emit  an  onion-like  smell.  It  grows  well  in 
sugar  solutions.  The  bacillus  is  very  enduring  and  the  spores  may  live 
nineteen  years.  It  exists  in  the  primary  wound  and  in  the  brain  and  cord 
in  44  per  cent,  of  severe  infections,  so  that  tetanus  no  longer  ranks  as  a 
simple  toxemia.  The  bacillus  has  been  found  in  the  blood  and  sputum. 
Tetanus  is  traumatic;  in  the  so-called  idiopathic,  rheumatic  form,  the 
atrium  is  either  microscopic  or  pharyngeal.  The  bacillus  produces  toxins 
which  are  100  to  400  times  as  toxic  as  strychnine.  They  are  tetano- 
spasmin  and  -lysin.  Tetanus  symptoms  result  from  the  tetanus  toxins 
alone,  but  both  infection  and  virulence  are  enlianced  by  association 
with  various  putrefactive  microorganisms,  and  innocuous  solutions  of 
tetanus  poison  become  lethal  if  combined  with  sterilized  cultures  of  these 
putrefactive  bacteria.  The  bacillus  does  not  produce  inflammation, 
though  mixed  infections  are  usual.  Mice,  guinea-pigs  and  rabbits  are 
inoculable.  In  nature  the  bacillus  is  found  in  the  alimentary  tract  of 
herbivora,  whence  it  occurs  in  manure,  garden  earth,  street  or  house 
dust,  hay,  putrefying  fluids  and  splinters.  The  disease  is  ten  to  twenty 
times  as  frequent  in  the  tropics  as  in  temperate  zones,  because  the  bacillus 
thrives  in  heat.    It  may  lurk  in  certain  districts,  as  in  Prague,  the  eastern 


134  BACTERIAL  DISEASES 

end  of  Long  Island,  or  the  West  Indies  where  negroes  are  more  often 
and  more  seriously  affected  than  whites. 

Mode  of  Infection. — Incised  wounds  are  obviously  less  dangerous  than 
punctures,  gunshot  or  contused  wounds  or  hematomata.  Tetanus 
occurred  less  frequently  in  our  Civil  War  than  in  the  Spanish-American 
conflict,  in  which  many  cases  developed  among  the  Spaniards.  It  may 
result  from  circumcision,  hypodermic  injections,  tooth-extraction  and 
vaccination  (95  cases),  and  Peterson  (1910)  collected  150  cases  of  post- 
operative tetanus,  of  which  70  dated  since  1890;  and  in  all,  catgut  was 
used.  Parturition,  lack  of  attention  to  the  navels  of  the  newborn,  the 
use  of  imperfectly  sterilized  catgut,  leech-bites  or  pin-pricks  may  cause 
its  development.  Chauffard  (1903)  collected  18  cases  of  infection  from 
injections  of  gelatin  for  acute  hemorrhage,  Dieulafoy  11  cases  after 
injections  for  aneurysm,  Seibert  18  cases  after  antitoxin  given  for  diph- 
theria, and  preventive  inoculations  against  the  plague  caused  19  deaths. 
The  germ  is  very  frequently  found  in  gelatin,  which  should  therefore 
be  sterilized  three  times  in  very  small  amounts,  each  time  for  thirty 
to  forty-five  minutes  at  212°.  There  is  danger  from  the  use  of  toy  pistols 
and  blank  cartridges  for  Fourth-of-July  celebrations;  415  deaths  from 
tetanus  are  listed  in  the  United  States  for  1903  as  against  10  in  1912 
(Jour.  Amer.  Med.  Assn.);  French  clinicians  describe  a  visceral  tetanus 
originating  from  the  intestines  in  which  latter  tetanus  spores  have  been 
found. 

Incubation.^ — This  lasts  from  six  to  twelve  hours  in  severe  experi- 
mental inoculations,  from  two  to  nine  days  in  less  intense  inocula- 
tions, and  in  man,  in  33  per  cent,  of  cases  the  symptoms  appear  in  one, 
and  in  66  per  cent,  in  two,  weeks. 

Symptoms. — ^These  appear  suddenly.  Ehrlich's  side-chain  theory  gives 
a  satisfactory  explanation,  the  anterior  horn  cells  of  the  cord  and 
medulla  combining  with  the  toxins  and  causing  the  spasms.  The  first 
signs  are  rigidity  of  the  jaw  ("lockjaw,"  trismus)  and  stiffness  of  the 
neck.  In  most  animals  the  muscles  become  rigid  near  the  seat  of 
inoculation  first,  and  sometimes,  in  injuries  received  in  war,  the  muscles 
of  a  limb  may  be  first  involved;  the  toxin  travels  along  the  nerve  trunks. 
The  horse,  like  man,  develops  trismus  first.  The  poison  incites  the 
anterior  cells  of  the  cord  and  medulla  to  tonic  contraction. 

The  fades  tetanica  results  from  zygomatic  spasm,  which  produces 
the  risus  sardonicus — a  smiling  expression  to  the  upper  and  a  sad  ex- 
pression to  the  lower  part  of  the  face;  the  forehead  is  lined,  the  eyebrows 
raised  and  approximated,  the  eyeballs  fixed,  the  masseters  prominent, 
the  teeth  set  and  the  nares  dilated.  The  spinal  extensors  are  tonically 
contracted,  arching  the  head  backward  and  the  trunk  forward  {opistho- 
tonos);  the  abdominal  muscles  are  retracted  stiffly;  in  rare  cases  the 
contracture  is  lateral  (pleurothotonos),  or  forward  (emprosthotonos),  or 
the  body  is  straight  and  rigid  (orthotonos) .  The  limbs  are  extended,  the 
legs  more  so  than  the  arms,  and  the  feet  and  hands  least.  The  spasms 
are  chiefly  tonic,  but  momentary  clonic  exacerbations  may  result  from 
peripheral  stimulation  of  the  sensory  nerves  or  those  of  special  sense, 
by  the  least  touch,  jar,  draught,  light  or  sound.    The  reflexes  are  enor- 


TETANUS  135 

moiisly  increased,  particularly  those  of  the  skin.  The  spasms  occasion 
violent  muscular  pain,  oppression  over  the  lower  chest  and  epigastrium, 
speechlessness,  insomnia  and,  from  participation  of  the  medulla,  profuse 
sweats  and  increased  and  irregular  heart  action.  The  temperature  may 
be  high,  normal  or  subnormal.  After  death  a  temperature  of  114°  has 
been  observed.  The  sensorium.  is  usually  clear.  Evacuation  of  the 
bladder  and  rectum  is  difficult,  and  erection  or  ejaculation  may  occur. 
The  urine  is  decreased  and  sometimes  contains  albumin,  sugar,  acetone 
or  indican,  but  no  increase  of  urea  and  creatin.  In  some  cases  the  lymph 
glands  adjacent  to  the  seat  of  infection  are  enlarged.  In  very  rare 
cases  the  toxins  cause  death  without  muscular  spasm;  i.  e.,  they  combine 
with  other  than  nervous  tissues.  Axhausen  collected  10  instances  of 
localized  tetanus,  in  which  the  disease  did  not  extend  from  parts  first 
involved. 

Diagnosis. — The  diagnosis  is  based  on  the  nature  of  the  wound,  the 
Bacillus  tetani,  trismus  (necessary  for  diagnosis),  the  facies  and  opisthot- 
onos. Serum  from  cases  of  tetanus  obtained  by  blistering,  is  fatal 
to  white  mice  in  twelve  to  twenty-four  hours.  In  strychnine  poisoning 
the  history,  tests  for  the  drug  in  the  stomach  washings  and  urine,  the 
more  abrupt  onset  of  the  spasm  and  reflex  excitability,  the  more  diffuse 
and  violent  clonic  intermittence  of  the  convulsions,  their  greater  involve- 
ment of  the  hands  and  feet,  and  the  later  appearance  of  trismus  and  its 
interparoxysmal  relaxation,  are  entirely  distinctive.  Hysteria,  hydro- 
phobia and  tetany  (q.  v.)  are  wholly  different  from  tetanus.  In  menin- 
gitis the  sensorium  is  affected.  Trismus  may  be  due  to  dental  caries, 
parotitis,  or  temporomaxillary  arthritis  with  a  tender  area  in  front 
of  the  tragus.  Escherich's  pseudotetanus  is  characterized  by  tonic 
contractures  of  the  jaw,  back  and  limbs  after  an  acute  infection  and 
convalescence  after  a  few  weeks. 

Prognosis. — The  following  factors  are  important: 

1.  Incubation. — The  later  after  inoculation  tetanus  develops,  the 
lower  is  the  mortality;  it  is  91  per  cent,  if  it  appears  in  the  first  week, 
81  per  cent,  in  the  second,  and  53  per  cent,  if  later. 

2.  Site  of  Infection. — Infection  in  the  arms  results  in  a  70  per 
cent,  mortality;  in  the  legs,  90  per  cent.  (Norris);  in  cephalic  tetanus 
{tetamts  facialis  described  by  Charles  Bell  in  1830),  the  mortality  is 
almost  100  per  cent.;  Brown  (1912)  found  94  records  of  cephalic  tetanus, 
and  in  all  but  1  case,  the  trauma  was  cephalic;  in  84  per  cent,  the  first 
symptom  was  trismus,  followed  later  by  various  paralyses;  in  16  per 
cent,  paralysis  antedated  the  trismus;  paralysis  may  be  facial  or  involve 
the  pontine  and  medullary  nuclei,  which  sometimes  causes  dysphagia 
(hydrophobic  type)  or  paralysis  of  the  eye  muscles.  The  author  observed 
these  symptoms  in  a  boy  who  had  been  kicked  over  the  ear  by  a  horse. 
Lloyd  found  7  cases  of  facial  diplegia.  Tetanus  or  trismus  neonatorum, 
especially  described  by  Beumer  (1887),  is  due  to  an  infection  of  the 
navel  in  the  second  week  of  life.  It  prevents  nursing  and  is  fatal  by 
the  fourth  day  in  83  per  cent,  of  cases.  In  the  West  Indies  50  per  cent. 
of  the  children  died  of  tetanus  at  one  time,  in  the  Western  Hebrides, 
07  per  cent.,  and  in  Iceland,  100  per  cent.    Anders  and  Morgan  collected 


136  BACTERIAL  DISEASES 

1307  cases  (1850  to  1905).  Tetanus  puerperalis,  particularly  described 
by  Heyse  (1893),  usually  follows  difficult  labor,  abortions  or  ministration 
by  mid-wives,  and  is  generally  fatal.  In  three  years  there  were  232 
cases  in  Bombay  (Gowers). 

3.  Course. — Hippocrates  observed  that  patients  who  survive  the 
fourth  day  may  recover;  68  per  cent,  die  in  the  first  four  days;  88  per 
cent,  of  acute  and  75  per  cent,  of  chronic  cases  die. 

4.  Traltvia. — The  death-rate  in  traumatic  cases  is  over  80  per  cent.; 
in  the  so-called  idiopathic  cases  it  is  50  per  cent,  or  lower. 

5.  Sex. — ^lore  women  recover  than  men. 

6.  Symptoms. — Slight  trismus  is  favorable;  high  fever,  involvement 
of  the  pons  or  medulla,  respiratory  spasm,  dysphagia  and  ocular  paralysis 
are  unfavorable. 

Treatment. — 1.  Prophylaxis  concerns  surgical  antisepsis  in  punctured 
icounds,  hematomata,  trauma  due  to  blank  cartridges  or  toy  pistols, 
in  labor  and  care  of  the  navel  in  the  newborn.  Immense  credit  is  due  the 
Journal  of  the  America?!  Medical  Association  in  its  campaign  for  a  rational 
Fourth  of  July.  Since  the  bacillus  is  anerobic,  punctured  wounds 
should  be  widely  incised,  treated  with  iodine,  phenol  or  peroxide,  and 
packed.  In  extensive  injuries,  extirpation  of  the  regional  lymphatics, 
or  amputation  may  be  indicated. 

2.  Antitoxin  Therapy. — Behring  and  Kitasato  (1890)  discovered 
an  antitoxin  and  were  able  to  immunize  animals  by  cultures  heated 
or  treated  with  Lugol's  solution,  which  changes  the  toxins  to  toxoids 
(Ehrlich).  The  antitoxin  is  found  in  animals  immune  to  tetanus,  as 
crocodiles  and  chickens,  and  in  the  blood,  milk  and  bile  but  not  in  the 
tissues.  Tetanus  antitoxin  is  not  bactericidal,  i.  e.,  it  does  not  act 
on  the  bacHli.  It  neutralizes  the  tetanus  toxin  in  the  blood  before  it 
has  become  fixed  in  nervous  tissue.  From  the  above  it  is  obvious  that 
(a)  serum  prophylaxis  may  be  successful  in  Fourth-of-July  wounds; 
in  the  Prague  obstetrical  clinic  it  abolished  tetanus  after  every  other 
measure  failed.  (6)  If  used  early  it  may  neutralize  circulating  toxins 
which  have  not  yet  become  attached  to  nervous  receptors,  (c)  When 
the  toxins  have  combined  with  the  motor  cells,  it  may  abstract  some  of 
the  virus  fixed  in  the  cells;  15,000  to  25,000  units  for  adults  and  10,000 
units  for  children  (or  1500  and  1000,  respectively,  for  proph}'laxis) 
are  injected  daily  near  the  site  of  inoculation.  As  absorption  requires 
three  days,  intravenous  administration  has  been  advised  (as  well  as 
subdural  injection,  which  some  consider  dangerous).  The  antitoxin  is 
eliminated  in  eight  days.  Anaphylaxis  has  resulted  (r.  page  88). 
Antitoxin  reduces  the  mortality  of  established  tetanus  20  per  cent. 
(Permin) . 

3.  Clonic  convulsions  may  be  minimized  by  absolute  quiet,  seclusion 
and  darkening  the  room.  Morphine  hypodermically  relieves  pain 
and  cutaneous  reflex  irritability,  one-quarter  grain  every  four  to  six 
hours  for  a  day  or  two,  but  the  pupils  and  respiration-rate  must  be 
carefully  watched.  An  occasional  corrective  hypodermic  of  atropine 
should  be  given.  Chloral  hydrate  depresses  the  motor  elements  of  the 
cord;  twenty  grains  may  be  given  every  two  hours  for  three  doses,  but 


GONORRHEAL  INFECTION  137 

even  this  amount  may  cause  dangerous  cardiac  symptoms  in  alcoholics 
or  arteriosclerotics.  Digitalis  may  be  given  with  chloral  hydrate  to 
steady  the  heart,  and  morphine  and  'potassium  bromide  to  enhance  its 
depressomotor  action  and  lessen  the  cutaneous  irritability.  The  bromides 
are  given,  5iss  every  three  hours  for  six  doses,  after  which  the  interval 
should  be  lengthened.  Inhalations  of  chloroform  and  amyl  nitrite, 
*  or  lumbar  puncture  may  inhibit  the  onset  of  severe  attacks. 

4.  Nutrition. — The  nasal  catheter  or  feeding  by  rectum  overcomes 
the  difficulties  offered  by  trismus  or  dysphagia. 

5.  Other  Measures. — (a)  Baccelli  secures  better  results  with  hypo- 
dermics of  2  per  cent,  phenol  solution  than  with  serotherapy  (150  to 
300  drops  daily);  in  190  cases,  the  mortality  was  only  17  per  cent. 
ih)  Wassermann  advises  subdural  injection  of  an  emulsion  of  sheep 
brains,  (c)  Meltzer  and  Auer  use,  after  lumbar  puncture,  intraspinal 
injections  of  a  25  per  cent,  solution  of  magnesium  sulphate — 1  e.c.  for 
each  25  pounds  of  the  patient's  weight;  Kocher  prefers  a  10  or  15  per 
cent,  solution;  the  magnesium  paralyzes  the  motor  nerves,  and  relieves 
the  symptoms,  giving  the  patient  rest  and  ease;  six  out  of  seven  of 
Kocher's  patients  recovered  and  in  Fox's  24  cases  the  mortality  was 
46  per  cent.  The  dangers  are  excessive  bronchial  secretion  (relieved  by 
atropine)  and  paralysis  of  the  respiratory  centre.  In  one  case  the  writer 
observed  retention  of  urine,  maniacal  delirium  and  quadriplegia.  It 
must  not  be  injected  unless  spinal  fluid  first  runs  out  through  the 
aspirating  needle. 

GONORRHEAL  INFECTION. 

Lightly  spoken  of  as  "the  badge  of  virility,"  gonorrhea  is  often 
neglected.  In  its  so-called  latent  form  it  may  be  conveyed  to  the  wife, 
on  whom  it  entails  suffering,  sterility  and  invalidism. 

I.  Regional  Invasion. — Gonorrhea  may  invade  the  prostate,  seminal 
vesicles  or  testes,  the  vagina,  uterus,  tubes  or  peritoneum,  the  rectum, 
bladder  and  kidneys  and,  in  children,  it  causes  institutional  epidemics 
of  vulvovaginitis. 

II.  Gonococcal  Septicopyemia. — Thrombophlebitic  or  lymphangitic 
generalization  has  been  discussed  under  Septic  Infections.  The  fever 
is  toxemic  or  septicemic,  intermittent  and  often  marked  by  great  varia- 
tions. The  gonococcus  has  been  found  in  the  blood  (Thayer  and  Blumer, 
1895);  myocardium;  pleura  (15  cases  collected  by  Lemoine  and  Gallis, 
1905);  and  in  the  joints  {v.  i.),  kidneys,  spleen,  muscular  abscesses  and 
lymph  glands;  in  meningomyelitic  foci  (30  cases,  Barrie);  in  myositis 
(7  cases  collected  by  Harris  and  Haskell,  1904) ;  in  arteritis  and  phlebitis 
(25  cases  collected  by  Heller,  1904) ;  in  felons,  osteomyelitis  and  perios- 
titis; perichondritis  (of  the  ears);  horny  skin  eruptions  or  keratosis  (21 
instances,  F.  E.  Simpson,  1912);  49  cases  of  ulcerative  gonorrheal 
endocarditis  were  collected  by  Kulbs  in  1907,  of  which  only  12  were 
above  criticism.  Septicopyemic  lesions  may  be  due  to  Neisser's  diplo- 
coccus  alone  or  to  mixed  infections. 

Gonorrheal  arthritis  is  a  form  of  mild  septicemia — occasionally  part 
of  a  septicopyemia.    It  was  described  by  Selle  and  Sweidiaur  in  1781, 


138  BACTERIAL   DISEASES 

but  first  clearly  by  Brande,  1854;  the  gonococcus  was  first  found  by  Pet- 
rone  (1883)  and  cultivated  by  Hoch  (1893).  It  develops  in  2  or  3  per 
cent,  of  gonorrheal  infections  and  is  the  most  common  disease  of  the 
joints.  Eighty  per  cent,  show  an  acute  urethritis;  in  the  balance  the 
urethritis  has  subsided  or  become  chronic.  It  has  followed  experimental 
gonorrhea,  cuts  during  operating  and  primary  gonorrheal  conjunctivitis 
(18  cases  reported  by  Lucas).  About  90  per  cent,  occur  in  males,  and* 
50  per  cent,  between  twenty  and  fifty  years  of  age.  Too  active  treat- 
ment and  sexual  indulgence  during  the  florid  stage  of  gonorrhea  are 
predisposing  causes. 

S3rmptoms. — Fever  rarely  exceeds  102°.  The  joints  alone  may  be 
involved,  or  there  may  be  more  septicemic  evidences,  as  endocarditis. 
Gonorrheal  "rheumatism"  is  more  than  synovitis;  the  accessory  bursse, 
contiguous  tendon  sheaths  and  extracapsular  structures  are  often  in- 
volved— gonorrheal  arthritis.  It  is  often  held  that  it  affects  one  joint 
(monarticular)  or  at  least  few  joints  (oligarticular) ;  though  fewer  joints 
are  involved  than  in  genuine  rheumatism,  in  Gerhardt's  series  two  to 
nine  joints  were  involved  in  87  per  cent.,  and  one  joint  only  in  13  per 
cent.  Gonorrheal  arthritis  frequently  involves  joints  which  usually 
escape  in  acute  articular  rheumatism,  e.  g.,  the  sacro-iliac  synchondrosis, 
sternoclavicular,  temporomaxillary  and  intervertebral  joints.  The 
knee  is  affected  in  70  per  cent.,  the  ankle  in  27,  fingers  and  toes  in  19, 
hip  in  13,  ^Tist  in  12,  shoulder  in  10  and  the  elbow  in  9  per  cent.,  of 
the  cases.  Within  the  joint  a  greenish  serofibrin  exudes,  and  without 
the  joint  there  is  edema  and  infiltration.  Suppuration  may  occur 
sometimes  with  or  without  coincident  pyogenic  infection,  especially  in 
the  joints  and  tendons  of  the  hand.  Gonococci  are  found  with  variable 
frequency,  the  highest  reported  percentage  being  75.  Injection  of  a 
sterilized  emulsion  of  gonococci  may  cause  subcutaneous  local  reaction 
and  induration,  slight  fever  and  local  swelling  in  the  joints  (Bruck 
and  Irons) — a  form  of  cutaneous  allergy.  A  positive  complement- 
fixation  test  is  indicative  of  gonorrhea. 

Konig's  pathological  classification  includes  (1)  simple  hydrops  of  the 
joint,  (2)  catarrhal  or  serofibrinous  hydrops,  (3)  pyarthrosis  and  (4) 
gonorrheal  phlegmon,  affecting  the  soft  parts.  A  clinical  classification 
may  be  made  as  follows:  (1)  Arthritic  form,  pain  with  exudation;  (2) 
acute  or  subacute  polyarthritis,  by  itself  or  with  septicemia;  (3)  the 
periarthritic  form  (polytendosynovitis  and  polybursitis,  often  with 
periostitis) ;  (4)  acute  monarticular  form,  with  local  reaction,  sometimes 
with  suppuration;  (5)  the  chronic  monarticular  hydrarthrosis  especially 
of  the  knee,  a  far  less  frequent  form;  and  (6)  simple  arthralgia  (the 
painful  heel,  talalgia  or  Jaquet's  blenorrhagic  foot). 

Course. — The  course  is  chronic  and  sometimes  relapsing;  iritis  is 
fairly  frequent;  atrophy  in  the  contiguous  muscles  may  occur,  or  anky- 
losis, which  is  oftener  plastic  than  osseous.  In  exceptional  instances, 
sciatica,  permanent  arthritic  changes  resembling  arthritis  deformans 
{q.  v.),  exhaustion  psychoses  or  multiple  neuritis  develop. 

Treatment. — Recovery  is  a  matter  of  time  and  nature,  rather  than 
of  therapy.     The  salicylates  are  inert  and  the  iodides  unsatisfactory. 


TUBERCULOSIS,  139 

In  the  acute  stage,  immobilization  by  plaster  casts  or  splints,  and  in 
the  chronic  stage,  blisters,  Pacquelin  cautery,  massage,  passive  move- 
ments and  extension,  to  overcome  residual  exudation  and  contractures, 
are  useful.  Some  cases  are  helped  by  Rontgen  rays  and  superheated 
air  (see  Arthritis  Deformans).  Passive  congestion  frequently  benefits. 
In  intractable  cases  incision  and  drainage  are  indicated.  Vaccine 
therapy  is  promising  in  chronic  and  subchronic  complications;  it  is 
generally  futile  in  vulvovaginitis  of  children,  chronic  deep  urethritis 
and  blenorrhagic  endocarditis;  in  polyarthritis  opinions  differ;  25-100 
million  are  used. 

TUBERCULOSIS.  ^ 

Definition. — A  specific  infection,  characterized  (a)  etiologically  by 
the  Bacillus  tuberculosis,  (fe)  pathologically  by  nodes  or  tubercles,  or 
dift'use  tuberculous  infiltration,  and  (c)  clinically  by  symptomatology 
varying  with  the  tissues  or  organs  invaded. 

History. — The  term  phthisis  (wasting)  was  first  used  by  Hippocrates. 
The  history  of  tuberculosis  includes  several  epochs: 

EjMch  I. — The  anatomical  tubercle  was  recognized  by  Sylvius  (1614- 
1672),  Morton  (1689)  whom  some  consider  the  real  pioneer,  Mangetus 
(1700)  and  Bayle  (1810),  who  described  the  miliary  tubercle.  Laennec, 
in  1819,  spoke  for  the  unity  of  phthisis.  Virchow  held  that  caseation 
was  only  a  retrogressive  change  and  not  necessarily  tuberculosis.  In 
1857  Buhl  described  miliary  tuberculosis.  Cruveilhier,  Rillet  and 
Barthez  identified  scrofula  and  tuberculosis. 

EjMch  II. — ^Villemin  (1865)  positively  established  the  inoculability 
of  tuberculosis  by  experiments  on  animals.  From  the  time  of  Hippo- 
crates and  Aristotle,  tuberculosis  was  feared  as  a  contagion,  and  the 
older  pathologists,  as  Morgagni,  dreaded  to  section  phthisical  subjects. 
The  histology  of  the  tubercle  was  developed  by  Wagner,  Schiippel  and 
Virchow;  Langhans  fully  described  the  giant  cells  previously  seen 
by  Virchow  and  Rokitansky;  tubercles  were  found  in  lupus  (Friedlander, 
1875),  lymph  glands  (Schiippel,  1871)  and  fungus  joints  (Koster,  1876). 
The  firm  and  ancient  belief  in  its  contagiousness  led  to  the  successful 
search  for  the  cause. 

Epoch  III  began  with  Koch's  announcement,  in  1882,  of  the  tubercle 
bacillus.  His  report,  as  health  officer  in  an  obscure  German  town,  was 
so  complete  that  scarcely  a  single  point  has  been  added  to  his  initial 
communication.  The  bacillus  was  found  in  all  tuberculous  lesions,  such 
as  chronic  phthisis,  miliary  tuberculosis,  intestinal  ulcers,  "scrofulous" 
lesions,  bone  and  joint  disease,  lupus  and  in  the  sputum,  in  cattle,  etc.; 
it  occurred  in  no  other  disease;  it  was  cultivated  by  him  and  inoculated 
into  animals  with  reproduction  of  tuberculosis,  thereby  fulfilling  what 
has  become  known  as  "Koch's  law." 

Bacillus  Tuberculosis. — 1.  Morphology. — It  is  a  thin,  slightly  curved, 
narrow  rod,  measuring  1|  to  4)[i  long;  it  contains  no  spores,  the  light 
unstained  areas  in  its  body  being  vacuoles  or  degeneration;  it  is  im- 
motile;  in  young  cultures  it  is  shorter  than  in  the  sputum;  in  old  cultures 
and  in  lung  cavities  it  is  longer  and  is  frequently  thread-like.    Pleomor- 


140  BACTERIAL  DISEASES 

phism  is  often  noted,  as  bulging  sides  or  ends,  thread-like,  or  branching 
forms  and  forms  like  actinomyces.     (See  Plate  V). 

2.  Staining  Reaction. — It  stains  slowly  and  gives  up  the  stain 
reluctantly.  Ziehl's  solution  is  the  best  (fuchsin  1,  absolute  alcohol 
10  and  5  per  cent,  carbolic  solution  100).  The  sputum  is  spread  out  in  a 
dish  over  a  black  background  and  the  yellow-green  areas  selected  are 
thinly  distributed  on  the  slide  w^hich  is  held  in  the  hand,  and  dried  at 
some  distance  from  the  flame;  it  is  then  stained  by  the  carbol-fuchsin, 
being  passed  repeatedly  but  lightly  through  the  flame  (without  boiling) 
to  deepen  the  stain;  it  is  then  washed,  treated  with  33  per  cent,  nitric 
acid,  washed  well  in  water  and  then  alcohol,  and  dried.  Uhlenhuth's 
method,  as  modified  by  Loeffler  detects  bacilli  in  15  to  35  per  cent, 
when  not  found  by  other  methods.^  The  bacillus  resists  destaining 
because  of  its  wax-like  envelope,  an  almost  pathognomonic  feature.  For 
clinical  purposes  only  (a)  the  bacilli  found  in  bronchiectasis  and  gangrene 
of  the  lung  (q.  v.),  (b)  the  smegma  bacillus  and  (c)  the  leprosy  bacillus 
need  be  considered;  the  leprosy  germs  are  intracellular,  cover  the 
nucleus  of  the  containing  cell,  and  are  stained  in  six  or  seven  minutes 
with  alcoholic  fuchsin,  while  tubercle  bacilli  are  extracellular  and  stain 
slowly;  the  smegma  bacillus  causes  many  errors  in  genito-urinary 
examinations;  it  grows  rapidly  in  twenty-four  hours,  does  not  show 
the  beaded  appearance  seen  in  the  Bacillus  tuberculosis,  and  stained 
and  counter-stained  in  the  usual  way,  becomes  tinged  with  methylene 
blue.  Much  found  that  some  tubercle  bacilli  stain  by  Gram  and  not 
by  carbol-fuchsin;  he  proved  by  culture  and  inoculation  that  they  were 
Koch's  bacilli  and  that  they  could  be  converted  into  the  less  virulent 
acid-fast  form. 

3.  Cultures. — The  bacillus  develops  best  at  body  heat  in  one  or  two 
weeks;  blood  serum  is  the  best  medium,  but  growths  are  also  successful 
on  bouillon,  glycerine-agar  and  potato;  they  are  dry,  thin,  grayish  and 
scale-like.  The  germ  is  a  facultative  aerobe  and  multiplies  by  transverse 
fission.  It  does  not  lead  a  saprophytic  life  in  nature,  outside  the  bodies 
of  animals  and  of  man. 

4.  Chemistry,  Metabolism,  Resistance,  Virulence,  Etc. — It  con- 
tains two  to  sixteen  times  as  much  fat  as  other  bacteria.  A  waxy  sub- 
stance envelops  the  bacillus;  it  also  develops  tuherculin  whose  chief  com- 
ponents are  peptone,  albumose  and  alkaloidal  substances;  it  is  soluble  in 
glycerin.  It  is  not  proved  that  it  develops  a  definite  toxin.  Its  resisting 
powers  are  as  a  rule  limited.  Drying  is  endured  by  the  bacillus  for  six  or 
even  ten  months.  In  decomposing  media  its  average  life  is  one  to  one 
and  a  half  weeks.  Heat  (106°)  kills  it  in  a  few  minutes.  It  may  survive 
14°  below  zero  for  weeks.    Sunlight  kills  the  bacillus  in  minutes  to  hours. 

'  5  to  20  c.c.  of  sputum  are  placed  in  a  flask  with  an  equal  quantity  of  .50  per  cent, 
antiformin  and  the  mixture  is  boiled.  Solution  of  the  sputum  occurs  at  once.  To  10  c.c. 
of  the  cooled  solution  (which  is  sterile  and  from  which  cultures  or  inoculations  can  be 
made)  1.5  c.c.  of  a  mixture  of  10  volumes  of  chloroform  and  90  volumes  of  alcohol  are 
added  and  the  whole  thoroughly  shaken.  The  specimen  is  centrifugalized  about  fifteen 
minutes.  Chloroform  is  found  at  the  bottom  of  the  tube,  and  on  its  upper  surface  the 
sediment  collects.  The  supernatant  fluid  is  poured  off,  and  with  a  pipette  the  sediment  is 
transferred    to  a  glass  slide. 


i 


PLATE  V 


Tubercle  Bacilli  and  Elastic  Fibers. 


TUBERCULOSIS  141 

Koch  assumed  an  equal  virulence,  while  the  Arloing  school  finds  that 
it  has  an  attenuated  virulence  in  glandular  and  osseous  lesions,  and 
Theobald  Smith  holds  that  bovine  cultures  are  more  virulent  for  rabbits 
than  is  human  sputum.  Large  numbers  are  found  in  fresh  tubercles; 
few  are  found  in  chronic  articular,  osseous  or  glandular  foci,  and 
inoculations  may  be  necessary  to  demonstrate  the'  nature  of  long- 
standing lesions.  Arloing  and  Courmont  found  that  serum  from  inoculated 
rabbits  or  goats,  agglutinized  tubercle  bacilli  in  a  dilution  of  1  to  5  or 
20,  in  two  to  twenty-four  hours;  agglutination  was  noted  in  95  per  cent. 
of  the  cases  of  lung  tuberculosis  and  in  50  per  cent,  of  the  cases  of  surgical 
tuberculosis. 

Associated  or  Mixed  Injection. — Symbiosis  has  been  noted  with  the 
streptococcus,  staphylococcus  and  pneumococcus,  to  a  lesser  degree 
with  the  Bacillus  pyocyaneus,  influenza,  etc.  {v.  i.) 

Prevalence  in  Man. — Tuberculosis  is  the  greatest  foe  of  man  and 
five  million  die  yearly  from  this  plague;  it  causes  14  per  cent,  of  all 
deaths,  and  33  per  cent,  of  deaths  between  fifteen  and  forty-five  years  of 
age ;  it  causes  more  deaths  than  war,  famine,  plague,  cholera,  yellow  fever 
and  smallpox  combined;  in  Germany,  in  1894,  the  deaths  from  diphtheria, 
croup,  measles,  scarlatina,  pertussis  and  typhoid,  together,  were  7000 
less  than  those  from  tuberculosis. 

Quiescent  (latent),  obsolete  or  healed  tuberculosis  was  found  by  Heitler 
in  many  postmortems  upon  those  dying  of  other  diseases  (4.8  per  cent, 
among  16,562  autopsies).  Latent  tuberculosis  occurs  in  25  to  33  per 
cent,  of  the  population  (Baumgarten,  Birch-Hirschfeld),  and  50  per  cent. 
(Cruveilhier  and  DejerineJ,  91  per  cent.  (Burkhardt)  and  in  97  per  cent, 
of  all  necropsies  (O.  Naegeli). 

Prevalence  in  Animals. — (a)  Cattle. — In  Germany  it  is  found  in  from 
4  to  20  per  cent.  In  New  York  the  tuberculin  test  was  positive  in  17 
per  cent.  Theobald  Smithy  and  later  Koch,  contended  that  bovine 
and  human  tuberculosis  were  separate  infections;  most  TVTiters  incline 
to  this  view.  In  cattle  tuberculosis  is  less  often  attended  by  softening 
of  the  tubercle,  and  the  serous  membranes  are  more  often  involved; 
the  lungs  and  pleurae  are  involved  in  40  per  cent.,  the  lungs  alone  in  20 
per  cent.,  and  the  pleurae  and  peritoneum  in  15  per  cent.  (6)  Swine 
are  affected  more  often  in  Europe  than  in  this  country;  in  Saxony  tuber- 
culosis occurs  in  1  per  cent,  and  in  Copenhagen  and  Dantzig,  in  11  per 
cent.;  because  their  infection  commonly  results  from  eating  tuberculous 
offal,  the  type  is  alimentary  (90  per  cent.),  (c)  Other  mammals:  Dogs, 
cats,  horses  and  sheep  are  rarely  diseased.  Monkeys  in  captivity  die 
frequently  (43  per  cent.)  from  tuberculosis,  referable  to  foul  cages. 
(d)  In  reptiles,  it  is  rarely  seen  except  in  captivity,  {e)  In  birds,  tuber- 
culous lesions  are  more  frequent  in  the  liver,  spleen,  intestine,  mesenteric 
glands,  bones  and  joints,  than  in'  the  lungs,  though  parrots  suffer  from 
skin  and  lung  localizations.  Avian,  bovine,  reptilian  and  human  tuber- 
culosis are  closely  related  types.  Tubercles  are  not  uncommon  in  animals 
from  nematodes,  protozoa  and  bacteria  and  in  man,  from  the  streptothrix 
and  aspergillus  (pseudotuberculosis). 


142  BACTERIAL   DISEASES 

Atrium. — The  details  will  be  considered  under  the  different  clinical 
localizations  of  the  disease. 

1.  By  the  Respiratory  Tract. — The  bacillus  enters  the  respiratory 
tract  by  inhalation.  In  the  vast  majority  of  cases  the  sputum  of  diseased 
persons  is  causative  both  oj  the  disease  and  its  great  frequency  of  local- 
ization in  the  respiratory  organs.  It  has  been  estimated  that  a  phthisical 
person  voids  three  mihions  of  tubercle  bacilli  daily.  Cornet  holds  that 
the  greatest  danger  lies  in  the  drying  of  the  sputum  in  the  room,  on  the 
handkerchief,  the  lips,  beard,  hair,  fingers  and  clothing  or  in  the  street 
and  other  open  places.  Fliigge  contends  that  dried  sputum  is  rapidly 
sterilized  by  sunlight  and  is  less  dangerous  than  the  moist  expectoration, 
and  demonstrated  that  in  coughing,  which  seemingly  voids  no  secretion, 
in  singing,  sneezing  or  talking,  small  and  almost  invisible  drops  of  moisture 
containing  the  bacilli  are  Avoided;  he  cultivated  bacilli  from  glass  plates 
covered  with  solid  culture  media  and  held  near  the  patient;  he  believes 
that  minute  particles  remain  in  suspension  in  the  air  and  thus  infect 
other  individuals.  The  ubiquity  of  the  tubercle  bacillus  is  exaggerated, 
though  of  great  importance  in  poorly  ventilated,  dark  dweUing-rooms, 
hospitals,  cloisters,  hotels  or  prisons,  frequented  by  victims  of  tuber- 
culosis. Cornet  found  the  bacilli  in  the  dust  of  such  rooms  in  large 
numbers,  and  demonstrated  that  animals  confined  in  rooms  T^dth  dried 
tuberculous  sputum  readily  acquired  tuberculosis.  Straus  collected  the 
germ  from  the  nose  in  31  per  cent,  of  the  attendants  in  tuberculous 
wards.  The  closer  the  contort  with  tuberculous  subjects,  the  greater  is  the 
danger  of  infection.  In  crowded  prisons  in  Austria  the  prison  mortality 
is  40  to  GO  per  cent.,  against  the  general  mortality  of  11  to  15  per  cent. 
In  nursing  sisterhoods,  the  death-rate  exceeded  75  per  cent.,  as  observed 
by  the  writer  in  one  small,  closely  cloistered  community.  In  Phila- 
delphia, Flick's  studies  showed  that  33  per  cent,  of  infected  houses 
contributed  more  than  1  case.  In  our  dispensary  service,  7  rapidly 
fatal  cases  were  observed  in  one  family  fHarpolej.  Oral  breathing, 
caused  by  adenoids  and  inhalation  of  coal-dust  or  stone-dust,  are 
favoring  factors. 

Dustmg,  sweeping  or  shaking  the  bedclothes  disseminates  the  virus; 
there  is  less  danger  of  infection  when  the  T\dndows  and  doors  are  open 
and  when  dusting  is  done  T\dth  moist  cloths  rather  than  with  feather- 
dusters.  In  hospital  wards  there  are  more  germs  in  the  air  dtiring  the 
cleaning  hour  than  during  the  other  twenty-three  hours.  However,  if 
bacilli  are  in  the  dust,  they  are  not  necessarily  in  the  inhaled  air;  if 
inhaled,  they  may  be  caught  in  the  upper  air-passages  whose  secre- 
tions antagonize  their  development,  and  are  often  waved  back  by 
the  ciliated  epithelium  of  the  lower  air-passages;  when  bacilli  are 
inhaled  into  the  respiratory  tract  ^a)  no  lesions  may  result,  (h)  the 
lungs  may  become  diseased,  or  (cj  the  germs  may  pass  the  mucosa  of  the 
mouth  or  bronchi  and  cause  cervical  or  peribronchial  tuberculous  adenitis. 
Cornet  holds  that  the  statement  that  "every  man  lives  in  the  environ- 
ment of  tuberculosis"  is  exaggeration.  ^Married  persons,  because  of 
their  intimate  association,  may  contract  the  disease  from  each  other, 
as  was  noted  bv  Ettmiiller  and  ^lorton  in  the  seventeenth  centurv. 


TUBERCULOSIS  143 

2.  By  the  Digestive  Tract. — Bacilli  may  pass  the  mucosa,  espe- 
cially in  children,  and  produce  the  first  lesions  in  the  mesenteric  glands. 
Park  and  Krumwiede  hold  that  in  young  children  6  to  10  per  cent,  of 
tuberculous  deaths  are  due  to  the  bovine  type  of  bacillus,  and  that 
juvenile  tuberculous  adenitis  and  abdominal  tuberculosis  are  more  often 
due  to  bovine  than  the  human  bacillus.  In  pulmonary  tuberculosis 
in  adults.  Park  and  Krumwiede  did  not  once  find  the  bovine  bacilli  in 
the  sputum  in  1042  cases;  Kossel  found  in  709  sputa,  705  bacilli  humani, 
2  certain  and  1  doubtful  bacilli  bovini  and  1  with  both  types;  in  other 
words,  the  bacillus  humanus  is  found  almost  exclusively  in  pulmonary 
tuberculosis  of  which  twelve  times  as  many  people  die  as  from  all  other 
localizations  combined.  In  cows,  a  tuberculous  mastitis  was  formerly 
thought  necessary  to  milk  infection,  but  milk  may  be  infective  from  cows 
with  tuberculosis  which  does  not  invade  the  udders.  Pigs,  fed  on  tuber- 
culous milk,  develop  intestinal  or  pulmonary  tuberculosis.  Butter  may 
contain  tubercle  bacilli.  Meat  is  less  dangerous,  as  it  is  usually  well  cooked, 
but  tubercles  in  raw  offal  frequently  infect  swine.  Harbitz's  figures 
show  that  the  entry  of  tuberculous  infection  is  (i)  respiratory  in  41  per 
cent.,  (ii)  digestive  in  22  per  cent.,  (iii)  respiratory  or  digestive  in  21  per 
cent.,  and  (iv)  in  the  lymph  nodes,  elsewhere  or  doubtful  in  16  per  cent. 
Gohn  holds  that  95  per  cent,  of  infections  in  children  are  pulmonary  or 
aerogenic,  not  lymphadenogenic,  in  origin. 

3.  Direct  Inoculation. — Inoculation  through  the  skin,  genito- 
urinary tract,  trauma  or  operations  is  far  less  significant. 

"^  Predisposing  Factors. —  These  are  important,  hut  tuberculosis  is  best 
considered  and  treated  as  an  injection,  communicated  and  acquired  by 
direct  personal  contact. 

1.  Heredity. —  (a)  Hereditary  Predisposition  to  Tuberculosis. — A 
tuberculous  family  history  is  obtained  in  infected  individuals  in  25  per 
cent.  Kuthri  found  essentially  the  same  percentage  of  family  tuber- 
culosis in  non-tuberculous  as  in  tuberculous  cases.  Tuberculous  parents 
may  infect  their  children  (50  per  cent.),  as  they  may  infect  others,  but 
97  per  cent,  escape  the  disease  when  removed  from  their  parents.  Accord- 
ing to  Rieffel,  3  per  cent,  of  children  acquire  tuberculosis  when  both 
parents  are  sound  and  22  per  cent,  when  both  parents  are  tuberculous. 
Hereditary  predisposition  is  no  obstacle  to  prevention  and  treatment. 
Cornick  argues  that  heredity  promotes  resistance. 

(6)  Congenital  Tuberculosis. — Baumgarten  thought  that  children 
actually  inherit  the  bacillus,  which  remains  latent  for  years,  and  then 
develop  an  active  tuberculosis.  Congenital  tuberculosis  can  be  acquired 
only  through  the  spermatozoon,  ovum  or  placenta.  The  spermatozoon 
and  ovum  can  not  carry  bacteria.  Placental  tuberculosis  has  been  ob- 
served according  to  Warthin  and  Cowie  in  only  5.  human  cases,  and  in 
slightly  over  100  cases  in  animals  (Friedman,  1905).  Virchow  never 
saw  a  case.  Usually  there  is  a  placental  focus  before  the  fetal  blood  is 
infected,  but  the  bacillus  may  pass  directly  to  the  fetus.  Schmorl  and 
Geipel  found  tuberculosis  in  50  per  cent,  of  placentae  of  tuberculous 
mothers. 

The  arguments  against  hereditary  tuberculosis  are  (1)  that  children 


> 


144  BACTERIAL  DISEASES 

born  with  the  disease  die  very  early;  (2)  that  tuberculosis  in  the  first 
months  of  hfe  is  extremely  rare;  (3)  in  congenital  infection,  the  liver  is 
chiefly  diseased  because  of  its  vascular  relations  to  the  placenta;  in 
tuberculosis  of  children,  the  lungs  and  glands  are  more  often  diseased, 
i.  e.,  respiratory  infection  is  extra-uterine.  (4)  Removed  from  their 
tuberculous  parents,  children  thrive  well. 

2.  Environivient. — Environment  is  but  another  name  for  exposure 
or  contact-infection.  Dampness  and  poor  drainage  reduce  the  physio- 
logical resistance.  Trudeau  showed  that  inoculated  animals,  kept  in 
dark,  damp  cellars,  die,  while  others,  allowed  to  run  at  large,  outlive 
the  infection.  Density  of  population  raises  the  proportion  of  tuberculous 
cases.  In  recent- years  the  large  cities  have  showni  an  apparent  decrease 
of  tuberculosis,  e.  g.,  Chicago,  Glascow,  New  York  and  London.  In 
Massachusetts  the  total  is  less  by  half  than  fifty  years  ago.  The  decrease 
is  attributed  to  more  intelligent  hygiene.  It  is  possible  that  this  decrease 
is  explained  by  the  fact  that  pneumonia  carries  off  the  less  resistant  of 
the  population;  in  ]\Iunich  the  death-rate  from  tuberculosis  was  12  per 
cent,  when  typhoid  was  epidemic ;  when  typhoid  was  practically  abolished 
the  tuberculosis-rate  increased  to  16  per  cent.,  i.  e.,  4  per  cent,  of  those 
with  tuberculosis  had  previously  died  from  typhoid. 

3.  Occupation. — Work  in  close,  damp  rooms,  in  dust,  in  crowded 
quarters,  particularly  when  associated  with  poor  food,  alcoholism,  worry 
and  overexertion,  lowers  resistance  and  promotes  tuberculosis  when 
exposure  to  infected  individuals  exists.  Clerks,  stenographers  or  waiters 
are  more  easily  infected  than  are  those  working  in  the  fresh  air.  ^Miners 
do  not  suffer  more  frequently,  as  dampness  prevents  the  drying  of  in- 
fected sputum. 

4.  Age. — Cornet's  figures  show  the  following  death-rate  per  10,000 
of  population:  First  year  2  to  3,  the  child  being  in  close  contact  with 
the  mother.  These  figures  grow  smaller,  until  the  lowest  figure  is  reached, 
namely,  |  from  the  fifth  to  tenth  years;  fifteenth  to  twentieth  years, 
17  to  19;  twentieth  to  thirtieth  years,  32  to  36;  thirtieth  to  fortieth 
years,  44;  fortieth  to  fiftieth  years,  55;  fiftieth  to  sixtieth  years,  76; 
sixtieth  to  seventieth  years,  100;  seventieth  to  eightieth  years,  70; 
over  eightieth  year,  20.  In  the  first  decade  of  life,  glandular,  meningeal, 
osseous  and  cutaneous  tuberculosis  are  more  frequent. 

5.  Sex. — Before  twenty  years  of  age  girls  are  more  prone  to  tuber- 
culosis, because  their  life  is  more  sedentary.  After  twenty  years  males 
more  often  contract  the  disease,  because  of  their  greater  exposure  to 
infection.  Repeated  pregnancies  and  protracted  lactations  lower  re- 
sistance to  infection. 

6.  Climate. — Warm,  dry  climates,  high  altitudes  and  lack  of  sudden 
variations  in  temperature  are  inimical  to  tuberculosis.  The  French 
Alps  and  other  localities  were  long  free  of  tuberculosis  until  crowded  by 
infected  subjects.  The  chief  advantages  of  many  resorts  seem  to  be 
their  sparse  population  and  inaccessibility. 

7.  Race. — In  this  country  the  Irish  and  negroes  are  most  frequently 
diseased.  The  Indians  have  justly  come  to  dread  the  "coughing  white 
man,"  and  they  die  in  large  numbers  from  consumption.    These  instances 


TUBERCULOSIS  145 

are  explained  by  exchanging  a  country  for  a  city  life.    Infection  among 
Jews  is  peculiarly  infrequent. 

S.  IxDiYiDUAL  Predispositiox. — The  oldest  medical  -^Titers  described 
the  winged  scapulse,  paralytic  thorax  and  depressed  sternum;  but 
poor  development  is  often  an  expression  of  already  existing  tuberculosis; 
phthisis  also  occurs  in  splendidly  developed  chests,  exposure  to  infection 
being  the  most  important  factor.  Tuberculosis  confers  no  immunity 
to  relapses  or  to  new  localizations;  a  lung  lesion  may  heal  while  a  co- 
incident intestinal  lesion  progresses. 

9.  Trauma. — Bacilli  in  the  blood  may  be  localized  in  a  bone  or  joint 
by  trauma;  a  blow  on  the  head  or  spine  may  initiate  meningitis  in  a 
tuberculous  subject;  pleurisy  or  pulmonary  tuberculosis  may  be  initiated 
by  injury  to  the  chest,  arousing  latent  lesions  in  the  peribronchial  glands. 

10.  Other  Factors. — These  are  diabetes,  in  which  25  to  50  per  cent, 
die  of  tuberculosis  of  the  lung;  psychoses,  especially  of  the  depressive 
type;  anemia,  which,  however,  is  more  often  the  result  than  the  cause 
of  tuberculosis;  heavy  colds,  measles  and  pertussis,  and  less  often  scarlatina, 
influenza  or  diphtheria,  may  predispose  to  infection,  or  more  probably 
often  awaken  slumbering  glandular  tuberculosis  by  the  irritative  action 
of  products  absorbed  from  the  bronchi  or  lungs.  Enterocolitis  in  children 
or  typhoid  in  adults  may  in  a  similar  way  awaken  or  initiate  abdominal 
tuberculosis.  Contracted  kidney,  cirrhotic  liver,  sclerosed  arteries,  stenosis 
of  the  pulmonary  artery,  aneurysm  and  a  hypoplastic  aorta  are  pre- 
disposing factors.  Rokitansky  noted  that  valvular  disease  of  the  left 
heart  prevents  or  checks  infection,  because  it  congests  the  lungs;  Bier's 
congestion  treatment  of  surgical  tuberculosis  is  based  on  this  point; 
Birch-Hirschfeld,  in  4359  autopsies,  found  chronic  pulmonary  tuber- 
culosis in  21  per  cent.,  and  in  107  autopsies  of  valvular  heart  disease 
it  was  present  in  but  2.8  per  cent.  Potain,  in  54  cases  of  mitral  stenosis, 
found  pulmonary  tuberculosis  in  16.6  per  cent,  (see  Valvular  Disease 
OF  THE  Heart).  Syphilis,  cancer,  pleurisy  (q.  v.)  and  hemoptysis  (g.  v.) 
are  occasional  predisposing  factors. 

General  Histopathology  of  the  Tubercle. — The  only  pathognomonic 
feature  of  the  tubercle  is  Koch's  bacillus,  as  similar  infective  granulomata 
are  seen  in  strongylus  in  sheep,  in  actinomycosis,  syphilis,  etc.  Baum- 
garten  described  the  changes  following  inoculation  of  the  anterior  chamber 
of  the  eye :  (a)  On  the  first  day  the  bacilli  increase  and  spread  along  the 
lymph  spaces.  (6)  By  the  sixth  day,  the  fixed  connective-tissue  cells 
proliferate  under  the  stimulus  of  the  bacillus;  these  epithelioid  or  endo- 
thelioid  cells  are  large,  rounded  or  polygonal,  with  distended  nuclei, 
sometimes  contain  tubercle  bacilli  and  show  karyokinetic  figures;  the 
bacilli  multiply  and  the  endothelial  cells  of  the  vessels  proliferate.  In 
this  stage  it  is  called  the  epithelioid  tubercle,  (c)  On  the  tenth  day 
leukocytes  emigrate,  an  inflammatory  reaction  to  the  toxins  secreted 
by  the  bacillus;  most  of  the  white  cells  are  polymorphonuclear,  many 
of  which  degenerate;  later  there  are  mononuclears  which  do  not  suffer 
retrogressive  changes;  the  mononuclears  crowd  the  epithelioid  cells  and 
dominate  the  histological  picture,  especially  with  complicating  trauma 
(lymphoid  tubercle),  {d)  The  reticulum  of  the  tubercle  consists  of  the 
10 


146  BACTERIAL  DISEASES 

stretched  fibers  of  the  infected  tissue.  Tubercles  contain  no  bloodvessels. 
(e)  The  epithelioid  cells  increase  in  size  and  are  often  multinucleated. 
From  them  or  the  extravasated  leukocytes,  by  growth  or  fusion,  giant 
cells  develop;  they  contain  many  large,  oval  nuclei  and  tubercle  bacilli; 
the  bacilli  may  number  50  to  a  cell  in  very  active  processes  or  even  may 
be  the  chief  histological  finding  in  very  chronic  forms,  such  as  lupus, 
scrofulous  glands  or  fungoid  joint  disease;  they  are  few  or  absent  in 
miliary  tuberculosis ;  there  seems  to  be  an  antagonism  between  the  nuclei 
and  bacilli,  for  if  the  nuclei  lie  on  the  margin  of  the  cell,  the  bacilli  are 
centrally  grouped,  and  if  the  nuclei  lie  at  one  pole  of  the  cell,  the  bacilli 
concentrate  at  the  other  pole.  The  cellular  inclusion  of  the  bacilli  is 
possibly  a  phagocytosis.  The  completed  miliary  tubercle  is  non-vascular, 
cellular,  millet-seed  (miliary)  in  size,  gray  in  color  and  translucent  or 
opaque  from  later  caseation  {v.  i.);  it  is  the  invariable  pathological 
unit  of  all  tuberculous  lesions  and,  more  or  less,  is  a  continuous  process. 
In  the  diffused  inflammatory  tubercle,  the  diffuse  areas  result  from  the 
fusion  of  myriads  of  miliary  tubercles. 

The  tubercle  then  undergoes  one  of  two  degenerations,  caseation  or 
induration:  (1)  Caseation  results  from  degeneration  of  the  tubercle, 
beginning  at  its  centre,  from  ischemia  (vascular  obliteration)  and 
coagulation  necrosis  (the  bacillus  and  its  toxins).  Inoculations  with 
dead  bacilli  may  cause  tubercles  and  even  caseation.  The  area  of 
coagulation  necrosis  then  gradually  becomes  more  yellow  and  granular, 
and  finally  results  in  an  amorphous,  homogeneous,  cheesy  debris.  Casea- 
tion is  a  dangerous,  destructive  degeneration.  (2)  Induration  or  encap- 
sulation results  from  growth  of  connective  tissue  around  the  conglom- 
eration of  tubercles;  it  limits  the  tubercle,  is  the  measure  of  the  resisting 
power  of  the  surrounding  tissue,  of  the  process  of  bacteriolysis,  and  is 
a  conservative  change.  It  occurs  most  frequently  in  the  peritoneum, 
but  also  in  the  lungs  and  other  tissues.  Inflammation,  varying  with  the 
tissue  involved,  may  complicate  the  histological  findings.  Suppuration 
may  result  from  mixed  infection  with  streptococci,  though  Koch  held 
that  pus  may  be  formed  by  the  tubercle  bacillus  itself;  the  ordinary 
tuberculous  "cold  abscess"  is  not  actual  pus,  but  merely  thick,  amor- 
phous, granular  debris. 

Extension. — (1)  Tubercles  develop  at  the  point  of  infection  and  in 
the  nearest  lymph  glands,  which  permanently  or  temporarily  arrest  the 
process.  (2)  Infection  may  occur  through  the  uninjured  mucosa  or 
skin,  but  the  process  rarely  passes  beyond  the  tributary  lymph  glands. 
(3)  The  later  advance  of  the  process  can  be  traced  clearly  at  autopsy, 
along  the  lymph  vessels. 

I.  Tuberculosis  Miliaris  Acuta. — Definition. — An  acute  general,  some- 
times almost  universal,  embolic  dissemination  of  the  tubercle  bacillus 
in  great  numbers  by  the  blood  or  lymph  stream,  resulting  pathologically 
in  the  wide-spread  formation  of  miliary  tubercles  in  various  tissues,  and 
clinically  in  fatal  toxemia,  pulmonary,  meningitic  or  other  symptoms. 

Etiology. — 1.  Development. — Acute  miliary  tuberculosis  always  de- 
velops from  a  tuberculous  focus,  which  is  found  in  97  to  100  per  cent,  by 
careful  dissection;  it  may  be  small  or  even  miscroscopic;  von  Buhl, 


TUBERCULOSIS  147 

who  first  fully  described  the  affection  (1856),  recognized  that  miliary 
dissemination  occurred  by  absorption  from  old  tuberculous  foci,  as 
pyemia  results  from  local  suppuration.  It  is  curious  that  miliary  tuber- 
culosis occurs  from  foci  so  small  as  to  be  easily  overlooked,  and  that  large 
tuberculous  lesions  seldom  result  in  miliary  dissemination. 

2.  Lesion. — A  description  of  all  primary  foci  would  enumerate  every 
possible  localization  of  tuberculosis.  Pulmonary  tuberculosis  causes 
over  50  per  cent,  of  cases  of  acute  miliary  tuberculosis.  Glandular 
lesions  rank  next,  and  articular,  osseous,  genito-urinary  and  serous- 
membrane  tuberculosis  cause  most  of  the  balance.  The  more  the  tubercle 
is  indurated,  the  less  is  the  danger  of  dissemination.  Acute  generaliza- 
tion only  follows  the  introduction  into  the  circulation  of  large  numbers 
of  bacilli,  for  they  do  not  multiply  in  the  blood.  A  few  bacilli  reaching 
the  circulation  cause  a  solitary  tubercle.  Repeated  ruptures  of  moderate 
numbers  of  bacilli  cause  the  so-called  chronic  miliary  tuberculosis  {v.  i.). 

3.  Access  of  Bacilli  into  Blood  Stream. — Sir  Astley  Cooper, 
in  1798,  found  tubercles  in  the  thoracic  duct.  In  1877,  Weigert  demon- 
strated that  tubercles  invade  the  vessel  walls,  which  Rokitansky  had  de- 
clared immune.  Tuberculosis  reaching  a  vessel  usually  causes  its  gradual 
obliteration  and  thus  localizes  the  process,  but  in  some  cases  bacilli  reach 
the  lumen  of  the  vessel  and  are  distributed  in  the  direction  of  its  current. 
The  most  frequent  process  is  periangitis,  by  which  a  tubercle  adheres 
to  and  empties  into  a  vein.  Less  common  is  endangitis,  by  which  bacilli 
lodge  in  the  intima,  and,  grouping  there,  further  disseminate  the  infec- 
tion. The  most  common  method  is  periadenitis  of  a  tuberculous  bronchial 
gland,  its  adhesion  to  a  pulmonary  vein  and  final  rupture  into  it.  Tuber- 
culous lesions  may  rupture  into  the  azygos,  cavse,  pulmonary  artery, 
aorta,  thoracic  duct  or  jugular  or  other  veins. 

4.  Organs  Involved. — (a)  Rupture  into  a  pulmonary  vein  floods 
the  arterial  circulation  with  bacilli,  whence  miliary  deposits  occur  in 
the  brain,  choroid,  liver,  spleen,  kidneys,  myocardium,  bones,  serous 
and  mucous  membranes  and  in  the  bloodvessels  themselves.  (6)  Rupture 
into  a  portal  venous  radicle  affects  chiefly  the  liver,  (c)  Into  the  pul- 
monary artery,  the  lungs  and  {d)  into  a  peripheral  artery,  the  tissue 
supplied  by  it. 

5.  Predisposing  Factors. — Miliary  dissemination  is  most  frequent 
in  children,  especially  between  one  and  four  years  of  age,  because  the 
circulation  is  faster,  metabolism  is  quicker,  thrombosis  of  the  vessels 
is  less  frequent,  tissue  reaction  is  less  marked  and  the  lymph  vessels 
and  spaces  are  wider.  Deyletiiig  factors,  pregnancy,  the  puerperium, 
trauma,  bone  operations,  measles,  ^pertussis  and  mixed  infections  are 
somewhat  predisposing  causes. 

Symptoms. — The  clinical  picture  varies  greatly,  depending  on  the 
quality  (virulence)  and  quantity  of  bacilli;  the  toxins  thrown  into  cir- 
culation from  the  primary  focus;  and  the  localization  of  the  tubercles 
formed.     Toxemic  precede  local  sym,ptoms. 

Types. — Waller  (1845)  distinguished  the  following  forms: 
1.  Typhoid  Type. — The  febrile  onset  may  be  gradual  or  sudden, 
\\\\.\\  or  without  chills.     The  patient  often  exhibits  only  great  toxemia 


148  BACTERIAL  DISEASES 

with  little  local  reaction  from  the  tubercle,  therefore  with  few  local  findings; 
this  type  may  be  due  to  a  large  caseous  focus  flooding  the  blood  stream 
with  toxins.  The  status  tyyliosiis,  delirium,  headache,  continuous  or 
weakly  remittent  fever,  enlarged  spleen,  diazo  reaction  and  bronchitis 
suggest  typhoid  but  the  fever  is  more  variable  and  the  pulse  runs  higher; 
less  frequently  roseolse,  meteorism,  diarrhea  and  intestinal  hemorrhage 
may  cause  even  a  closer  resemblance  to  typhoid  (see  page  46).  Unless 
the  meninges  or  lungs  are  involved  the  diagnostic  confusion  may  be  in- 
superable. Epistaxis  is  less  common;  hyperesthesia  and  herpes  are 
more  common  but  all  symptoms  may  be  deceptive  except  the  typhoid 
bacillemia  and  Widal  reaction  in  typhoid,  as  opposed  to  the  choroidal 
tubercles,  etc.,  in  miliary  tuberculosis.  Acute  miliary  bacillemia  is  more 
common  in  children  than  in  adults,  and  runs  a  course  of  ten  to  twenty 
days,. or  somewhat  longer.  The  writer  saw  typhoid  and  miliary  tuber- 
culosis in  the  same  subject. 

2.  Respiratory  Type. — In  this  type  the  toxemia  is  subordinated 
to  the  local  miliary  eruption.  Tachypnea,  dyspnea  and  cyanosis,  loithout 
proportionate  physical  findings  are  almost  unmistakable;  the  respiratory 
urgency  and  rapid  pulse,  without  cardiac  disease  and  with  a  tympanitic 
pulmonary  resonance  declare  the  diagnosis.  The  following  forms  are 
less  characteristic:  Pneumonia  may  be  closely  simulated  by  the  fever, 
chills,  pain,  cough,  rusty  sputum,  increased  breathing,  dyspnea,  cyanosis, 
or  even  by  tubular  breathing  (in  children).  Capillary  bronchitis  (broncho- 
pneumonia) requires  differentiation  after  recent  measles,  or  after  pertussis 
mth  patches  of  atelectasis.  Diagnosis  should  be  made  from  senile 
bronchitis  and  emphysema  m  the  aged,  in  whom  the  miliary  type  is 
frequently  afebrile.  Tubercle  bacilli  in  the  sputum  or  urine  may  occur 
accidentally.    The  course  averages  three  or  four  weeks. 

3.  Meningeal  Type. — Tuberculous  meningitis  appears  as  the  only 
apparent  trouble,  whereas  it  is  but  a  part  of  a  miliary  dissemination. 
jNIeningitis  occurs  in  80  per  cent,  of  cases  of  miliary  tuberculosis.  The 
increased  respiration,  deep  breathing  and  increased  irregular  pulse  are 
suggestive  and  the  choroid  findings,  lumbar  puncture  and  Kernig's  sign 
are  corroborative.  In  children  who  are  prone  to  this  type  of  miliary 
tuberculosis,  toxemia  may  closely  simulate  actual  meningitis,  as  in 
Henoch's  cases,  where  only  brain  edema  was  found. 

4.  Other  Types. — ^The  mention  of  these  infrequent  types  shows  the 
liability  of  diagnostic  error;  the  latent  type,  marked  only  by  catarrhal 
symptoms,  and  often  called  grippal;  the  ambulant  type,  with  death 
after  a  few  days  of  indisposition;  nephritic;  apoplectiform,  delirium 
tremens,  suffocative  or  asthmatic  type;  and  the  fulminant  type,  where 
the  patient  dies  in  a  few  hours.  Sepsis,  miliary  carcinosis,  uremia  or 
the  cyanosis  of  nitrobenzol  poisoning  may  be  suggested. 

Individual  Symptoms. — 1.  Temperature. — Continuous  fever  may  be 
observed  in  very  diffused  acute  forms,  but  it  is  lower  than  in  typhoid. 
Remittent  or  interviittent  fever  is  more  common;  miliary  tuberculosis 
following  pulmonary  phthisis  may  change  neither  the  hectic  fever  of 
the  latter  nor  its  euphoria.  The  typus  inversus  usually  lasts  but  a  few 
days.    In  17.5  per  cent,  of  cases  the  course  is  afebrile;  involvement  of  the 


TUBERCULOSIS  149 

meninges,  hemorrhages,  vomitmg  or  diarrhea  may  depress  the  fever; 
low  temperatures  are  common  in  the  aged,  in  ambulant,  bronchitic  and 
cardiac  types. 

2.  Circulation. — (a)  The  pulse  is  fast  in  yroyortion  to  the  fever, 
120  to  140-160;  the  blood-pressure  is  low  but  dicrotism  is  infrequent; 
a  pulse  under  100  is  very  rare  (in  old  people  or  meningitic  localization). 

(b)  The  heart  is  somewhat  dilated  and  an  apical  systolic  murmur,  with 
accentuation  of  the  second  pulmonic  sound,  is  frequent.  On  rare  occasions 
a  pericardial  rub  is  due  to  roughening  of  the  serosa  by  the  miliary  eruption. 

(c)  Tubercle  bacilli  were  first  found  at  autopsy  in  the  blood  by  Weichsel- 
baum  and  ]\Ieisels,  and  clinically  by  Lustig  and  Riitimeyer.  In  the 
death  agony  from  lung  tuberculosis,  bacilli  may  enter  the  blood,  (d) 
The  leukocytes  are  usually  not  increased;  Matthes  notes  increase  in  the 
polymorphonuclears. 

3.  Respiration. — Early  symptoms  are  frequent,  (a)  There  is  very 
often  a  severe  continuous  cough,  always  a  suspicious  symptom.  It  is 
due  to  the  toxins  or  to  irritation  of  the  vagus  twigs  by  miliary  nodes 
in  the  lung;  it  causes  muscular  pain,  voids  little  sputum  and  ceases  later 
if  the  brain  becomes  involved.  (6)  The  breathing  is  increased  to  40  to 
60  in  adults,  and  to  80  to  90  in  children,  (c)  Dyspnea  and  cyanosis 
develop  from  irritation  of  the  vagus  or  involvement  of  the  diaphragm. 
The  tachypnea,  dyspnea  and  cyanosis  are  pecidiarly  significant  diagnostic- 
ally  in  that  they  have  no  adequate  explanation  in  the  physical  findings. 
{d)  The  sputum  is  scant,  foamy  white  and  mucous;  it  seldom  contains 
dots  of  blood,  and  is  rarely  rust}'  without  complicating  pneumonia. 
It  may  be  more  abundant  in  subacute  cases,  {d)  The  physical  findings 
are  not  as  marked  as  the  urgent  respiratory  symptoms  would  indicate. 
A  tympanitic  note  is  very  frequent,  resulting  from  relaxation  of  the  lung, 
or  acute  emphysema  from  coughing.  Dulness  only  results  from  older 
tuberculous  foci  in  the  lung,  or  from  complications.  Auscultation  reveals 
fine  rales,  especially  suggestive  over  the  upper  chest,  where  stasis  is 
uncommon.  The  .T-rays  reveal  small,  bright  pin-head  spots  early  in  the 
disease.  Jiirgensen  noted  a  fine  pleural  rub,  due  to  pleural  tubercles. 
Terminal  pulmonary  edema  is  frequent.  At  autopsy  innumerable 
translucent  nodes  are  scattered  through  the  lung,  most  apparent  on 
oblique  illumination. 

4.  Nervous  System. — Nervous  symptoms  may  predominate,  and 
are  toxemic  or  organic:  (a)  The  toxemic  symptoms  are  headache,  dulness, 
vertigo  and  tinnitus;  these  are  followed  by  delirium,  muscular  adynamia 
and  tremor,  and  eventuate  in  stupor,  broken  by  fits  of  delirium,  and 
coma.  In  rare  instances  coma  may  develop  early  in  an  apoplectiform 
fashion,  or  the  sensorium  may  be  normal,  (b)  Meningitic  symptoms 
may  develop,  such  as  headache,  retraction  of  head,  spinal  tenderness 
and  rigidity,  paralysis  of  the  cranial  nerves,  Kernig's  sign,  convulsions 
and  coma.  The  cerebrospinal  fluid  is  generally  under  increased  pressure 
and  contains  globulin,  lymphocytes  and  often  tubercle  bacilli.  The 
findings  at  autopsy  are  those  of  tuberculous  meningitis  (page  150). 

5.  Digestive  System. — The  tongue  is  coated  and  there  is  anorexia 
and  constipation.    Nausea  and  vomiting  are  usually  meningitic.    Diarrhea 


150  BACTERIAL  DISEASES 

is  infrequent,  but  bloody  stools  may  occur  with  tympany.  Ascites  is 
infrequent  in  miliary  tuberculosis  of  the  peritoneum  (as  distinguished 
from  tuberculous  peritonitis).  Litten  once  heard  a  friction  rub  over  the 
liver.  Miliary  tubercles  may  occur  in  the  stomach  and  bowels,  most 
frequently  in  children. 

6.  Choroidal  Tubercles. — These  occur  in  16  to  75  per  cent,  of 
cases,  after  one  or  several  weeks.  They  occur  singly  or  in  large  numbers 
in  very  generalized  tuberculosis,  usually  in  both  eyes,  as  whitish-yellow 
protuberances  with  irregular  washed  borders.  They  become  large  and 
cause  so  much  atrophy  of  the  retinal  pigment  layer  that  they  can  be 
seen  through  it.  Daily  examination  for  them  is  necessarv.  (See  Plate 
VI,  Fig.  6.) 

7.  Other  Symptoms. — One  of  Wunderlich's  cases  was  reduced  to 
one-quarter  of  his  ordinary  weight.  The  spleen  is  enlarged  in  70  per 
cent.,  but  is  usually  smaller  than  in  typhoid,  except  in  children,  where  it 
may  assume  great  dimensions,  with  swelling  of  the  lymphatic  glands. 
The  urine  is  concentrated  and  dark,  may  contain  albumin  and  often 
shows  the  diazo  reaction.  Hemorrhages  into  the  gums,  nose,  retinae 
and  intestines  are  infrequent.  The  skin  is  pale,  cyanotic,  damp  and 
sudaminous.  Herpes  may  be  observed,  as  well  as  rose  spots,  petechia 
and  terminal  edema;  miliary  tubercles  in  the  skin  were  found  by  Tileston, 
especially  in  children;  the  pin-head  eruption  is  a  red  papule,  becoming 
vesicular  and  finally  encrusted  and  appears  in  crops  on  the  buttocks, 
thighs  and  genitalia;  in  71  per  cent,  the  tubercle  bacillus  was  found. 

Remissions  may  occur,  even  for  a  month  or  two,  the  toxemia  subsiding 
while  the  tubercles  continue  to  develop.  The  fall  of  the  fever  resulting 
from  brain  implication  may  be  deceptive.  As  a  rule  the  course  is  acute, 
even  stormy  or  peracute,  and  death  may  occur  before  the  tubercles  have 
time  to  form.  Severe  infection  is  fatal  in  two  or  three  weeks,  moderate 
infection  in  one  or  two  months.  Chronic  miliary  tuberculosis  is  rare. 
Recovery  is  almost  impossible;  Waller  and  others  believe  that  it  excep- 
tionally occurs,  even  with  bacilli  in  the  blood.  Therapy  is  unavailing; 
symptoms  should  be  treated  expectantly,  as  in  typhoid  or  meningitis. 

II.  Tuberculous  Meningitis. — Etiology. — Most  cases  occur  between  the 
second  and  tenth  years  (75  per  cent.),  some  in  adolescence  and  few  late  in 
life.  Tuberculosis  in  children  is  usually  generalized,  and  miliary  tubercu- 
losis is  in  80  per  cent,  associated  with  meningeal  disease.  Tuberculous 
meningitis  is  always  secondary  to  pulmonary  or  glandular  tuberculosis, 
less  frequently  articular,  genito-urinary,  cerebral  and  other  localizations. 
Measles,  whoojnng-cough,  typhoid  or  pneumonia  may  seemingly  arouse 
latent  tuberculous  foci.  Trauma  is  of  occasional  clinical  and  medico- 
legal importance.  In  the  case  of  a  baggage  man  thrown  upon  his  occiput 
an  acute  tuberculous  meningitis  resulted  in  death;  the  autopsy  disclosed 
an  apical  focus,  from  which  the  bacilli  infected  the  injured  brain.  In 
one  instance,  meningitis  and  coma  followed  an  anesthetic,  given  to 
examine  a  tender  spine,  and  was  fatal  within  a  week. 

Pathology. — The  diagnosis  is  made  macroscoincally  in  the  majority 
of  cases.  The  exudate  is  gray,  yellow  or  green,  gelatinous,  purulent  or 
serous  and  covers  the  base  from  the  chiasm  to  the  medulla  (basilar 


PLATE  VI 


Retinal  Findings  in  the  More  Important  Diseases. 

Tubercles    in    choroid.       7.    Syphilitic    ehoroidoretinitis.      8.    Albuminuric 
retinitis.     9.  Hemorrhages  in  pernicious  anemia.       (From   Sahli.) 


TUBSRCULOSIS  151 

meningitis) .  Tiny  tubercles  are  found  on  the  nerves  and  along  the  Sylvian 
artery  where  "they  look  like  lice  eggs  on  a  hair."  Careful  search  is  some- 
times necessary  for  their  detection.  They  are  more  clearly  seen  in  the 
translucent  arachnoid,  and  on  superficial  examination  look  like  minute 
air  bubbles.  They  are  seen  frequently  over  the  convexity  or  between  the 
two  hemispheres.  The  ventricular  fluid  is  increased  and  tubercles  and 
inflammation  of  the  ependyma  are  not  uncommon;  the, external  and 
internal  communications  of  the  ventricles  may  be  obliterated.  The 
substance  of  the  brain  shows  ischemic  or  encephalitic  softening.  The 
cerebrospinal  fluid  is  increased  and  is  clear  or  cloudy,  rarely  purulent. 
In  the  cord  the  exudate  may  be  a  quarter  of  an  inch  in  thickness,  and 
is  largely  disposed  over  the  posterior  part  of  cord  because  of  the  patient's 
dorsal  decubitus;  the  membranes  sometimes  appear  granular,  as  "though 
sown  Avith  fine  sand."  Wartmann  found  tubercles  in  the  substance  of 
the  cord  in  87  per  cent,  of  his  cases.  The  cranial  and  spinal  nerve  sheaths 
are  bulging.  Microscopically ,  exudation  is  found.  The  nodes  are  proved 
to  be  tubercles;  bacilli  are  found  in  them  and  in  the  cerebrospinal  fluid. 
The  microscope  in  some  cases  proves  the  existence  of  tuberculous  menin- 
gitis not  visible  to  the  naked  eye.  Neuritis  of  the  cranial  and  spinal 
nerves  is  constant.  The  optic,  oculomotor  and  facial  nerves  are  the 
most  often  affected.  The  usual  histopathology  of  tubercle  is  seen  with 
tuberculous  endarteritis  and  periarteritis,  small  encephalitic  and  myelitic 
foci,  swelling  of  the  neuroglia  and  degeneration,  especially  of  the  axis- 
cylinders. 

Symptoms. — Prodromes  are  more  prominent  in  children  than  adults; 
fever,  emaciation  and  anemia  are  due  to  preexisting  lung  or  glandular 
tuberculosis.  Irritability,  change  in  disposition,  tendency  to  cry,  in- 
ability in  children  to  play  or  in  adults  to  work,  unrest,  insomnia  and 
headache  may  develop  in  a  week  to  three  months.  Trauma,  measles 
or  pertussis  may  be  the  inciting  cause.  The  onset,  in  86  per  cent,  develops 
more  gradually  than  in  the  epidemic  form,  so  that  the  classical  description 
comprises  three  stages:  (a)  The  stage  of  irritation,  with  headache,  vomit- 
ing, remittent  fever  reaching  102°,  the  cri  hydrencephalique  of  Coindet, 
night  terrors,  pain  and  rigidity  in  the  neck  and  spine,  small,  irregular 
pupils,  delirium,  grinding  of  the  teeth,  hyperesthesia,  rigidity  of  the 
limbs,  the  neck  sign  (page  91)  and  Kernig's  sign  (in  22  of  Koplik's 
82  cases);  (6)  the  stage  of  brain  pressure,  with  paralytic  and  irritative 
conditions  in  the  eye  muscles,  as  ptosis  or  strabismus;  with  paralysis 
of  other  cranial  nerves  or  monoplegia  or  hemiplegia  from  involvement 
of  the  cortex,  and  frequently  aphasia  and  dulness;  with  general  or 
Jacksonian  convulsions;  slow,  irregular  and  variable  pulse;  retracted  ab- 
domen, constipation,  continued  vomiting;  sighing  respiration;  and  very 
frequently  with  optic  neuritis;  and  (c)  the  stage  of  paralysis,  in  which 
the  vomiting  and  often  the  headache  cease,  absolute  coma  develops, 
and  the  rapid  pulse  vacfllates  in  rate  and  rhythm.  Biot's  alternating 
apnea  and  hyperpnea  or  Cheyne-Stokes's  breathing  appears,  emaciation 
is  extreme,  the  pupils  are  wide  and  immobile,  the  eyeballs  roll  upward, 
and  a  typhoid  state  with  dry  tongue  or  abdominal  distention  prevails. 
Temporary  remissions  of  days  or  weeks  are  occasional,  in  which  the 


152  BACTERIAL    DISEASES 

pulse  remains  irregular,  but  the  patient  lapses  again  into  coma,  the  fever 
rises  very  high  (107°;  or  falls  low  (even  to  93",'.  and  death  occurs  in  some 
weeks  from  cardiac  or  respiratory  failtire,  dysphagia  or  inanition.  This 
division  into  stages  is  not  wholly  satisfactory,  because  the  stages  may 
overlap  but  the  progression  of  symptoms  is  somewhat  as  described. 

Tubercles  in  the  choroid  are  found  clinically  by  Eiclihorst  in  17.5  per 
cent,  of  cases.  Heinzell  did  not  find  them  in  41  cases.  At  postmortem- 
examination  Litten  found  them  in  about  75  per  cent.  (See  Plate  YI.) 
Leukocyiosis  is  absent  and  the  spleen  is  enlarged  in  33  per  cent. 

Many  variations  exist.  The  process  may  be  wholly  latent,  bemg 
masked  by  miliary  tuberculosis  or  meningeal  s^Tnptoms  may  dominate 
when  the  greatest  pathological  changes  are  in  the  lungs).  Coma  may  be 
sudden,  resembling  apoplexy,  especially  in  adults;  in  these  cases  the 
hemiplegia  probably  restdts  from  changes  in  the"  arteries.  Only  rarely 
is  the  course  A"ery  chronic.  It  may  appear  to  be  a  psychosis.  In  adults 
the  course  is  more  rapid,  the  headache  and  delirium  more  marked  and 
the  convexity  more  frequently  in^-oh-ed  than  in  children.  In  Holt's 
series,  three-quarters  of  sporadic  meningitides  were  tuberculous  and 
most  arose  from  contact  ^dth  infected  adults. 

Death  is  usual,  but  Bokay  cohected  37  undoubted  recoveries  (1914;. 
(See  Ceeebeospixal  Fever  for  differentiation  and  treatment.; 

m.  Tuberculosis  of  the  Lungs  Phthisis,  Consumption >. — The  lungs 
are  involved  with  great  frequency,  not  because  they  are  peculiarly 
susceptible,  but  because  aerogenous  infection  is  the  most  frequent  cause 
of  tuberculosis.  Hematogenous  infection,  as  in  miliary  tuberculosis, 
and  hTuphogenous  infection  also  occur. 

Pathology. — The  tubercle  bacillus  localizes  in  the  bronchi  tuber- 
culous lymphangitis  .  bronchioles  or  alveoli  ! tuberculous  pneumonia;, 
and  causes  tubercles  as  described  in  the  general  pathology.  There 
is  cellular  hyperplasia  of  the  ah-eolar,  epithelial  and  endothelial  cells, 
and  fibrinous  inflammation  develops.  Isolated  tubercles,  by  fusion 
cause  the  conglomerate  tubercle. 

Extension. —  o)  Lymphatic  ecdension  is  the  most  common  form.  In 
young  individuals  the  lymph  paths  are  wider  and  absorption  greater, 
so  that  intoxication  and  bacillary  migration  are  more  active.  Absorption 
is  greater  after  trauma,  pneumonia,  measles,  pertussis,  emaciation,  e.  g., 
as  convalescing  typhoid,  etc.  Bacilli  may  pass  the  bronchi  and  reach 
the  glands  at  the  hilum,  which  in  turn  may  infect  the  blood  or  break 
into  the  lung.  Extension  is  usually  along  the  lymph  vessels  in  the 
bronchial  walls  'lymphangitis  tuberculosa  .  hj  Extension  by  the 
air  passages  is  common;  when  a  tubercle  ruptures  into  the  bronchi,  its 
contents  may  be  coughed  or  waved  upward  by  the  ciliated  epithelia  if 
they  are  intact;  on  the  other  hand,  a  deep  breath  may  aspirate,  or  cough- 
ing may  impel,  infected  particles  into  soimd  areas,  where  they  develop 
new  foci;  if  the  bacilli  are  living,  an  active  tuberculosis  develops;  if 
dead,  a  lobar  or  lobular  pneumonia  is  more  common,  (c)  Extension  by 
the  bloodvessels  may  cause  a  miliary  dissemination  in  the  lungs  or  in  the 
entire  body.  Preliminary  to  the  clinical  description  in  which  special 
pathological  features  \nll  be  described,  it  may  be  said  that  some  caseated 


TUBERCULOSIS  153 

areas  fuse  into  large  infiltrations;  some  encapsulate  or  calcify  and  thus 
effect  a  temporary  arrest  or  a  permanent  recovery;  other  caseated  areas 
soften,  forming  ulcers  and  cavities. 

Symptoms. — A  clinical  description  covering  all  types  is  impossible, 
as  the  course  may  be  galloping  or  extremely  chronic;  one  form  is  marked 
pathologically  by  caseation,  another  by  ulceration;  one  symptom,  as 
hemoptysis,  may  indicate  the  type  and  may  be  the  first  and  chief  symp- 
tom; in  some  persons  the  symptoms  suggest  other  diseases  and  the 
physical  findings  are  indeterminate;  in  others  the  findings  are  remarkably 
dissociated  from  the  usual  symptoms.  Therefore  the  symptoms  and 
signs  usually  found  will  be  covered  first  and  the  special  types  will  be 
dealt  with  afterward: 

1.  Local  Respiratory  Symptoms. — These  are  usually  the  first  noted, 
but  may  only  appear  months  after  the  primary  focus  has  begun  to  spread; 
they  are  due  to  the  local  tubercle  and  its  toxin. 

(a)  Cough. — Cough  is  one  of  the  first  symptoms  and  is  the  most  constant 
symytom;  it  is  usually  present  from  the  incipiency  to  the  close  of  phthisis. 
It  is  due  to  toxins  irritating  the  vagus  twigs,  which  irritation  is  referred 
to  the  medulla,  from  which  issue  muscular  contractions  with  the  glottis 
closed,  to  evacuate  the  slight  secretion;  the  sensitive  interarytenoid 
space  and  tracheal  bifurcation  initiate  this  reflex.  Less  often  coughing 
is  due  to  pleurisy,  pharyngitis,  enlarged  bronchial  glands  or  laryngitis. 
It  is  slight  at  first,  and  has  no  characteristic,  other  than  being  dry, 
difficult  and  paroxysmal.  Later  it  becomes  more  frequent  but  less 
difficult  as  the  secretion  increases.  In  some  cases  it  is  most  severe  in  the 
morning,  the  secretion  having  accumulated  over  night,  while  in  others 
it  is  most  severe  at  night,  for  the  lungs  become  congested  by  the  dorsal 
decubitus;  saliva  reaching  the  larynx  during  the  night,  may  cause  a 
sudden  explosive  cough.  It  is  provoked  by  dust,  smoke,  variations  in 
temperature,  opening  windows  or  getting  into  the  cool  bed,  by  exertion, 
laughing  or  taking  alcohol.  It  is  less  conspicuous  in  the  phlegmatic, 
aged  and  insane.  When  obstinate  it  may  invoke  constant  vomiting  and 
induce  great  emaciation. 

■  (6)  Sputum. — The  sputum  is  first  caused  by  the  toxins,  and  later 
by  the  secretion  from  the  tuberculous  focus.  At  first  it  is  glairy  and 
contains  myelin,  sago-like  bodies  composed  of  transformed  alveolar 
cells.  It  later  becomes  yellow  from  admixture  of  pus,  yellow,  green  or 
red  from  saprophytic  organisms,  and  blood  may  give  it  a  red,  rusty, 
flesh-like  or  chocolate  hue.  Other  bacteria  and  saprophytes  are  frequent 
{v.  Bacteriology).  It  tastes  sweet  and  smells  slightly  fetid.  Its  amount 
varies  from  a  few  globules  to  over  a  pint.  It  is  most  abundant  in  cavities; 
it  stagnates  before  death,  because  of  the  patient's  muscular  weakness; 
children  are  prone  to  swallow  the  sputum.  Nummular  sputum  from 
cavities  is  flat,  "coin-like,"  greenish-gray,  extremely  abundant  and  sinks 
in  water,  as  it  is  airless;  it  occurs  in  other  cavities  as  in  bronchiectasis. 
The  only  characteristic  of  the  sputum  is  the  tubercle  bacillus  {v.  s.);  it 
may  be  seen  before  the  advent  of  any  physical  finding,  but  in  other 
cases  it  must  be  sought  repeatedly,  as  it  appears  only  when  ulceration 
communicating  with  a  bronchus  develops.     The  tubercle  bacillus  is  found 


154  BACTERIAL  DISEASES 

in  onh'  one-third  of  the  cases  of  incipient  tuberculosis.  Falk  and  Tedesko 
found  that  salicylic  acid  may  be  detected,  after  administration  by  the 
mouth,  in  any  of  the  serous  fluids  and  inflammatory  exudates,  but  not 
in  the  saliva  or  bronchial  secretion.  If  found  in  the  sputum  it  is  believed 
to  be  evidence  of  involvement  of  the  lung  substance  itself.  Elastic  fibers 
are  found  in  80  per  cent.,  and  originate  from  the  vessels  or  parenchyma 
of  the  lung.  They  are  elongated  and  twisted,  and  sometimes  shreds  of 
the  vessel  wall  are  seen;  those  from  the  lung  substance  often  show  its 
alveolar  arrangement.  Elastic  fibers  can  often  be  located  by  flattening 
the  sputum  between  two  plates  of  glass  and  picking  out  the  yellowish 
areas  for  microscopic  examination.  Treatment  with  caustic  potash  arid 
centrifuging,  facilitate  their  detection  when  they  are  scanty.  They 
merely  denote  a  destructive  process,  hence  are  also  found  in  abscess, 
gangrene,  infarction  and  pneumonia  (see  Plate  V).  Detritus,  pus  cells, 
red  cells,  alveolar,  bronchial  and  buccal  epithelium,  myelin  droplets 
and  pigment,  are  also  found.  The  so-called  lung  calculi  are  sometimes 
voided;  they  are  calcified  particles  from  old  areas  of  caseation,  from 
bronchial  obstruction,  or  from  peribronchial  lymph  glands;  from  the 
glands  large  calcareous  masses  may  cause  fatal  obstruction  of  the  trachea, 
or  suffocation  may  be  averted  only  by  immediate  low  tracheotomy. 
The  significance  of  albumin  in  the  sputum,  emphasized  by  Roger  and 
Levy-Valensi,  is  not  great. 

(c)  Hemoptysis. — Hemoptysis  (hsemoptoe,  spitting  of  blood)  occurred 
in  37  per  cent,  of  Prior's  1000  cases;  others  place  it  at  66,  even  90 
per  cent. ;  it  is  most  frequent  in  adult  males  and  is  rare  before  puberty. 
(a)  Early  hemoijtysis  is  due  to  erosion  of  a  small  vessel  by  tubercles  in  its 
perivascular  lymph  sheath.  The  toxins,  by  causing  coagulation  in  the 
vessels  in  and  near  the  affected  lung  area,  usually  prevent  extensive 
early  hemorrhage.  Hemoptysis  is  the  first  symptom  in  4  per  cent,  of 
phthisis  cases  and  in  16  per  cent,  the  only  symptom;  in  most  cases, 
however,  other  symptoms  develop;  bacilli  and  elastic  fibers  may  be 
seen  at  the  time  of  bleeding.  Reiche  recently  corroborated  the  old 
statement  that  early  hemoptysis  is  not  unfavorable.  The  bleeding 
develops  in  quietude  in  66  per  cent,  of  cases  but  may  be  induced  by 
coughing,  laughing,  exertion  or  excitement;  there  may  be  a  premonitory 
rise  of  blood-pressure.  Often  without  cause,  it  comes  on  suddenly  with 
a  warm,  salty  taste  in  the  mouth  and  the  evacuation  of  a  dram  or  more  of 
bright  frothy  blood,  clear  or  mixed  with  mucus;  small  particles  of  darker 
blood  are  brought  up,  for  a  few  days,  after  which  it  disappears;  in 
4125  of  the  Brompton  Hospital  cases,  69  per  cent,  evacuated  less  than 
half  an  ounce.  Bubbling  rales  may  be  heard  on  the  side  of  the  lesion, 
and  moulds  of  the  bronchioles  may  be  voided.  F.  Strieker  collated  900 
cases  of  hemoptysis  in  the  German  army;  in  480  cases  there  was  no 
apparent  cause  and  of  these  87  per  cent,  were  tuberculous;  of  43  cases 
brought  on  by  exertion,  74  per  cent,  were  tuberculous;  and  of  24  cases 
due  to  trauma,  half  were  tuberculous.  The  occurrence  of  early  hemor- 
rhage, before  other  symptoms  of  phthisis,  led  Hippocrates,  Boerhaave 
and  Van  Swieten  to  think  that  hemoptysis  caused  phthisis,  while  Laennec, 
Louis  and  Traube  correctly  regarded  it  as  a  symptom  of  already  estab- 


TUBERCULOSIS 


155 


lished  phthisis;  the  earlier  idea  is  explained  by  the  fact  that  blood  and 
bacilli  may  be  aspirated  into  other  parts  of  the  lung,  in  which  the  process 
develops  anew;  fever,  rapid  pulse  and  dyspnea  following  hemoptysis 
are  ominous  {v.  i.  Acute  Forms).  (6)  Laie  hemoptysis  may  be  slight  or 
profuse.  Profuse  bleeding  is  usually  due  to  erosion  of  aneurysmatic 
bloodvessels  running  across,  or  in  the  walls  of  cavities  (Rasmussen); 
Kidd  found  ruptured  aneurysms  in  70  of  82  fatal  cases;  occasionally 
larger  vessels,  as  the  pulmonary  artery,  are  ulcerated.  A  pint  or  a  quart 
may  spurt  out  of  the  mouth  causing  acute  anemia,  suffocation  or  rapid 
exsanguination.  Blood  may  accumulate  in  large  cavities,  never  reaching 
the  air  passages.  Hemoptysis  is  usually  a  sign  of  tuberculosis  but  also 
occurs  from  other  causes  {v.  Diseases  of  the  Lungs). 

(d)  Dyspnea. — Just  as  it  is  absent  in  pleurisy  of  gradual  onset,  it  is 
often  absent  even  when  the  respiratory  area  is  enormously  contracted 
(great  infiltration,  great  cavity  formation  or  induration  of  two-thirds 
of  the  respiratory  space) ;  in  sudden  miliary  tuberculosis  the  dyspnea  is 
great.     In  some  cases  dyspnea  may  follow  pressure  of  glands  on  the 


104 

DAY    1 

3 

4 

5 

6 

103 

102 

A 

f\ 

101 

A 

/ 

A 

\ 

100 

/\/  \ 

/\ 

\ 

99 

n? 

V 

'      \ 

\ 

'    \/ 

V 

\ 

9S 

V 

\j 

Fig.  13. — Hectic  fever  curve  in  phthisis. 


vagus,  stagnating  secretion,  extensive  vicarious  emphysema  or  massive 
pleural  adhesions,  yet  it  is  most  often  due  to  the  rapid  heart  action.  In 
the  last  stages  it  may  cause  orthopnea  and  result  from  intercurrent 
pneumonia  or  pneumothorax.  Germain  See  described  a  tuberculous 
pseudoasthma. 

{e)  Pain. — Pain  is  observed  in  66  to  75  per  cent,  of  cases.  Its  location 
may  be  apical,  diaphragmatic,  anteriorly  from  the  clavicle  to  the  third 
rib  or  under  the  scapula.  Its  character  is  sticking  and  intermittent, 
but  not  intense;  the  skin  is  often  hyperesthetic.  Its  cause  is  chiefly 
acute  pleurisy,  for  lung  disease  and  chronic  pleurisy  are  generally  painless; 
other  causes  are  muscular  fatigue  from  coughing,  intercostal  neuralgia 
and  pneumothorax. 

2.  General  Symptoms. — ^These  result  from  ahsorption  of  the  toxins 
secreted  in  the  local  lesions. 

(a)  Fever. — This  is  present  in  the  great  majority  of  cases  and  is  almost 
imariable  in  the  early  stages.  Probably  the  dominant  cause  is  the 
tuberculous  toxin.  Fever  marks  the  tubercle  formation,  fusion  of  foci, 
a(Kance  of  the  disease,   degeneration   of   the  tubercle,   and   probably 


156  hACTBRIAL  DISEASES 

secondary  infection,  though  the  associated  streptococci  are  usually  far 
from  virulent.  Enzymes  and  their  action  upon  the  body  cells  (auto- 
lysis) may  be  causative.  The  cessation  of  fever  is  synchronous  with 
temporary  or  permanent  arrest  of  the  disease,  as  manifested  by  improved 
health,  strength  and  weight.  It  is  easily  increased  by  exercise,  excitement 
or  trivial  causes. 

Types. — ^There  is  no  typical  curve  nor  can  fever  be  classified  as  initial 
or  ulcerative  fever.  The  vesperal  hectic  is  the  most  common  curve, 
and  indicates  slow  disintegration  and  absorption  of  toxins.  Intermittent 
fever  may  resemble  malaria  and  usually  indicates  rapid  and  marked 
tissue-disintegration;  remittent  fever  most  often  occurs  late  in  the 
clinical  course;  continuous  fever  occurs  early  or  in  acute  consumption, 
but  rarely  resembles  the  typhoid  curve;  in  some  unfavorable  cases  the 
fever  falls  from  high  to  subnormal  registers,  sometimes  with  collapse; 
the  typus  inversus  with  morning  exacerbation  and  vesperal  fall  is  very 
uncommon.  Fever  may  be  absent  in  patients  with  old  cavities  and 
fibrous  induration.  Chills  have  no  relation  to  the  fever  or  its  intensity. 
As  fever  is  indicative  of  toxemia,  it  is  often  associated  with  anorexia, 
accelerated  pulse  and  emaciation. 

(6)  The  Blood. — (i)  The  red  cells  rarely  number  less  than  three 
million;  anemia  may  antedate  all  other  symptoms,  whence  the  frequent 
confusion  with  chlorosis.  Rarely  severe  anemia  of  the  aplastic  form 
or  with  hemolytic  icterus  develops.  Again,  anemia  may  be  incon- 
spicuous or  late.  In  some  cases  the  red  cells  are  increased,  notably 
in  individuals  prone  to  hemoptysis,  (ii)  The  hemoglobin  averages 
75  per  cent.;  it  may  be  decreased  more  than  the  number  of  red  cells 
{chloranoBmie  tuherculeuse) .  (iii)  The  leukocytes  may  be  normal;  they 
are  increased  in  cavity  formation  (secondary  infection),  caseous  pneu- 
monia or  protracted  pyrexia;  after  injection  of  tuberculin  the  eosinophiles 
show  a  decided  increase.  Steffen  holds  that  the  lymphocytes  are  increased 
early  and  the  polynuclears  later  (mixed  infection),  (iv)  Recent  reports 
of  positive  bacillemia  are  ascribed  to  acid-fast  bacilli  in  the  water  employed 
in  staining. 

(c)  Sweating. — Night  sweats,  more  important  than  in  any  other  dis- 
ease, occur  in  90  per  cent,  of  cases  (Louis),  and  are  due  to  the  action 
of  toxemia  on  the  sweat-centre.  Heavy  coverings  sometimes  induce 
sweating.  The  term  "night  sweats"  refers  to  their  usual  occurrence 
between  2  and  5  a.m.  They  are  more  frequent  in  acute  than  in  chronic 
phthisis,  in  younger  than  in  older  subjects,  when  cavities  are  forming 
and  the  fever  is  variable. 

{d)  Pulse. — ^The  rapid  pulse  is  associated  with  indigestion,  muscular 
adynamia  and  malnutrition  {v.  page  166). 

3.  Physical  Signs. — In  adults  the  apex  of  an  upper  lobe,  more  often 
the  right  than  the  left,  is  first  affected  (Laennec) .  The  reasons  ascribed 
are  various,  such  as  a  poor  apex  blood  supply,  slower  lymph  current 
and  less  expansion — which  are  scarcely  proved.  More  probably  cough- 
ing drives  infection  upward  from  the  bronchi,  and  the  clavicle  or  first 
rib  compresses  the  bronchi  passing  to  the  apex  and  thus  lessens  its  venti- 
lation.   The  summit  of  the  apex  is  not  invaded  first;  Birch-Hirschfeld, 


TUBERCULOSIS  157 

in  early  cases  which  died  from  causes  other  than  tuberculosis,  found  that 
in  24  per  cent,  the  disease  began  in  the  fourth  or  fifth  order  of  bronchi 
in  the  upper  lobe  and  that  the  posterior  were  affected  earlier  than  the 
anterior  divisions. 

(a)  Insjjedion. — (i)  The  nutrition  may  be  good,  but,  later,  emaciation 
is  marked.  The  face  is  pale,  the  cheeks  hectic,  the  nose  pointed,  the 
eyes  hollowed  and  glistening,  the  neck  thin  and  the  chest  is  altered  in 
various  ways;  in  some  cases  it  is  long  and  narrow,  with  wide  interspaces, 
sharp  costal  angles,  prominence  of  Louis's  angle,  atrophy  of  the  scapular 
muscles  and  more  vertically  directed  ribs;  in  others  it  is  flattened 
anteroposteriorly  and  the  ribs  are  closely  apposed;  in  still  others  the 
funnel-chest  may  be  seen.  Laennec  recognized  that  the  "paralytic 
chest"  was  the  result  and  not  the  cause  of  phthisis.  Examining  the 
patient  in  a  good  light,  the  following  may  be  noted:  (ii)  Deficient  ex- 
pansion above  or  below  the  clavicles,  especially  when  examined  from 
behind  and  above;  in  the  lower  chest,  impaired  excursion  of  the  dia- 
phragm. Deficient  expansion  may  be  due  to  pleural  adhesions,  to  atel- 
ectasis of  the  lung  resulting  from  caseous  nodes  obstructing  the  bronchi, 
to  a  cavity,  or  to  induration,  an  effort  toward  encapsulation  and  recovery. 
(iii)  Distention  of  the  chest  may  be  due  to  vicarious  emphysema,  effusive 
pleurisy  or  pneumothorax,  (iv)  The  cardiac  impulse  may  be  widened 
by  retraction  of  the  left  lung  away  from  the  heart. 

(5)  Palpation. — Palpation  shows  (i)  decreased  expansion,  elicited  by 
standing  behind  the  patient  with  the  thumbs  above  either  clavicle  and  the 
fingers  below  it,  or  by  standing  in  front  of  the  patient  and  spreading  the 
hands  over  the  anterolateral  parts  of  the  thorax,  (ii)  Increased  vocal  frem- 
itus, obtained  when  the  lung  is  infiltrated  (caseous  foci  or  pneumonia), 
indurated  or  the  seat  of  cavities,  all  of  which  increase  conduction  of  the 
voice-sounds  from  the  bronchi.  Superficial  show  more  clearly  than  deep 
lesions ;  thick,  pleural  adhesions  or  plugging  of  the  bronchi  with  caseous 
material  decrease  the  fremitus,  (iii)  The  systolic  distention  of  the 
pulmonary  artery  and  the  second  pulmonic  closure  are  better  felt  when 
the  lung  retracts  from  the  heart  or  when  it  is  infiltrated  in  its  vicinity. 
(Pottenger  describes  intercostal  rigidity  over  the  disease  focus.) 

(c)  Percussion. — (i)  Incipient  infiltration  gives  a  short  percussion  note, 
which  later  becomes  dull;  the  apex  is  first  involved  in  88  per  cent,  of 
cases.  Dulness  may  be  found  under  the  middle  of  the  clavicle,  at  which 
level  Birch-Hirschfeld  found  the  anatomical  beginning  of  tuberculosis. 
The  apices  are  best  percussed  when  standing  behind  the  patient;  the 
right  apex  is  normally  less  resonant  than  the  left.  The  lung  lying  behind 
the  clavicle  can  be  tested  by  gently  tapping  the  clavicle  with  one  finger. 
To  detect  slight  early  alterations  in  note,  percussion  should  be  gentle, 
symmetrical  parts  should  be  compared,  the  patient  should  hold  his 
breath  in  full  inspiration  and  the  muscles  must  be  relaxed ;  each  patient 
has  his  own  percussion  note,  varying  with  his  muscle,  fat  and  bone.  The 
apex  reaches  1  to  2  inches  above  the  clavicle,  and  behind  to  the  vertebra 
proifiinens.  A  focus  as  large  as  a  cherry  may  cause  dulness,  but  usually 
impaired  resonance  is  produced  only  by  consolidation  measuring  1|  by 
2\  inches  in  area  and  within  f  inch  of  the  surface,  and  foci  of  these 


158  BACTERIAL   DISEASES 

dimensions  lying  deeper  than  2  inches  escape  detection.  Smah,  multiple 
or  deep  foci  give  a  tympanitic  note.  The  dulness  may  extend  from  the 
clavicle  to  the  second  and  third  costal  cartilages,  then  to  1.5  inches  below 
the  apex  of  the  lower  lobe  (level  of  the  fifth  dorsal  vertebra);  this  area 
is  almost  always  involved  when  the  upper  lobe  shows  distinct  con- 
solidation; extension  occurs  outward  and  do-umward  along  the  interlobar 
fissure;  then  it  extends  to  the  apex  of  the  upper  lobe  on  the  other  side.^ 
Often  the  first  dulness  of  consolidation  is  found  behind,  in  the  supra- 
or  interscapular  region,  (ii)  Shrinking,  fibrous  induration  and  a  thick- 
ened pleura  give  apical  or  other  dulness.  Sometimes  the  lung  becomes 
vicarioush-  emphysematous  about  an  old  focus  which  is  thus  hidden 
clinically  and  pathologically,  (iii)  A  tympanitic  or  cracked-pot  resonance 
may  be  obtained  over  cavities  (r.  i.). 

(d)  Auscultation. — This  is  the  most  important  aid,  next  to  the  micro- 
scopic examination  of  the  sputum,  (i)  The  vesicular  murmur,  especially 
at  the  apex,  is  altered,  for  detection  of  which  the  patient  is  best  examined 
T\dthout  deep  breathing  or  coughing;  the  jerky  "cog-wheel"  breathing, 
described  by  Jackson  (1833),  may  be  due  to  small  tubercles  in  the  bronchi, 
somewhat  stenosing  their  lumina;  it  also  occurs  in  normal  individuals 
from  forced,  muscular  breathing,  or  pounding  of  the  heart  on  the  lung 
during  inspiration.  The  breathing  may  be  wavy,  weak,  indeterminate 
or  puerile.  Rude,  rough  inspiration  is  due  to  peribronchial  tubercles 
compressing  the  bronchioles.  The  expiration  is  frequently  prolonged, 
rougher  and  higher  pitched,  in  apical  "catarrh;"  it  is  long,  sharp  and 
bronchial,  in  older  foci;  what  seems  clinically  to  be  catarrh  is  often 
consolidation  pathologically.  In  comparing  the  breathing,  inspiration 
on  one  side  should  be  compared  with  that  of  the  other,  and  expiration 
similarly  noted.  The  breath-sounds  are  physiologically  higher  pitched 
on  the  right  than  on  the  left  side,  (ii)  Bronchial  breathing  is  caused  by 
various  consolidations  (tuberculous,  pneumonic,  neoplastic  or  gangrenous) 
and  by  cavities,  tuberculous  and  otherwise.  Bronchial  breathing  of 
moderate  degree  is  physiological  in  the  interscapular  region,  but  is  less 
intense  than  that  of  consolidation,  (iii)  Rales  are  rather  an  evidence  of 
infiltration  (consolidation)  than  of  "catarrh."  If  they  are  heard  in  the 
apex,  the  presence  of  tuberculosis  should  be  suspected,  though  they  may 
occasionally  occur  there  physiologically,  or  after  influenza.  The  vibra- 
tions of  the  accessory  muscles  of  respiration,  when  the  patient  takes  a 
long  forcible  breath,  are  easily  differentiated  from  rales  after  a  little 
experience.  Rales  may  not  be  heard  unless  the  patient  breathes  deeply 
or  coughs;  auscultation  should  be  made  before,  and  then  after,  coughing 
noiselessly  and  inspiring  with  the  least  muscular  force.  In  incipient 
consolidation,  small,  crackling,  crepitant  rales  are  heard  over  the  alveoli 
and  smaller  bronchioles  at  the  end  of  inspiration;  they  later  become 
larger,  ringing  and  resonant,  indicating  that  the  alveoli  and  bronchioles 
have  become  airless  over  a  considerable  area,  or  that  softening  or  forma- 
tion of  cavities  is  in  progress;  scattered,  clear,  large,  crackling  rales  are 
heard  over  small  cavities  in  the  apex  or  the  smaller  bronchi,  and  indicate 

1  There  is  a  non-tuberculous  shrinking  of  the  right  upper  lobe,  in  mouth-breathers,  due 
to  collapse  of  the  apex  [Kronig],  or  to  tuberculous  glands  about  the  right  bronchus  (Bing) 


TUBERCULOSIS  159 

a  viscid  secretion.  Clicking  rales  are  generally  attributed  to  softening; 
they  may  occur  near  the  heart  as  it  beats  upon  an  adjacent  infiltration. 
Gurgling  and  consonating  rales  suggest  cavity  or  bronchiectasis.  In 
emphysematous  patients,  whose  chests  exhibit  sibilant  and  bubbling 
rales,  diagnosis  of  developing  tuberculosis  may  be  most  difficult,  (iv) 
Bronchophony  (a  bronchial  quality  imparted  to  the  voice-sounds)  is 
heard  when  the  patient  speaks  during  auscultation;  it  indicates  infil- 
tration or  cavity  formation  but  is  absent  when  the  bronchi  are  plugged. 
Often  testing  the  whispered  voice  is  of  value.  Egophony  is  merely  a 
higher  grade  of  bronchophony  and  occurs  as  Skoda  demonstrated,  in 
cases  of  consolidation,  in  medium-sized  cavities  and  above  pleural  exu- 
dates, (v)  Pleural  friction  results  from  fibrinous  pleurisy  or  rough 
turbercles  in  the  pleura,  (vi)  A  systolic  bruit  over  the  subclavian  artery 
is  probably  due  to  pleural  adhesions  to  the  artery. 

(e)  Rontgen  Rays. — Shadows  may  be  due  to  consolidation,  thick- 
walled  cavities,  calcified  foci,  gangrene,  pleural  callus  or  pleural  exudate. 
The  excursion  of  the  diaphragm  can  be  followed;  shadows,  due  to  the 
muscles,  may  be  readily  eliminated  by  moving  the  arms. 

Summary. — The  above  findings  may  be  grouped  together,  because  they 
are  found  together  clinically,  one  part  showing  consolidation,  another, 
cavity  formation  or  induration,  (a)  The  signs  of  consolidation  are 
decreased  expansion,  increased  vocal  fremitus,  initial  tympany  followed 
by  dulness,  high-pitched  expiration,  then  distinct  bronchial  breathing, 
crepitant  rales  and  bronchophony,  (b)  The  sigris  of  induration  are  re- 
traction or  lagging  behind  of  the  fibrous  area  on  breathing,  increased 
vocal  fremitus,  dulness,  usually  large  rales,  bronchial  breathing  and 
bronchophony,  (c)  The  signs  of  cavity  formation  are:  (i)  Increased 
vocal  fremitus,  if  it  is  near  the  surface;  (ii)  tympanitic  note,  which 
may  increase  in  intensity  when  the  cavity  is  percussed  with  the  mouth 
open  (Wintrich's  change  of  note),  when  percussed  during  inspiration 
(Friedreich's  change  of  note),  or  with  the  patient  in  the  sitting  posture 
(Gerhardt's  change);  the  note  may  be  metallic;  the  cracked-pot  note, 
Laennec's  bruit  de  pot  fele,  is  obtained  in  cases  of  superficial  cavities 
measuring  2§  inches  with  thin  walls,  which  communicate  with  an  open 
bronchus  by  a  small  opening;  variation  in  the  percussion  note  from 
accumulation  (dulness),  or  emptying  of  secretion  (tympany),  is  most 
suggestive  of  cavity  formation;  percussion  may  cause  the  patient  to 
cough  and  void  much  sputum;  (iii)  the  breathing,  which  is  loudly 
bronchial,  or  if  the  cavity  is  quite  large,  metallic,  amphoric  or  metamor- 
phosing (which  begins  normally  and  suddenly  becomes  bronchial  or 
vice  versa);  (iv)  bronchophony  and  egophony;  (v)  large,  resonant  rales, 
which  are  the  most  frequent  and  important  finding;  metallic  rales  in  the 
apices  are  most  suggestive  of  cavities;  they  may  acquire  an  amphoric 
character  in  very  large,  thin-walled  excavations;  (vi)  nummular  sputum; 
(vii)  systolic,  sometimes  booming  or  metallic  murmurs,  due  to  propagation 
of  the  heart  tones;  they  may  be  heard  at  some  distance  from  the  patient. 

Gavities  are  due  to  the  breaking  down  of  caseous  areas  and  are 
usually  connected  with  the  bronchi,  into  which  their  emptying  is  partly 
favorable,  in  that  the  infective  material  is  evacuated;  and  partly  un- 


160  BACTERIAL  DISEASES 

favorable,  because  it  opens  up  avenues  for  infection  by  aspiration.  Once 
formed,  they  generally  remain  or  increase;  they  may  leave  fistulous 
cicatrices  (Laennec's  cicatrices  fistuleuses) ;  if  they  are  held  by  adhesions 
the  cavities  persist,  contracting  cicatrization  being  impossible;  there  is 
danger  of  their  further  extension  by  secondary  infection,  or  of  gangrene. 
The  cavity  has  a  well-marked  limiting  membrane,  from  which  pus, 
nummular  sputum,  elastic  fibers,  and  grayish,  granular  detritus  composed 
of  masses  of  tubercle  bacilli  are  voided;  the  cavities  are  frequently 
multilocular,  may  heal  on  one  side  and  extend  on  another,  and  sometimes 
occupy  an  entire  lobe  or  even  an  entire  lung.  They  may  rupture  into  the 
pleura,  pericardium  or  bloodvessels;  the  author  saw  a  rupture  into  the 
mamma,  resulting  in  diffuse  subcutaneous  emphysema. 

Stages  of  Pulmonary  Tuberculosis. — Tuberculosis  usually  proceeds  for 
six  to  eighteen  months  before  any  symptoms  appear. 

1.  Phthisis  Incipiens. — ^The  general  and  local  symptoms  appear  as 
above  described,  with  fever,  anemia  and  rapid  pulse.  The  modes  of  onset 
are  various.  The  most  frequent  picture  is  that  of  a  patient  with  an 
obstinate  cold  or  a  "  grippe"  which  does  not  regress;  the  sputum  may  show 
tubercle  bacilli  and  the  apex  some  rales.  In  others,  disordered  digestion 
and  a  rapid  pulse  awaken  suspicion.  The  voice  may  be  lost,  passing 
as  a  simple  laryngitis.  There  may  be  only  a  moderate  depreciation 
of  health,  languor  and  neurasthenic  manifestations;  in  young  girls  a 
chlorosis  may  be  hastily  diagnosticated.  Malaria  is  a  common  escape 
in  explaining  an  obscure  fever.  Tuberculosis  may  appear  in  other  more 
directly  suggestive  forms,  such  as  hemoptysis,  pleurisy  or  cervical  adenitis. 
The  physical  findings  are  often  uncertain  or  absent. 

2.  Phthisis  Confirmata. — Distinct  physical  findings  indicate  not 
incipient  phthisis,  but  confirmed,  established  phthisis. 

3.  Phthisis  Consummata. — This  is  advanced  consumption,  with 
marked  hectic  fever,  cavity  formation  and  emaciation. 

Course. — ^The  average  case  of  ''chronic  ulcerative  phthisis,"  with 
the  symptoms  and  signs  already  described,  stands  midway  between  the 
following  very  acute  and  extremely  chronic  groups: 

1.  Acute,  Galloping  or  Florid  Consumption. — This  type  con- 
stitutes 10  per  cent,  of  phthisis  and  develops  from  some  old  focus,  as 
tuberculosis  of  the  bronchial  glands,  or  a  small  cavity  which  by  intra- 
bronchial  rupture  disseminates  the  process ;  possibly  the  virulence  of  the 
germ  is  greater  in  these  cases;  diabetes,  alcoholism,  measles,  whooping- 
cough  or  influenza,  may  be  the  immediate  cause. 

(a)  Acute  Pneumonic  Form. — ^The  acute  pneumonic  form  is  acute 
caseous  pneumonia.  This  term  indicates  the  great  clinical  resemblance 
to,  and  confusion  with,  acute  lobar  pneumonia;  but  it  must  be  remem- 
bered that  genuine  lobar  pneumonia  does  not  caseate,  and  that  this 
form  is  not  synonymous  with  tuberculosis  complicated  by  pneumococcic 
pneumonia,  which,  in  this  association,  runs  its  usual  course.  Acute 
caseous  pneumonia  begins  in  an  individual  in  seemingly  perfect  or  but 
slightly  reduced  health.  An  initial  rigor  is  fairly  common,  or  spitting  of 
blood  may  be  the  first  symptom.  There  are  often  herpes,  cough,  pain 
in  the  side,  rapid  breathing  and  sudden  fever,  which  frequently  imitate 


TUBERCULOSIS  161 

exactly  the  onset  of  genuine  pneumonia.  The  resemblance  may  persist 
but  often  certain  variations  arouse  suspicion.  The  fever  is  remittent  or 
intermittent,  and  more  variable  than  in  lobar  pneumonia;  dyspnea  and 
cyanosis  are  less  frequent  than  a  gradually  increasing  pallor;  sweating 
is  usually  copious.  In  a  few  days  dulness  prevails  over  a  lower  lobe  but 
much  more  often  over  an  upper  lobe  or  over  an  entire  lung.  The  breathing 
at  first  indistinct,  may  remain  so,  but  often  becomes  bronchial.  The 
sputum  is  often  typically  pneumonic,  viscid  and  rusty,  or  of  an  olive  or 
grass-green  color;  elastic  fibers  are  seldom  found.  Tubercle  bacilli  are 
sometimes  found,  but  in  this  case  originate  not  from  the  fresh  pseudo- 
pneumonic  patches,  but  from  the  causal  focus;  in  few  cases  can  the 
physical  signs  of  the  primary  cavity  in  an  upper  lobe  be  elicited.  The 
physical  findings  change  but  little,  though  the  crepitant  rales  are  replaced 
by  coarse  mucous  rales;  the  anticipated  crisis  does  not  occur,  and  most 
cases  are  called  unresolved  pneumonia  until  the  increasing  anemia,  loss 
of  strength  or  rapid  pulse,  suggests  tuberculous  pneumonia.  Albuminuria 
is  uncommon;  the  diazo  reaction  is  present.  Five-sixths  of  the  cases 
die  within  six  weeks;  in  some  few  cases  considerable  regression  may  occur 
and  it  is  barely  possible  for  the  course  to  last  three  months  or  more. 
The  findings  at  autopsy  are  an  old  focus  of  tuberculosis,  a  ruptured  cavity 
or  gland;  from  it  caseous  material,  containing  bacilli  and  tuberculous 
toxins,  is  aspirated  into  many  finer  alveoli  and  bronchioles,  where  it 
excites  a  miliary,  caseous,  lobar  pneumonia.  The  inflammation  is  due 
wholly  to  Koch's  bacillus  or  its  toxins,  and  is  (i)  partly  fibrinous  a,nd 
desquamative,  red  and  white  polynuclear  and  mononuclear  cells  being 
poured  out;  proliferative  changes  are  noted,  as  the  epithelioid  and  giant 
cells  seen  in  the  typical  tubercle;  caseation  ensues,  as  shown  in  the 
already  fused  and  fusing  yellowish-gray  areas;  (ii)  the  most  rapid  exuda- 
tion is  serous,  Laennec's  "gelatinous  or  smooth  pneumonia,"  probably 
due  to  the  tubercle  toxins  and  not  to  mixed  infection;  this  part  of  the 
inflammation  may  regress  without  caseation;  Cavities  rarely  form  in 
this  type. 

(b)  Acute  Disseminated  Form. — It  may  occur  as  a  special  type,  or  may 
complicate  the  ordinary  form  of  phthisis.  Following  the  rupture  of  a 
small  area  of  softening,  usually  located  only  at  the  postmortem,  and 
following  dissemination  by  aspiration,  there  develop  (i)  fever,  repeated 
hemoptysis,  chills,  rapid  pulse,  increasing  dyspnea,  diffuse  crepitant  or- 
bubbling  rales,  delirium,  or  even  a  status  typhosus,  (ii)  The  sputum 
is  absent  or  scanty,  and  the  bacilli  are  sometimes  absent  throughout 
the  course.  Death  may  occur  acutely  in  three  or  four  weeks  without 
physical  signs  having  appeared  and  without  breaking  down  of  the  foci; 
or  a  remission  may  take  place,  after  which  there  is  (iii)  breaking  down 
of  the  indistinct  foci  which  cause  slight  dulness  and  distant  bronchial 
breathing,  simulating  lobular  pneumonia.  At  autopsy  scattered,  yellow, 
])artly  caseous,  peribronchial,  nodular  foci  are  seen;  in  some  cases  the 
presence  of  tuberculosis  is  proven  only  by  microscopic  examination,  for, 
without  caseation,  the  foci  may  resemble  ordinary  bronchopneumonic 
patches;  secondary  infection  with  streptococci  is  said  to  cause  these 
lesions,  but  they  result  from  the  tubercle  bacillus  alone. 
11 


162  BACTERIAL   DISEASES 

(c)  Acute  Disseminated  Ulcerative  Form. — This  type  is  often  observed 
in  children  between  two  and  six  years  of  age,  in  pregnancy,  alcohohsm, 
diabetes  and  influenza.  The  foci,  which  vary  in  size  from  a  pea  to  a 
walnut,  are  widely  disseminated;  they  fuse,  soften  early  and  develop 
cavities  without  walls,  which  are  only  ulcers  or  necrotic  caseous  material. 
There  are  present  clinically  hectic  or  continuous  fever,  pronounced 
anemia,  exhausting  sweats,  rapid  emaciation  and  viscid,  purulent  and 
bacilli-laden  sputum;  diffuse,  fine  and  large  rales  and  bronchial  breathing 
may  be  heard,  but  the  physical  signs  are  often  vague.  The  galloping 
course  ends  fatally  in  one  to  four  months. 

(d)  Acute  Miliary  Form. — ^Acute  miliary  tuberculosis  (q.  v.)  develops 
in  3  per  cent,  of  cases  of  pulmonary  phthisis. 

2.  Chronic  Tubeeculosis.  —  (a)  Chronic  Ulcerative  Form.  —  The 
ordinary  phthisis  may  run  a  course  which  is  long  latent,  except  for 
anemia,  dyspepsia  or  other  indistinctive  symptoms.  After  the  detection 
of  an  apical  catarrh,  the  cough,  fever,  sweats  and  anorexia  may  subside; 
another  relapse  may  occur  after  years  of  quiescence,  or  exacerbations 
develop,  with  loss  of  weight  and  strength.  Recovery  may  occur,  even 
with  pronounced  physical  signs.  New  tuberculous  manifestations  may 
be  reinfections  rather  than  relapses. 

(b)  Phthisis  Fibrosa. — ^The  fibrosis  excited  by  the  tubercle  bacillus 
may  begin  acutely  or  insidiously.  Auclair  thinks  the  bacillus  secretes 
two  toxins,  one  with  a  necrosing  action  which  leads  to  caseation,  and 
another  with  an  indurating  action  which  leads  to  fibroid  phthisis. 
There  may  be  no  cough,  sputum,  bacilli,  fever,  emaciation  or  anemia. 
Ulceration  may  result  only  from  mixed  infection.  Sometimes  there  is 
hemoptysis.  If  left-sided,  the  spleen  rises  higher  and  the  retraction  of  the 
lung  away  from  the  heart  makes  the  cardiac  shock  more  diffuse,  and  the 
pulsation  of  the  pulmonary  trunk  more  visible.  If  right-sided,  the  liver 
rises,  the  right  ventricle  is  apparently  enlarged  (from  lung  retraction) 
and  is  often  actually  hypertrophied  and  dilated  from  increased  tension 
in  the  pulmonary  circuit.  The  heart  may  be  drawn  to  the  right  or  left 
by  the  inevitable  pleural  adhesions,  bronchiectases  are  not  uncommon, 
the  sound  lung  is  vicariously  emphysematous,  and  the  diseased  lung  is 
smaller,  flatter  and  depresses  the  shoulder,  impairing  expansion  and  often 
presenting  bronchial  breathing  and  large  rales. 

(c)  Pleuritic  Form. — ^The  pleuritic  form  follows  small  latent  foci 
in  the  lungs,  lymph  glands,  etc.  (See  Pleurisy.)  Exudates  not  due 
to  rheumatism,  inflammation  in  contiguous  organs  or  tumor  always 
suggest  tuberculous  pleurisy.  Pleurisy,  in  fact,  more  often  precedes 
than  succeeds  pulmonary  tuberculosis  and  repeated  attacks  are  frequent, 
with  moderate,  irregular  or  continuous  fever,  perhaps  with  rales  in  the 
apex  of  the  affected  side  (not  the  rales  frequently  heard  just  above  the 
upper  level  of  the  exudate),  or  with  dulness  in  the  contralateral  apex. 
Bowditch,  following  up  90  cases  of  pleurisy,  found  that  33  per  cent, 
developed  phthisis. 

Variations  According  to  Age. — 1.  Children. — Tubercle  bacilli  pass  the 
bronchial  mucosa  and  produce  tuberculosis  of  the  bronchial  and  medi- 
astinal glands;  the  wide  lymph  vessels  and  more  active  metabolism  have 


TUBERCULOSIS  163 

already  been  noted;  the  process  in  the  glands  attacks  secondarily  the 
hilum  of  the  lung  and  the  lower  lobes  (90  per  cent.),  which  explains  the 
frequency  of  miliary  tuberculosis  from  involvement  of  the  thoracic  duct 
and  bloodvessels. 

(a)  Chronic  Generalized  Tuberculosis. — The  younger  the  child  the 
more  general  is  the  tuberculosis.  Measles,  pertussis  and  influenza  are 
prone  to  arouse  a  latent  tuberculosis  in  the  bronchial  glands.  The  course 
is  generally  more  active  than  chronic,  like  that  of  tumors  in  children. 
Emaciation,  anemia,  enlargement  of  the  spleen  and  liver,  and  moderate 
intumescence  of  the  peripheral  lymph  glands  are  the  variant  features  of 
this  type.  Hectic  fever  is  seen  chiefly  in  children  over  three  years.  The 
sputum  is  swallowed,  but  washing  the  stomach  recovers  bacilli-laden 
sputum. 

(6)  Acute  Miliary  Tuberculosis  (q.  ■».). 

(c)  Localized  Lung  Tuberculosis. — (i)  The  acute  caseous  type  resembles 
pathologically  bronchopneumonias  of  other  causation;  the  microscope 
may  be  necessary  to  detect  its  nature.  Hemoptysis  is  rare;  Henoch 
observed  over  a  dozen  cases  under  six  years  of  age.  (ii)  Chronic  forms 
are  very  infrequent  under  six  years. 

In  children,  physical  findings  are  often  absent  except  rales  between 
the  third  and  fifth  ribs  in  front  or  over  the  lower  lobes.  Cavities  are 
rare,  and  if  softening  develops  do  not  freely  communicate  with  the 
bronchi.  In  half  the  cases  the  wrong  diagnosis  is  made  (Henoch).  Per- 
cussion is  more  difficult  than  in  adults,  because  of  the  small  chest  and  its 
thinner  walls.  (A  cracked-pot  resonance  can  be  obtained  in  a  normal 
young  chest  by  strong  percussion.)  Children  breathe  irregularly,  and 
puerile  respiration  is  physiological.     Induration  is  rare, 

2.  The  Aged. — Hemoptysis  is  rare,  physical  findings  are  less  frequent 
than  in  adolescence,  because  the  breathing  is  weaker,  and  emphysema 
is  more  common.     Cough  and  fever  are  less  conspicuous. 

Diagnosis  of  Pulmonary  Tuberculosis. — Early  diagnosis  is  most  im- 
portant, (i)  A  positive  family  history  is  of  some  value,  but  it  does  not 
establish  the  diagnosis  in  a  doubtful  case,  nor  does  its  absence  exclude 
tuberculosis,  (ii)  The  symptoms  of  onset,  toxemic,  digestive,  etc.,  are 
important,  (iii)  The  Bacillus  tuberculosis  distinguishes  pulmonary  tuber- 
culosis (a)  from  other  catarrhs,  such  as  acute  and  chronic  bronchitis 
or  influenza;  (6)  from  other  consolidations,  e.  g.,  pneumonia,  broncho- 
pneumonia, neoplasm  or  syphilis;  (c)  from  other  vomicae,  such  as  abscess, 
gangrene,  actinomycosis,  echinococcus,  syphilis  or  bronchiectasis;  and 
(d)  from  indurations  other  than  tuberculous.  Every  sputum  should 
be  examined.  Cultures  and  inoculations  are  made  in  doubtful  cases. 
(iv)  In  doubtful  cases  repeated  physical  examinations  are  imperative; 
auscultation  is  more  valuable  than  percussion;  too  great  reliance  should 
not  be  placed  on  negative  findings;  coincident  lesions  in  a  lower  lobe  and 
in  an  upper  apex  are  almost  surely  tuberculous.  Many  patients  are 
needlessly  alarmed  by  precocious  diagnoses. 

(v)  Tuberculin  Tests. — The  principle  is  the  same  in  all;  the  tuber- 
culous subject  develops  a  hypersensitiveness  to  the  tuberculous  poison — 
known  as  the  allergistic  reaction,  i.  e.,  a  specific  reaction  of  the  organism 


164  BACTERIAL  DISEASES 

to  poisons  with  "which  it  is  already  acquainted;  the  tuberculin  seeks  out 
the  point  (of  disease)  in  which  the  receptors  are  accumulated,  (a)  The 
ophthalmo-readion  of  "WolfJ-Eisner  and  Calmette  (1907)  consists  of  drop- 
ping in  the  eye  one  drop  of  1  per  cent,  old  tuberculin  which  is  followed 
in  12  to  24  hours  by  a  reactive  conjunctival  hyperemia.  In  6300  tests 
Calmette  found  a  positive  reaction  in  90  per  cent,  of  tuberculous  patients, 
in  57  per  cent,  of  suspected  tuberculosis  and  in  17  per  cent,  of  apparently 
healthy  persons;  the  only  complications  were  keratitis  in  three  instances, 
conjuncti\'itis  in  20  and  a  reaction  lasting  over  three  weeks  in  72  instances. 
Ulcers  may  develop  if  tuberculin  is  instilled  into  diseased  eyes.  The 
reaction  may  develop  in  typhoid,  and  fails  in  advanced  tuberculosis, 
whence  the  poor  outlook  of  an  absent  reaction  in  manifest  phthisis. 
(h)  J^on  Pirqiiefs  test  is  vaccination  of  the  skin  under  a  drop  of  25  per  cent, 
old  tuberculin  (in  salt  solution);  in  24  hours  a  small  papule  appears. 
This  method  is  absolutely  safe,  mostly  adapted  to  children  (up  to  the 
foiu"th  year),  but  too  delicate  to  be  valuable  in  adults  unless  it  is  negative. 
It  is  positive  in  50  per  cent,  of  apparently  healthy  adults.  It  is  absent 
in  children  in  advanced  and  cachectic  tuberculosis,  whence  its  poor 
prognostic  significance,  and  in  many  intercurrent,  acute  infections,  as 
measles,  scarlatina,  t^'phoid,  etc.  (due  to  insufficient  antibodies  to  react 
to  the  tuberculin  or  to  antianaphylaxis).  The  test  may  react  in  24 
hours,  resulting  in  a  large  papule  or  dense  infiltration;  again  the  reaction 
may  be  prolonged,  chiefly  in  adults,  developing  a  papule  on  the  second 
or  third  day  and  lasting  a  long  time.  In  Mow's  test  equal  parts  of  lanolin 
and  old  tuberculin  are  rubbed  into  the  skin,  (c)  The  intracutaneous  test 
(Mantoux  and  Roux).  They  inject,  by  a  fine  very  sharp  needle,  0.01 
mgm.  tuberculin,  in  a  dilution  of  1  to  5000,  not  beneath  but  into  the 
skin  itself.  A  positive  reaction  consists  in  the  appearance,  after  a  few 
hoiu-s,  of  a  small  papule,  which  on  the  third  day  attains  its  maximum. 
It  is  more  sensitive  than  the  cutaneous  test,  {d)  Hypodermic  injection 
of  Koch's  tuberculin  produces  (i)  a  local  exudative  reaction,  and  after 
four  to  ten  hours,  a  (ii)  systemic  reaction,  characterized  by  chill,  fever 
of  even  5  degrees,  headache,  general  pains,  malaise,  nausea,  sometimes 
erythema  nodosum,  and  (iii)  an  increase  of  sputum,  rales,  or  even 
a  slight  area  of  pulmonary  dulness;  the  first  injection  of  Koch's  older 
tuberculin  should  be  small,  in  adults  0.2,  0.5,  1  or  5  milligrams — in  chil- 
dren 0.1  to  1  milligram.  It  is  held  that  in  a  positive  reaction  with  less 
than  5  mgm.,  the  focus  is  active;  if  with  5  to  10  mgm.,  it  is  inactive.  The 
reaction  is  specific  and  indicates  that  there  is  a  tuberculous  focus  in  the 
body,  but  not  necessarily  in  the  lungs,  unless  rales  develop  at  the  suspected 
spot  after  the  injection.  Contra-indications  to  its  use  are,  fever,  hemop- 
tysis, weak  heart,  nephritis  or  a  certain  diagnosis.  In  veterinary 
medicine  it  is  more  valuable,  leading  to  a  correct  diagnosis  in  90  or  97 
per  cent.  The  author  admits  a  reluctance  to  use  tuberculin;  four  cases 
of  miliary  tuberculosis  apparently  resulted  from  its  emplo^Tuent. 

Sticker  recommended  the  use  of  potassium  iodide  in  small  doses  (gr.  iij) ; 
it  congests  the  lungs  at  the  seat  of  the  lesion,  possibly  makes  the  aus- 
cultation findings  clearer,  and  carries  bacilli  into  the  sputum;  its  use 
is  dangerous. 


TUBERCULOSIS  165 

Pseudotuberculosis. — The  Rhizomucor  parasiticus,  the  ray  fungus, 
streptothrix,  blastomycetes,  yeasts,  the  aspergilhis  and  Pfeiffer's  pseudo- 
tuberculosis bacillus,  which  is  not  acid-fast,  may  cause  pseudotuber- 
culosis. The  form  caused  by  the  Aspergillus  fumigatus  is  described 
as  a  primary  lung  affection,  but  many  writers  consider  it  secondary 
only.  The  symptoms  of  streptothricosis  are  hemoptysis  (23  per  cent.), 
fatigue,  emaciation,  anorexia,  dry  cough  and,  later,  a  greenish,  purulent 
sputum.  The  physical  findings  are  bronchitis,  less  often  slight  consolida- 
tion or  cirrhosis  of  the  lung.  Ashton  and  Wright  (1905)  collated  26  cases, 
most  of  which  resembled  phthisis;  over  50  per  cent,  were  unmixed 
infections  and  76  per  cent.  died.  Pulmonary  thrush  is  rare,  Garin  finding 
only  6  recorded  cases  (1911);  the  symptoms  resemble  tuberculosis  and 
the  Endomyces  albicans  is  found  in  the  sputum  and  lung. 

Prognosis  of  Pulmonary^  Tuberculosis. — Two  issues  are  possible : 

1.  Recovery. — ^Autopsies  on  hospital  cases  show  25  to  97  per  cent, 
of  healed  tuberculosis.  Many  recoveries  are  only  relative,  since  Kurlow's 
inoculations  from  seemingly  latent  caseous  foci  into  guinea-pigs  were 
positive  in  77  per  cent.;  such  foci  may  be  aroused  by  intercurrent 
disease,  though  some  writers  regard  recurrence  as  fresh  infection.  Re- 
covery is  effected  by  agglutinins  (precipitins)  and  other  specific  antibodies 
{opsonins)  which  aid  in  phagocytosis.  The  result  is  encapsulation,  cica- 
trization and  calcification.  Liebermeister  believes  recovery  is  possible  in 
50  per  cent,  of  incipient  cases.  The  outlook  depends  on  several  factors: 
(a)  The  hereditary  vital  endowment  of  the  patient;  (6)  his  environment, 
social  situation,  habits  and  intelligence;  (c)  whether  the  localization  is 
single  or  multiple;  (d)  secondary  or  mixed  infection;  (e)  digestion; 
(/)  degree  of  toxemia  (fever  and  emaciation);  (g)  youth,  diabetes, 
pregnancy  and  lactation  are  unfavorable;  (h)  80  per  cent,  with  normal 
pulse-rate  were  alive  after  four  years  and  97  per  cent,  with  rapid  pulse 
were  dead  (Schneider);  and  (i)  complications  (v.  i.). 

2.  Death. — ^The  clinical  course  is  variable,  even  in  chronic  cases; 
it  averages  two  years  (Bayle,  Laennec,  Andral),  over  two  and  a  half 
years  (Pollock),  three  years  (Cornet)  and  seven  years  (Williams  and 
Dettweiler,  though  not  including  acute  or  infantile  forms) ;  the  course 
may  last  30  to  55  years.  Death  is  usually  peaceful  and  painless,  though 
at  times  it  comes  with  dyspnea,  delirium  or  convulsions.  Mechanism 
of  death:  (a)  Heart  failure  is  the  common  cause,  associated  with  edema, 
asthenia,  anemia  and  marasmus.  Other  causes  are  less  frequent,  as  (b) 
profuse  hemoptoe;  (c)  pneumothorax;  (d)  pulmonary  embolism  (clots 
or  gas);  (e)  uremia;  (/)  meningitis;  (g)  perforative  peritonitis;  and 
(h)  sudden  death  without  adequate  pathological  findings,  in  which 
Arnold,  Brissaud  and  Toupet  found  in  the  liver  large  numbers  of  bacilli, 
which  probably  caused  an  acute  intoxication  (the  injection  even  of  dead 
bacilli  causes  rapid  marasmus  and  death). 

Complications. — ^Tuberculosis  in  other  organs  will  be  considered  below 
under  separate  headings. 

1.  Respiratory. — (a)  Tracheitis  and  bronchitis  occur  in  almost  every 
case.  (6)  Dysphagia  usually  results  only  from  local  involvement  of  the 
pharynx  or  larynx;  swallowing  into  the  larynx  is  the  result  of  paralysis 


166  BACTERIAL  DISEASES 

of  the  epiglottic  depressors.  Hoarseness,  dysphonia  and  aphonia  sug- 
gest laryngeal  tuberculosis,  but  may  develop  from  syphilis,  toxemia  or 
catarrh;  from  paralysis  of  the  recurrent  laryngeal  nerve  from  pressure 
by  lymph  glands;  from  inflammation,  on  the  right  side  by  pleural  scars, 
and  on  the  left  by  large  pleural  effusions;  or  from  thickening  at  the 
hilum.  (c)  Pulmonary  gangrene  may  develop  in  the  cavity  wall.  Lobar 
pneumonia  is  not  infrequently  a  cause  of  death,  (d)  Dry  yleurisy  is 
an  almost  constant  complication,  and  is  a  conservative  process,  militating 
against  pneumothorax.  Exudative  pleurisy  more  often  develops  pre- 
viously to  lung  phthisis  than  during  its  course.  In  the  latter  instance 
it  is  usually  serofibrinous,  and  not  extensive.  Effusions,  by  compression, 
sometimes  seem  to  exert  a  favorable  effect  on  the  lung  lesion.  Litten 
thought  that  their  sudden  absorption  might  occasion  miliary  tuberculosis. 
Chyliform  or  adipose  effusions  may  occur  (see  Chylothokax  and  Chylous 
Ascites)  ;  purulent  forms  result  from  mixed  infection,  cavities  or  pneumo- 
thorax, (e)  Pneumothorax  is  observed  in  5  per  cent,  of  cases,  and  results 
from  rupture  of  superficial  rapidly  forming  cavities  without  a  limiting 
membrane.  Perforation  occurs  most  frequently  between  the  second  and 
fourth  interspaces,  and  between  the  mammary  and  axillary  lines.  Its 
onset  is  spontaneous,  or  results  from  straining  or  coughing,  whereon 
sudden  symptoms  develop,  as  great  dyspnea,  orthopnea  and  cyanosis, 
and  sudden  physical  signs,  as  dislocation  of  the  heart,  spleen  or  liver, 
sudden  ectasia,  unilateral  thoracic  immobility,  weak  vocal  fremitus, 
voice  sounds  and  breathing,  a  tympanitic  note,  and  succussion  when 
serum  or  pus  forms.  The  onset  is  occasionally  gradual  or  even  symptom- 
less. Death  may  result  in  a  few  hours,  but  life  may  be  prolonged  weeks 
or  months.  Infrequently  pneumothorax  (g.  v.)  may  exert  a  beneficial 
effect  on  the  lung  trouble. 

2.  Circulatory. — (a)  The  typical  ra%)id  pulse  first  appears  only 
after  meals  or  exertion,  but  later  becomes  permanent.  It  is  chiefly 
toxemic,  but  may  be  due  to  compression  or  inflammation  of  the  vagus 
from  lymphadenitis,  hyperthyroidism,  mediastinitis,  pleurisy  or  peri- 
carditis. There  is  a  constant  and  early  lowering  of  the  hlood  te?ision, 
and  the  vasomotor  instability  causes  the  bright  red  cheeks.  (6)  The 
heart  is  pale,  fatty,  flabby  and  weak,  and  has  been  described  as  atrophied 
since  the  time  of  Laennec,  but  Potain  considers  that  the  small  heart  is 
merely  accommodative  to  the  malnutrition  and  anemia.  Cardiac  hyper- 
trophy and  dilatation  are  due  to  renal  disease,  pericardial  or  pleural  adhe- 
sions, or  pulmonary  induration;  the  second  pulmonic  tone  is  accentuated 
in  one-third  of  the  cases.  Adhesive  or  effusive  pericarditis  (in  3  per  cent.) 
may  result  by  extension  from  pleurisy  or  caseated  lymph  glands,  or 
pyogenic  infection.  Endocarditis  tuberculosa  is  infrequent  (1  per  cent.) ; 
tubercle  bacilli  may  be  deposited  in  cardiac  clots,  or  endocarditic  ex- 
crescences of  non-tuberculous  origin;  this  endocarditis  is  due  to  miliary 
deposits  in  the  intima,  and  clinically  escapes  recognition  in  most  cases. 
Woolley  reported  11  cases  of  tuberculosis  of  the  aorta  (1911).  (c)  A 
functional,  systolic  murmur  is  very  common.  {d)  Thronihophlebitis 
occurs  in  less  than  1  per  cent,  of  cases. 


TUBERCULOSIS  167 

3.  Nervous  and  Muscular. — (a)  The  mental  power  may  be  normal; 
oftener  there  is  a  slight  mental  iveakness,  irritability,  self-concentration, 
triviality  and  lack  of  endurance.  Consumptives  are  usually  optimistic, 
even  on  the  day  of  their  death  {spes  phthisicorum);  occasionally  melan- 
cholia or  mania  develops;  anemia,  toxemia,  marasmus  and  edema  of  the 
brain  may  cause  terminal  aberration,  ih)  Neuralgia  and  hyperesthesia 
are  not  uncommon.  Toxemic  multiple  neuritis  develops  in  1  per  cent.; 
it  may  cause  pain,  sensory  disturbance  or  am^^otrophy.  (c)  The  toxms 
which  reduce  the  body  weight  one-half  or  more,  result  in  marked  muscular 
degeneration  and  atrophy,  which  cause  the  flat  chest,  and  possibly  the 
cardiac  wasting.  ^Yasting  is  expressed  in  terms  synonymous  with  tuber- 
culosis— consumption,  phthisis,  tabes.  The  muscles  are  dry,  pale,  fatty; 
they  show  transverse  rents,  obscure  markings,  granular  degeneration 
or  hyperplasia  of  the  connective  tissue,  or  myositis.  Their  wasting  and 
the  nervous  toxemia  explain  the  asthenia  and  incapacitation  for  work, 
a  matter  of  national  economical  importance.  The  muscles  are  often 
irritable,  show  fibrillary  contractions  and  when  tapped  or  pinched  show 
local  lumpy  contraction,  known  as  myoidema. 

4.  Digestive. — (a)  The  tongue  may  be  furred,  or  red  and  clean. 
Aphthse  are  frequently  distressing.  Excessive  redness  of  the  gums  is 
frequent,  (b)  Stomach  disorder  is  present  in  50  per  cent,  of  cases;  it 
may  be  the  initial  symptom  of  toxemia,  or  appear  only  late  in  the  process. 
Anorexia  varies  in  degree  and  occurrence,  being  most  marked  when  the 
fever  is  high,  and  most  frequent  in  those  with  previous  dyspepsia  or  poor 
appetite;  again  it  may  be  due  to  glands  compressing  the  vagus  (Peter, 
de  Mussy).  Cornet  instances  an  advanced  patient  who  complained  that 
he  could  only  eat  four  beefsteaks  for  dinner.  "The  patient,  with  fever, 
who  eats  and  digests  well,  is  tuberculous"  (Lesegue).  Brieger  found 
the  chemism  normal  in  50  per  cent,  in  the  incipient  stage,  in  33  per  cent, 
in  moderately  severe,  and  in  but  16  per  cent,  in  severe  advanced  cases. 
After  eating  there  may  be  a  sense  of  fulness  or  pain.  -  Nausea,  gagging 
and  vomiting  may  result  from  pharisTigitis,  forced  feeding  or  coughing 
(Morton's  "emetic  cough").  In  advanced  cases,  nausea  and  vomiting 
occur  from  overeating,  toxemic  gastric  catarrh,  swallowing  of  sputum, 
etc.;  anatomically,  the  stomach  shows  catarrh,  fatty  degeneration  of 
the  glands,  interstitial  hyperplasia  and  amyloid  infiltration,  (c)  Intes- 
tines: Diarrhea  is  usually  late;  it  may  be  caused  by  toxemia,  swallowed 
sputum,  intestinal  catarrh,  toxemic  obliteration  of  the  lymph  and  blood- 
vessels, ulcers  or  amyloid  degeneration  of  the  gut.  Tuberculous  ulcers 
in  the  small  gut,  cecum  and  ascending  colon  cause  diarrhea  in  but  half 
the  cases  and  probably  only  when  combined  with  catarrh  or  amyloid 
degeneration;  ulcers  in  the  lower  colon  and  rectum  almost  constantly 
induce  diarrhea,  which  may  therefore  occur  from  causes  other  than 
ulceration,  and  ulcers  may  exist  without  it.  Blood,  pus,  hematin  crystals 
and  tubercle  bacilli  are  not  always  present.  Tubercle  bacilli  may  pass 
through  with  the  sputum  swallowed,  without  intestinal  tuberculosis. 
Anal  fistula  occurs  in  3  per  cent,  of  cases,  (d)  The  liver  is  fatty  (in  10 
per  cent.);  Jonescu  (1902)  collected  33  cases  of  cirrhosis  cardiotuber- 
culosa — induration  from  stasis,  with  tuberculous  granulations  and  fatty 


168  BACTERIAL  DISEASES 

degeneration,    (e)  Tuberculous  peritonitis  {v.  i.)  occurs  in  10  per  cent,  of 
pulmonary  tuberculosis. 

5.  Amyloid  Degeneration. — Of  all  amyloid  degeneration  80  per  cent, 
is  due  to  tuberculosis,  and  69  per  cent,  to  ulcerative  phthisis.  It  is 
found  in  8.8  per  cent,  of  tuberculous  autopsies.  The  spleen  is  affected 
in  93  per  cent.,  the  kidney  in  77,  the  liver  in  62,  the  intestines  in  28  and 
the  stomach  in  12  per  cent,  of  cases. 

6.  Genito-urinary. —  Urinary. — The  loss  of  weight  causes  phos- 
yhaturia  and  increase  of  chlorides  (0.5  to  1  or  even  12  gm.)^  More 
protein  is  excreted  than  is  ingested.  Albuminuria  indicates  nephritis, 
amyloidosis  or  local  tuberculous  disease.  Acute  and  chronic  parenchy- 
matous nephritis  is  not  infrequent,  due  to  long-standing  toxemia.  Amy- 
loid disease  of  the  kidney  produces  albuminuria  in  but  50  per  cent, 
of  the  cases;  nephritis  is  also  present  in  75  per  cent.,  and  the  chronic 
parenchymatous  type  in  66  per  cent.  Flick  and  Walsh  found  tubercle 
bacilli  in  84  per  cent,  by  inoculating  guinea-pigs  with  the  urine;  tubercles 
were  found  in  63  per  cent.  Ehrlich's  diazo  reaction  is  very  frequent 
and  usually  of  unfavorable  import. 

Sexual. — The  sexual  desire  may  be  more  intense,  though  its  increase 
is  exaggerated.  The  menses  often  disappear  early,  and  conception  is 
less  apt  to  occur.  Pregnancy  often  temporarily  betters  the  condition, 
but  a  more  rapid  course  is  usual  after  delivery  {d.  page  190).  The 
mammary  enlargement  described  by  Bedor,  particularly  in  males,  is 
rather  a  chronic  interstitial  mastitis  than  an  actual  hypertrophy.  Bacilli 
have  been  found  in  the  milk  of  tuberculous  mothers. 

7.  Skin. — Pityriasis  versicolor  occurs  very  frequently.  Piery  claims 
that  bacilli  exist  in  the  sweat.  Cyanosis,  chloasma,  desquamation, 
coarseness  of  the  hair,  herpes,  lichen  and  purpura  are  sometimes 
observed.  Clubbing  of  the  fingers  (''Hippocratic  fingers")  and  toes 
develops  chiefly  in  chronic  cases,  is  largely  due  to  hypertrophy  of  the 
soft  tissues  and  is  not  pathognomonic,  for  it  occurs  also  in  congenital 
cardiac  disease,  aneurysm,  bronchiectasis,  emphysema,  etc.  (See  Acro- 
megaly.) Emphysema  of  the  skin  is  very  uncommon;  it  follows  inter- 
stitial emphysema  of  the  lungs  (due  to  rupture  of  the  alveoli),  pneumo- 
thorax or  cavities.  Edema  results  from  anemia,  cardiac  weakness, 
phlebitis,  nephritis  or  neuritis. 

Treatment  of  pulmonary  tuberculosis  is  considered  later,  after  descrip- 
tion of  other  localizations  of  the  tubercle  bacillus. 

rV. — Tuberculosis  of  the  Lymph  Glands. — Of  glandular  adenopathies 
68  per  cent,  are  found  in  the  first  ten  years  of  life.  It  occurs  fairly 
often  in  adolescence  and  sometimes  even  in  the  aged.  It  is  found  ana- 
tomically in  85  per  cent,  of  tuberculous  children,  and  in  25  per  cent,  of 
all  autopsies  on  children.  Scrofula  is  glandular  tuberculosis,  but  it 
presents  different  characteristics  from  those  of  pulmonary  infection 
(decreased  virulence  of  the  bacilli  in  scrofulous  glands,  infection  with 
the  bovine  bacillus,  or  infection  with  very  few  bacilli) .  The  skin,  mucous 
membranes  and  lymph  vessels  are  physiologically  more  permeable  in 
the  very  young,  and  an  increase  or  persistence  of  this  condition  is  regarded 
as  an  embryoism,  i.  e.,  a  structural  tendency  toward  infection.     The 


TUBERCULOSIS  169 

accessory  causes  are  the  same  as  in  pulmonary  tuberculosis:  (a)  An 
hereditary  tendency;  (b)  poor  hygiene,  dark  damp  dwellings  and  inade- 
quate nutrition;  (c)  infections,  as  pertussis  and  measles,  to  a  less  extent 
scarlatina,  diphtheria,  variola  and  syphilis. 

General  Characteristics. — (a)  It  usually  runs  a  chronic  course,  (b) 
Recurrence  is  frequent,  (c)  Multiple  lesions  are  usual,  (d)  Glandular 
in\olvement  is  frequently  associated  with  afl'ections  of  the  skin  (as 
eczema,  scrofuloderma  or  lupus),  inflammations  of  the  mucous  mem- 
branes (as  conjunctivitis,  otitis,  rhinitis  or  bronchitis),  and  disease  of  the 
bones  or  joints  (as  coxitis  or  Pott's  disease).  Escherich  refers  the  hyper- 
sensitiveness  of  the  skin  and  mucosae  to  the  presence  of  the  antibody — 
tuberculous  "allergy."    This  association  is  frequently  known  as  scrofula. 

General  Anatomy. — (a)  In  infection  with  very  few  bacilli  regression 
is  possible,  (b)  If  the  infection  is  sharper,  conglomerate  tubercles  form, 
with  the  following  issues:  death  of  the  bacillus  in  the  central  caseation, 
softening  and  external  rupture,  sometimes  calcification  or  extension 
locally,  generally  by  the  blood  current,  (c)  Hyperplasia  without  any  or 
with  very  late  caseation  results  from  infection  with  few  bacilli.  The 
lymphadenoid  tissue  is  compressed  by  epithelioid  spindle-shaped  cells; 
the  glands  may  reach  the  size  of  an  egg,  and  their  cut  section  may  show 
no  gross  evidence  of  tubercle,  (d)  Mixed  infection  causes  rapid  caseation, 
necrosis,  softening  and  early  rupture;  their  cut  section  appears  "like 
that  of  a  raw  potato  but  not  so  moist";  the  inflammation  often  causes  a 
periadenitis,  whereby  the  glands  fuse,  a  phlegmon  results,  and  general- 
ization of  the  process  throughout  the  body  ensues. 

1.  Cervical  Tuberculous  Adenitis. — Infection  occurs  through  the 
tonsils,  nose,  etc.;  the  bacillus  may  pass  through  the  mucosae  without 
producing  any  lesion  in  them.  The  cervical  glands  constitute  96  per  cent, 
of  Wohlgemuth's  series.  In  cervical  lymphadenitis,  the  glands  at  the 
angle  of  the  jaw"  and  beneath  or  anterior  to  the  sternomastoid  muscle 
are  most  often  involved;  in  bilateral  involverhent  the  glands  of  one 
side  are  usually  larger.  The  glandular  swelling  is  slow  in  onset,  inter- 
mittent in  progression  and  usually  unattended  by  pain  or  other  symptoms. 
In  some  cases  the  first  symptoms  are  acute,  but  the  trouble  subsides  in 
a  few  weeks.  The  nodes  first  are  discrete  and  freely  movable;  they  may 
blend  into  large  nodular  masses,  and  periadenitis  may  fuse  the  glands 
and  cause  their  adherence  to  the  skin,  which  becomes  edematous  from 
lymph  stasis,  dough-like  and  reddened.  Softening  and  fluctuation  are 
then  frequent,  with  burrowing  of  pus  and  external  rupture  through 
small  fistulse.  The  fistulse  widen,  discharge  cheesy  and  milky  material 
and  form  intractable  ulcers  covered  with  granulation  tissue.  Cicatri- 
zation leaves  deep,  deforming,  depressed  scars.  Extension  may  occur 
to  the  deeper  or  subpectoral  or  axillary  glands.  Fever,  anemia  and  other 
toxemic  manifestations  may  develop  as  in  lung  tuberculosis,  or  the 
adenopathy  may  be  the  sole  clinical  fact. 

2.  Bronchial  Glands. — In  autopsies  on  tuberculous  children  these 
were  affected  in  100  per  cent,  of  Northrup's  series,  and  in  adults  in  60 
per  cent.  In  children  tuberculosis  of  the  bronchial  glands  is  primary 
and  tuberculosis  of  the  lung  secondary.    In  adults  lung  involvement  is 


170  BACTERIAL   DISEASES 

usually  primary  and  bronchial  adenitis  secondary.  Biedert,  in  1346 
autopsies  on  tuberculous  children,  found  the  lungs  diseased  in  SO  per  cent., 
the  bronchial  glands  in  7S,  the  intestines  in  32  and  the  mesenteric  glands 
alone  in  40  per  cent. 

Symptoms. — In  most  cases  no  symptoms  develop;  in  others  pul- 
monary lesions  overshadow  the  bronchial  involvement;  in '  others 
miliary  tuberculosis  develops,  promoted  by  rupture  of  the  bronchial 
glands  into  the  pulmonary  vessels;  in  still  others  mediastinal  symptoms 
result;  in  very  few  cases  are  there  actual  physical  findings. 

Pressure  *S'?/7??pto?725.— Pressure  on  the  vagus,  kno^m  to  Wrisberg, 
causes  the  rapid  heart,  so  frequently  remarked  in  tuberculous  children; 
paroxysmal  dyspnea,  or  spasmodic  cough  which  sometimes  resembles 
whooping-cough  (i".  page  109) ;  lessening  of  the  sensitivity  of  the  bronchi, 
which  favors  infection;  and  finally  cardiac  dilatation.  Pressure  on  the 
recurrent  laryngeal  nerve  is  marked  by  hoarseness,  aphonia,  dyspnea  or 
laryngospasm.  The  air  passages  may  be  compressed,  as  evidenced  by 
dyspnea,  holding  the  head  backward  and  impaired  expansion  of  one  or 
both  sides  of  the  chest  (Grancher's  sign).  The  pupils  may  be  unequal 
from  pressure  on  the  s^TQpathetic  nerve.  Other  pressure  symptoms  are: 
hypertrophy  of  the  heart,  or  the  paradoxical  pulse,  from  pressure  on  the 
aorta;  edema  and  cyanosis  of  the  face  and  arms,  from  compression 
of  the  superior  vena  cava;  cough,  rales  or  hemoptysis,  from  stenosis  of 
the  pulmonary  veins;  a  murmur  over  the  innominate  vein  on  throwing 
the  head  backward;  and  dysphagia,  from  esophageal  compression. 

Signs. — Bronchial  breathing  is  occasionally  heard  between  the  second 
and  fourth  dorsal  vertebrae,  more  clearly  behind  than  in  front;  more 
on  the  right  than  on  the  left  side  (since  more  glands  are  clustered  around 
the  right  bronchus),  and  more  markedly  than  the  high-pitched  breathing 
heard  physiologically  over  this  region.  Propagation  of  the  whispered 
voice  is  D'Espme's  sign.  If  the  bronchus  is  compressed  there  is  neither 
bronchial  breathing  nor  increased  vocal  fremitus.  An  irregularly  out- 
lined dulness  is  elicited  on  exceptional  occasions  either  between  the 
clavicle  and  third  rib,  on  either  side  of  the  sternum,  or  behind,  on  per- 
cussing the  third  and  fifth  dorsal  vertebrae  (de  la  Camp's  sign).  Ad- 
jacent interscapular  tenderness  constitutes  the  spinalgia  of  Petrusky. 
A  tjinpanitic  note  in  the  upper  lobes  denotes  relaxation  of  the  lung. 
The  symptoms  and  signs  are  extremely  variable,  appearing  suddenly 
and  remitting  unaccountably. 

Issues. — (a)  Tuberculosis  of  the  lung;  (b)  miliary  tuberculosis;  (c) 
tuberculous  pleurisy  or  pericarditis;  (d)  rupture  into  the  air  passages, 
causing  sudden  suffocation;  (e)  fatal  hemorrhage  into  the  air  tubes, 
which  is  less  frequent;  (/)  rupture  into  the  esophagus,  or  traction  upon 
it  causing  an  esophageal  diverticulum. 

Diagnosis. — The  direct  diagnosis  rests  upon  tuberculous  adenopathies 
elsewhere,  pressure  symptoms,  physical  signs  and  a:-ray  plates.  As 
Henoch  puts  it,  "A  diagnosis  can  rarely  be  made  (from  the  physical 
signs),  but  if  made,  is  nearly  always  correct." 

3.  ^Mesenteric  Glands. — The  bacihi  pass  the  intact  intestinal 
mucosa  and  settle  in  the  mesenteric  glands.    Carriere  found  that  but  1 


TUBERCULOSIS  171 

per  cent,  of  cases  were  primary;  of  the  secondary  cases,  the  primary 
focus  was  in  the  peritoneum  in  40  per  cent.,  in  the  lungs  in  30,  in  the 
intestines  in  20,  in  other  glands  and  bones  in  5  per  cent.  each.  Hess 
holds  that  in  over  60  per  cent,  of  the  primary  infantile  cases  the  infec- 
tion is  by  bovine  bacilli;  in  adults  it  is  by  the  human  type  {v.  page  143). 
The  glands  may  be  palpable  as  thick,  nodular  masses  through  a  thin 
abdominal  wall,  but  are  often  obscured  by  the  abdominal  distention 
which  contrasts  strikingly  with  the  general  emaciation  (tabes  mesaraica) . 
Digestive  disturbance  is  frequent,  and  there  is  usually  a  diarrhea  with 
thin,  stinking  stools.  Compression  is  less  frequent  in  the  abdomen 
than  in  the  less  yielding  thorax,  though  the  veins  of  the  abdomen  may 
stand  out  and  edema  of  the  legs  may  appear.  The  glands  sometimes 
heal  by  induration  and  calcification,  or,  by  softening,  rupture  into  the 
intestine  or  peritoneum. 

4.  Generalized  Lymphadenitis  may  closely  resemble  Hodgkin's 
disease  (Paltauf  and  Sternberg).  This  form  is  common  in  the  negro. 
In  two  personal  instances  the  clinical  and  gross  pathological  findings 
were  typically  pseudoleukemic,  and  only  the  epithelioid  hyperplasia  and 
the  Bacillus  tuberculosis  stamped  them  as  tuberculous. 

The  treatment  of  tuberculous  lymphadenitis  is  that  of  tuberculosis 
in  general  {v.  i.).  Hyperplastic  tonsils  and  adenoids  require  removal, 
being  the  atrium  for  cervical  infections.  In  175  cases  of  cervical  adenitis 
treated,  surgically,  58  per  cent,  were  cured  after  three  years,  8  per  cent, 
had  recurrence,  11  per  cent,  developed  pulmonary  tuberculosis  and  23 
per  cent.  died.  In  another  series  of  700  cases  treated  medically,  28 
per  cent,  developed  tuberculosis  in  some  other  organ  (Demme).  The 
writer  relies  largely  upon  full  feeding,  .r-rays,  ample  sunlight  and  fresh 
air;  if  possible,  a  warm  sea-side  climate,  and  operation  if  finally  necessary, 
after  puberty.  The  syrup  of  the  iodide  of  iron  and  cod-liver  oil  are  very 
largely  used.  Inunctions  of  green  soap  are  recommended,  5ss  rubbed 
into  the  back  three  times  a  week.  Some  62  instances  of  tuberculous 
mesenteric  adenopathy  have  been  operated  upon  (Floderus). 

V.  Tuberculosis  of  the  Serous  Membranes. — These  membranes  may 
be  involved  separately  or  simultaneously;  multiple  serositis  or  poly- 
orrhomenitis  may  be  acute,  subchronic  or  chronic,  serous,  fibrinous  or 
purulent,  solitary  or  with  visceral  tuberculosis. 

1.  Pleura. — Tuberculous  pleurisy  has  been  touched  upon  as  a  com- 
plication of  phthisis,  and  is  separately  considered  under  Pleurisy 
(f/.  t.).  It  may  appear  as  an  apparently  primary  infection,  as  secondary 
to  unmistakable  phthisis,  or  as  a  terminal  infection.  Miliary  tubercles 
in  the  pleura  may  occur  without  pleurisy.  Pleurisy  results  from  direct 
bacillary  invasion,  or  possibly  from  simple  toxic  action.  In  some  cases 
the  pleura  proliferates  and  forms  a  massive,  adhesive,  obliterative  mem- 
brane. Sometimes  the  interstitial  tissue  of  the  lung  is  invaded  (pleuro- 
genous  cirrhosis). 

2.  Pericardium. — Accidental  miliary  deposits  are  distinguished  from 
tuberculous  pericarditis  wherein  inflammation  predominates.  It  is 
less  common  than  pleural  and  peritoneal  involvement  (in  3  per  cent,  of 
phthisis   autopsies).     Tubercles   may   be   detected   beneath   the   fibrin 


172  BACTERIAL  DISEASES 

deposits  or  adhesions.  It  may  be  symptomatically  latent;  it  may  form 
an  unessential  part  of  a  miliary  tuberculosis;  or  it  presents  the  ordinary 
symptoms  of  pericardial  effusion  or  concretion  (g.  v.).  Only  eight  primary 
cases  are  recorded  (Scagliosi,  1904), 

3.  Peritoneum. — Tuberculosis  of  the  peritoneum  became  a  clinical 
entity  when  Louis,  in  1825,  declared  that  chronic  peritonitis  was  tuber- 
culous. It  complicates  10  per  cent,  of  phthisis,  is  found  in  2  per  cent, 
of  autopsies  and  constitutes  one-quarter  of  all  peritonitides. 

Age. — It  is  almost  equally  frequent  in  the  second,  third,  fourth  and 
fifth  decades  (20  per  cent,  in  each) ;  66  per  cent,  of  cases  occur  between 
ten  and  forty  years  of  age. 

Sex. — Ninety  per  cent,  occur  in  women.  More  cases  are  found  in 
autopsies  on  males,  though  more  women  are  operated  on.  In  America 
it  is  common  among  the  negroes.  It  is  very  seldom  primary  (0.7  per  cent.) , 
but  is  secondary  to  (a)  lung,  bronchial  gland  or  pleural  tuberculosis  (in 
80  per  cent.);  (b)  intestinal  ulcers  or  mesenteric  and  retroperitoneal 
adenitis,  especially  in  children  (tubercle  bacilli  may  pass  the  intestinal 
wall  without  localizing  in  it);  (c)  tuberculosis  of  the  Fallopian  tubes 
(which  in  turn,  is  secondary  to  bronchial  adenopathy).  Tuberculous 
peritonitis  is  hematogenous. 

It  frequently  complicates  liver  cirrhosis  (though  it  is  strange  that 
tuberculosis  should  develop  in  any  stasis),  ovarian  tumors  or  trauma, 
which  disseminates  infection  from  some  quiescent  focus.  Sixty-two 
cases  are  reported  in  hernial  sacs. 

Types. — A  clinical  description  is  difficult,  for  the  disease  may  be 
acute  or  chronic,  latent  or  stormy,  circumscribed  or  diffuse;  it  may 
be  marked  by  adhesions,  free  or  encapsulated  ascites  or  by  large  tumor- 
like masses;  it  may  be  obscured  by  coincident  miliary  tuberculosis, 
liver  cirrhosis,  exudative  pleurisy  or  ulcerative  phthisis,  or  may  appear 
as  a  seemingly  primary  clinical  fact.  The  unessential  miliary  tubercle, 
and  the  small,  non-inflammatory  tubercles  over  intestinal  ulcers  are  not 
considered.     Certain  types  may  be  described: 

1.  The  acute  form  begins  with  severe  symptoms,  fever,  rapid  pulse, 
vomiting,  abdominal  tenderness  and  pain,  free  peritoneal  fluid,  which 
shifts  with  change  of  position,  and  meteorism  from  paresis  of  the  gut. 
This  type  may  resemble  typhoid  when  the  intoxication  is  more  marked 
than  the  local  signs.  The  peritonitic  local  signs  may  be  sharply  marked, 
but  always  less  so  than  in  suppurative  peritonitis.  Certain  cases  simulate 
appendicitis,  ileus  from  tuberculous  adhesions,  or  incarceration  beneath 
bands;  or  in  three  cases  precipitated  by  delivery,  puerperal  infection. 
Indicanuria,  so  frequent  in  other  acute  peritonitides,  is  usually  absent. 
The  ascitic  fluid  is  usually  lemon-colored,  serous  or  slightly  flocculent 
or  hemorrhagic,  and  of  a  specific  gravity  of  over  1.014;  the  leukocytes 
are  usually  mononuclear.  In  rare  instances  the  acute  peritonitis  is 
suppurative;  26  cases  are  on  record  due  to  perforation  of  a  tuberculous 
ulcer  in  the  gut.  In  some  cases  the  acute  type  is  a  terminal  infection. 
Though  commonly  diffuse,  there  is  sometimes  acute  local  pain  or  cir- 
cumscribed effusion.  Plastic  adhesions  occasionally  modify  the  freedom 
with  which  this  ascitic  form  shifts  with  alteration  of  posture.     Acute 


I 


TUBERCULOSIS  173 

tuberculous  peritonitis  comes  more  often  under  the  care  of  the  physician 
than  of  the  gynecologist  or  surgeon. 

2.  Subacute  or  chronic  forms  include:  (a)  The  fibrinoplastic  form, 
causing  adhesions,  may  result  from  the  acute  form  or  may  develop 
insidiously;  symptoms  and  signs  are  usually  lacking,  or  not  distinctive. 
(h)  The  fihrinocaseous  form  is  characterized  by  large  solid  masses,  by 
fusion  of  tubercles.  Between  the  recesses  formed  by  the  adhesions, 
pockets  of  exudate  frequently  occur,  containing  blood-stained  serum, 
cold  abscesses  or  cheesy  material;  the  intestine  is  thickened  and  con- 
tracted, the  mesentery  deformed  and  the  omentum  shrunken,  (c)  The 
effusive  form  is  marked  by  serous,  serofibrinous,  serohemorrhagic  and  less 
often  by  puriform  or  adipose  exudate. 

These  subtypes  vary  so  much  that  the  individual  symptoms  will  be 
considered  separately: 

Individual  Symptoms. — 1.  Adhesions  and  Retraction. — ^The  infil- 
trated omentum  gradually  indurates  and  retracts  above  the  navel  as  a 
fibrocaseous  tumor-like  mass;  it  may  often  be  palpated,  even  when  there 
is  much  exudate,  but  becomes  clearer  after  paracentesis;  it  has  beeii 
mistaken  for  gastric  carcinoma,  enlarged  liver  or  distended  gall-bladder, 
especially  in  chronic  forms  with  little  fever;  it  is  more  suggestive  of 
tuberculous  than  carcinomatous  peritonitis.  The  walls  of  the  gut  are 
frequently  so  thickened  that  intestinal  stenosis  results;  the  gut  may 
measure  but  one-half  or  one-third  of  its  original  length;  it  may  be 
thickened,  adherent  or  tumor-like.  The  entire  peritoneal  sac  may  be 
distorted  (peritonitis  deformans)  and  intestinal  stenosis  ensues.  The 
mesenteric  retraction  (mesenteritis  retrahens)  modifies  the  physical 
findings,  tympany  and  dulness;  the  mesentery  may  measure  one  inch  in 
thickness. 

2.  Ascites. — ^The  abdomen  is  moderately  enlarged  by  exudation 
and  meteorism.  Large  exudates  may  cause  widening  of  the  abdominal 
veins  because  the  cava  is  compressed,  as  in  ascites  (g.  v.).  The  abdomen 
protrudes  but  its  centre  is  not  usually  flattened  nor  its  sides  bulging  as 
in  the  ascites  of  liver  or  cardiac  disease,  but  it  is  often  prominent  in  the 
median  line,  as  in  ovarian  cyst;  most  of  Lohlein's  cases  were  sent  to  him 
with  a  diagnosis  of  ovarian  cyst.  Without  adhesions,  the  dulness  shifts 
with  change  of  posture,  with  tympany  over  the  supernatant  gut  and 
dulness  over  the  settling  fluid.  The  physical  signs  differ  from  common 
ascites  in  that  the  tympany  is  often  on  the  right  side,  the  mesenteritis 
retrahens  pulling  the  small  gut  to  the  right.  A  tuberculous  mass 
may  dislocate  the  tympanitic  intestines  to  the  left,  the  median  line  or 
pelvis.  In  very  rare  cases  the  fluid  may  rupture  into  the  bowel  or  ex- 
ternally through  the  Havel.  Dulness  may  indicate  adhesions,  thickening 
of  the  gut,  caseous  masses  or  enlarged  glands. 

3.  Meteorism. — Sudden  paresis  of  the  gut  in  the  acute  type  or 
tuberculous  tumors  impeding  peristalsis  cause  gaseous  accumulations. 
Meteorism  is  one  of  the  stigmata  of  tuberculosis  of  the  mesenteric  glands 
and  then  is  often  due  to  coincident  peritonitis;  in  both  conditions,  but 
most  often  in  children,  the  stools  are  fatty. 


174  ,  BACTERIAL  DISEASES 

4.  Palpation. — ^A  doughy  sensation  on  palpation  is  usually  referred 
to  peritoneal  adhesions  or  constricted  intestine,  but  in  some  instances 
is  due  to  early  infiltration  of  the  preperitoneal  tissues. 

5.  Other  Symptoms. — In  some  cases  the  Beatty- Bright  friction-ruh 
can  be  elicited.  Pelvic  effusion  is  common  in  women,  who  also  suffer 
from  painful  and  disturbed  menstruation.  Fever  is  frequently  irregular, 
sometimes  continuous,  remittent  or  hectic;  it  is  most  frequent  in  acute 
types  or  in  acute  exacerbations  of  chronic  cases;  the  disease  cannot  be 
excluded  by  the  absence  of  fever.  Fever,  pain  and  tenderness  distinguish 
tuberculous  encapsulation  from  simple  ascites.  Pain  and  tenderness  are 
generally  conspicuous,  though  less  than  in  suppurative  peritonitis  and  by 
no  means  constant.  Emaciation  is  frequent,  but  often  patients  with  tuber- 
culous peritonitis  present  a  good  color  and  robust  appearance.  Gastro- 
intestinal disturbances  are  frequent;  the  usual  constipation  is  occasioned 
by  impaired  peristalsis;  in  some  cases  diarrhea  is  caused  by  toxemia. 
In  rare  instances  there  are  icterus,  splenic  tumor,  and  other  complica- 
tions due  to  special  localizations  of  the  process. 

Diagnosis.^ — Sometimes  there  are  no  just  grounds  for  suspecting  the 
disease.  Importance  attaches  to  tuberculous  lesions  in  the  lungs,  pleurae, 
glands  or  Fallopian  tubes.  Multiple  serositis  is  extremely  suggestive. 
If  another  tuberculous  lesion  cannot  be  established,  tuberculous  peri- 
tonitis, which  constitutes  nearly  all  chronic  peritonitides,  is  very  probably 
present;  malignancy  must  be  considered.  A  positive  tuberculin  reaction 
does  not  prove  that  the  tuberculous  lesion  is  peritoneal.  Inoculation 
may  be  made  with  fluid  withdrawn  by  paracentesis.  (See  Pleurisy.) 
Exploratory  laparotomy  is  justifiable,  as  simple  abdominal  section  is  the 
foremost  therapeutic  measure. 

Course. — ^The  onset  is  usually  insidious  and  the  course,  independently 
of  therapeutic  measures,   shows   spontaneous  remissions. 

Treatment. — Rest  in  bed,  good  hygiene  and  fidl  feeding  very  often 
arrest  the  process  (in  25  per  cent,  of  cases).  The  tumors,  exudate  and 
adhesions  may  recede  and  no  symptom  reappear  for  months  or  years. 
Spontaneous  recovery,  first  described  by  Bamberger  was  ignored  until 
recent  times.  In  1864  Spencer  Wells  observed  that  healing  may  follow 
laparotomy.  Experiment  has  shown  that  the  tubercles  heal  by  degenera- 
tion, vascularization  and  development  of  connective  tissue. 

Operation  gives  various  results,  recovery  occurring  in  75  per  cent, 
of  1300  cases.  Operation  in  the  first  four  months  is  contra-indicated,  as 
the  early  exudate  has  strong  bactericidal  properties.  Simple  paracentesis 
is  inferior  to  laparotomy.  Lavage  is  superfluous.  It  is  thought  that  the 
access  of  air  or  sunlight  or  manipulation  is  the  potent  curative  factor 
in  operative  treatment;  the  withdrawal  of  fluid  allows  the  access  of  fresh 
serum  with  increased  antitoxic  properties.  Operation,  in  the  author's 
opinion,  is  clearly  of  great  value;  the  free  fluid  is  evacuated,  detritus 
or  pus  removed  and  the  (local)  cause,  as  pyosalpinx,  is  excised,  the 
percentage  of  recoveries  rising  to  71  to  92  per  cent.  Some  writers  believe 
that  the  tubercles  which  heal  after  operation  were  already  in  process  of 
healing  spontaneously.     (See  Pleurisy  for  autoserotherapy.) 


TUBERCULOSIS  175 

VI.  Tuberculosis  of  the  Brain  and  Meninges. — Involvement  may 
result  from  (a)  the  miliary  tubercle  (v.  s.),  (b)  the  solitary  or  conglomer- 
ate tubercle,  which  produces  symptoms  identical  with  those  of  brain 
tumor  (q.  v.),  (c)  the  tuberculous  abscess  and  (d)  meningitis  (in  4.7 
per  cent,  of  adults  dying  with  pulmonary  phthisis). 

Primary  cerebral  tuberculosis  is  extremely  rare,  and  in  reported  cases 
it  is  ])robable  that  microscopic  foci  elsewhere  escaped  detection. 

VII.  Tuberculosis  of  the  Eye. — Only  50  cases  occurred  in  141,000 
eye  patients.  The  number  of  reported  cases  of  conjunctival  tuberculosis 
is  150,  of  which  but  100  were  proved  tuberculous. 

Vni.  Tuberculosis  of  the  Alimentary  Tract. — 1.  Lips.— The  lips  are 
very  seldom  affected;  lupus  may  invade  them.  Tuberculous  ulcers 
are  very  painful  and  may  be  confused  with  cancer  or  chancre. 

2.  Gums. — The  gums  are  seldom  involved,  though  tuberculosis  has 
followed  caries  and  extraction  of  the  teeth. 

3.  Tongue. — This  is  involved  in  0.6  per  cent,  of  cases.  Tuberculous 
tumors  sometimes  break  down  into  cold  abscesses.  Tuberculous  ulcers 
develop  on  the  dorsum  or  edges;  they  have  rough  caseous  bases  with 
uneven  or  undermined  edges,  and  are  almost  never  primary;  syphilitic 
ulcers  are  differentiated  by  the  therapy  and  Wassermann;  cancer  by 
adenopathy;  and  both,  by  the  absence  of  bacilli  and  the  results  of 
inoculation. 

4.  Pharynx. — Primary  disease  is  most  infrequent,  and  involvement, 
secondary  to  pulmonary  or  laryngeal  phthisis,  occurs  in  0.,3  per  cent, 
only.  The  process  begins  in  the  lymphoid  structures,  which  are 
infected  by  tuberculous  sputum  or  food,  or  it  extends  by  the  lymph 
vessels  from  the  larynx.  Three-fifths  of  the  cases  are  associated  with 
tuberculous  intestines,  and  one-seventh  with  oral  tuberculosis.  The 
cervical  glands  may  be  affected  in  acute,  but  rarely  in  chronic,  cases. 
The  ulcerations  are  usually  superficial;  when  propagated  from  the 
larynx  the  most  distressing  dysphagia  results.  Retropharyngeal  abscess 
usually  results  from  suppurative  lymphadenitis  and  osseous  disease. 

5.  Palate. — Ulceration  occurs  in  1  per  cent,  of  phthisis  cases;  in 
coughing,  bacilli  come  in  forcible  contact  with  the  palate.  Lubinski 
observed  three  instances  among  16,000  throat  cases. 

6.  Tonsils. — The  tonsils  are  diseased  in  4  per  cent,  of  phthisis  cases; 
the  process  may  stop  at  the  tonsils,  for  they  act  as  barriers  to  infection, 
or  tuberculous  cervical  adenitis  may  develop.  Their  infection  may  be 
I)rimary,  and  Dieulafoy  holds  that  tonsillar  infection  may  be  followed 
by  a  descending  tuberculous  adenitis,  which  in  turn  infects  the  lungs. 
The  lesions  are  more  often  miliary  than  caseous. 

7.  Salivary  Glands. — Of  parotid  disease  14  records  exist. 

8.  Esophagus. — No  clear  primary  case  is  recorded,  and  Cone  could 
collect  only  48  secondary  cases.  Infection  by  contiguity,  from  the 
l)eribn)nchial  glands,  may  occasion  esophageal  perforation,  hemorrhage, 
di\crticula  or  stenosis.  Extension  from  the  larynx  or  pharynx  along  the 
lymph  tracts  or  from  the  spine  or  lung  cavities  is  possible. 

0.  Stomach. — There  are  only  4  primary  cases  on  record.  Secondary 
disease  is  estimated  at  0.4  per  cent.    Garre  collected  about  100  cases  of 


176  BACTERIAL    DISEASES 

tuberculous  ulcer,  of  which  25  were  operated  upon  for  pyloric  stenosis. 
The  HCl  is  inimical  to  gastric  tubercle.  Tuberculous  ulcer  of  the  stomach 
occurs  from  the  sputum,  invasion  by  contiguity  or  in  few  cases  from 
hematogenous  mfection. 

li^i.  Intestinal  Tuberculosis. — It  was  first  observed  by  Bayle  (ISlOj. 
'«;  It  is  usually  secondary  to  ulcerative  lung  tuberculosis  from  infective 
sputum;  its  frequency  is  30  to  50  per  cent.  Tubercle  bacilli  may  be 
swallowed  without  causing  intestinal  tuberculosis.  Of  all  intestinal 
ulcerations,  tuberculous  are  the  most  frequent.  Infection  from  the 
peritoneum,  mesenteric  glands  or  hematogenous  infection  is  barely 
possible,  ''h')  Primary  intestinal  tuberculosis  is  much  more  rare,  occurring 
in  only  0.1  per  cent,  of  adult  cases.  The  intestinal  mucosa  in  children 
often  ahows  of  the  passage  of  tubercle  bacilli  to  the  intestinal  lymph 
glands  without  disease  of  the  intestine  itself.  Koch  denies  infection 
by  milk,  and  Behring  affirms  that  it  is  the  chief  cause  of  tuberculosis. 

The  ulcers  are  most  frequent  in  <i)  the  ileocecal  region  and  next  in 
the  colon.  ^  iij  They  always  originate  in  the  lymphadenoid  follicles  or 
Peyer's  patches.  Small  tubercles  fuse  into  large  ones,  which  caseate  and 
ulcerate;  in  exceptional  cases  the  caseous  nodes  do  not  rupture  but  cause 
the  peritoneum  and  mucosa  to  bulge  out.  (iiij  The  ulcers  are  irregular 
in  shape  and  'ivj  their  disposition  is  ring-lil:e  around  the  gut  (extension 
by  the  bead-like  h-mphangitis  tuberculosa^ ;  rarely  they  lie  in  the  long 
axis  of  the  gut  and  are  ovoid,  incompletely  corresponding  to  Peyer's 
patches,  ('vj  They  are  single  or  multiple,  and  sometimes  co^'er  most  of 
the  large  and  small  intestines,  'vii  Their  bases  are  rough  or  caseous 
and  their  edges  infiltrated,  which  also  invades  the  contiguous  mucosa 
and  submucosa.  (vii;  Localized  adliesive  peritonitis  is  a  common  issue 
when  the  process  reaches  the  serosa;  perforation  occurs  in  5  per  cent, 
of  cases,  but  is  resisted  by  the  muscular  coat  and  by  adhesions;  it  results 
in  pericecal  abscess  and  suppurative  peritonitis.  Stenosis  of  the  intestine 
may  also  result,  single,  or  less  often  multiple  (129  cases  collected  by 
Arbuson,  190-4).  Eisenhardt  saw  10  complete  and  26  incomplete  recov- 
eries in  567  tuberculous  ulcerations.  Hepatic  suppuration  or  steatosis 
may  result. 

St]^iptoms. — The  symptoms  usually  commence  with  catarrhal  enteritis, 
pain  and  fever;  diarrhea  occurs  in  but  half  the  cases  of  ulceration. 
They  may  resemble  typhoid.  The  only  pathognomonic  finding  is  the 
tubercle  bacillus,  but  this  finding  may  result  also  from  swallowed  sputum. 
Rosenblatt's  method  of  detecting  the  bacilli  in  the  feces  is  to  give  laud- 
anum until  the  stools  become  hard;  in  the  mucus  on  their  surface,  the 
bacihi  are  usually  found  on  the  first  examination,  for  the  hard  feces 
apparently  scrape  the  bacilli  from  the  ulcers.  Pus  is  often  found.  Girode 
called  attention  to  the  black  stools,  which  are  ominous,  as  they  mdicate 
malnutrition;  the  picture  of  dysentery  is  rarely  observed;  fatal  hemor- 
rhage is  infrequent.  An  appendicitir:  form  may  be  noted,  with  recurrence 
and  fistuhe.  In  iyphliiis  iuherculosa  there  is  great  thickening  in  the  cecal 
region,  with  a  hard,  slightly  movable  or  totally  adherent,  vertical,  tender 
tumor.  The  onset  is  usually  msidious  T\dth  recurrent  pain,  increasing 
intestinal  stenosis  and  constipation  alternating  -^dth  diarrhea.    Hemor- 


TUBERCULOSIS  111 

rhage  is  infrequent,  fever  is  usually  absent  and  emaciation  is  sometimes 
pronounced.  Duguet  described  this  condition  in  1869,  and,  since  it  so 
fully  resembles  cancer  or  sarcoma,  it  attracted  the  especial  attention 
of  surgeons,  Bassini,  Bouilly  and  Billroth.  Campiche  collected  379 
cases,  of  which  25  per  cent,  died  from  the  operation;  35  per  cent,  were 
well  for  months  or  years;  and  40  per  cent,  ultimately  died  of  tuber- 
culosis. The  process  usually  begins  in  the  mucosa  (rarely  in  the  serosa) 
and  is  marked  by  ulceration,  villosities  in  the  mucosa,  great  local  infil- 
tration and  hypertrophy  of  the  bowel  and  destruction  of  the  ileocecal 
valve.  Patients  may  die  of  acute  obstruction,  or  only  after  a  chronic 
course  of  a  decade  or  more;  recovery  by  fibrosis  is  possible. 

In  the  rectum  ulcers,  lupus,  tuberculosis  cutis  and  periproctal  abscess 
are  sometimes  seen.  Fistula  in  ano  occurs  in  3  per  cent,  of  phthisic 
subjects  and  rarely  in  other  conditions;  the  idea  that  its  excision  excites 
phthisis  is  confusion  of  cause  and  effect. 

11.  Liver. — The  liver  is  involved  less  in  adults  than  in  children  (38 
per  cent.),  but  at  all  ages  it  is  of  pathological  interest  chiefly,  (i)  Large 
tubercles  may  develop  in  the  liver,  sometimes  with  peritonitis  and 
perihepatitis,  (ii)  Miliary  tubercles  (in  80  per  cent.)  are  of  no  clinical 
significance,  (iii)  Hanot  maintains  that  there  is  a  primary  cirrhosis  of 
the  liver,  associated  with  tubercles,  fatty  degeneration,  tuberculous 
peritonitis  and  perihepatitis  (v.  page  167);  at  the  most  it  is  extremely 
rare,  (iv)  Tuberculous  cholangitis  begins  in  the  bile  vessels  as  small 
nodes;  breaking  down,  they  resemble  cysts  or  abscesses. 

12.  Spleen. — The  spleen  is  involved  in  45  per  cent,  of  tuberculous 
children.  Franke  collected  29  cases  of  primary  tuberculosis;  10  were 
operated  on,  AA'ith  7  recoveries.     (See  Diseases  of  Spleen.) 

IX.  Tuberculosis  of  the  Genito-urinary  Tract. — Genito-urinary  tuber- 
culosis was  described  by  Morgagni  and  by  Bayle,  but  first  fully  by 
Lichtheim,  in  the  cadaver,  and  by  Rosenstein,  Babes  and  Smith,  clinically. 
It  is  most  frequent  in  the  period  of  greatest  sexual  activity  (twentieth 
to  fortieth  year),  and  72  per  cent,  occur  in  males. 

Modes  of  Infection. — 1.  Hematogenic  Infection. — This  is  the  most 
frequent  variety.  It  occurs  in  5  per  cent,  of  cases  of  chronic  pulmonary 
tuberculosis;  76  per  cent,  of  cases  are  secondary  to  some  pulmonary 
or  perihronchial  glandular  focus ,  which  very  often  is  latent,  so  that  most, 
seemingly  primary,  foci  are  secondary.  Jani  found  tubercle  bacilli  in 
sound  testes  and  prostates  (an  invasion  in  the  death  agony). 

2.  Urogenic  Infection. — Contrary  to  the  old  doctrine,  hematogenous 
infection  of  the  kidney  descends  to  the  lower  urinary  tract,  not  vice  versa. 
Transmission  is  very  rare  by  infected  fingers,  instruments,  catheters  or 
sexual  intercourse. 

3.  Infection  by  Contiguity. — The  Fallopian  tubes  are  diseased 
in  a  third  to  a  half  of  the  cases  of  tuberculous  peritonitis.  Jani  found 
tubercle  bacilli  in  the  tubes  in  women  dying  of  phthisis.  The  bladder, 
seminal  vesicles  and  vasa  deferentia  are  rarely  invaded  j)^^  contiguitatem 
from  peritoneal,  vertebral  or  rectal  foci. 

1.  Renal  Tuberculosis. — The  kidney  in  miliary  tuberculosis  is  involved 
m  90  per  cent.,  but  without  distinguishing  symptoms.     The  common 
12 


178  BACTERIAL  DISEASES 

clinical  form  is  the  caseous-ulcerative.  Caseous  nodes  develop  in  the 
cortex,  infection  reaching  it  from  the  blood  stream  (in  90  per  cent.); 
they  often  break  do'vvn  into  cavities,  form  cold  abscesses,  undergo  second- 
ary pyogenic  infection  or  remain  localized  in  one  pole  of  the  kidney. 
Tubercles  also  develop  in  the  apices  of  the  pyramids  and  pelvis  of  the 
kidney  and  form  caseous  infiltration  and  ulcers;  Caspar,  Walker  and 
Israel  proved  that  the  process  in  41  per  cent,  of  cases  descends  from  the 
kidney  to  the  bladder.  "When  the  process  is  developed  there  is  a  tuber- 
culous pyonephrosis.  The  entire  kidney  may  become  a  large  sac  of 
caseous  material,  detritus  and  lime  salts — degenerescence  massive.  The 
kidney  is  often  adherent  to  adjacent  structures;  its  capsule  is  thickened, 
its  removal  strips  off  particles  of  renal  substance  and  it  is  sometimes 
perforated,  causing  tuberculous  paranephritis.  The  surface  of  the  kidney 
may  be  smooth  and  normal,  lumpy  from  caseous  deposits  or  softened 
from  diffuse  ulceration.  In  exceptional  cases  spontaneous  healing  is 
possible.  ^^  hether  one  or  both  kidneys  are  diseased  depends  on  the  stage 
of  the  process,  and  is  a  most  important  matter  when  surgical  interference 
is  contemplated.  Israel,  in  his  celebrated  observations,  found  one  kidney 
involved  in  90  per  cent.,  and  Pallet  and  Albarran  in  85  per  cent.  (Natu- 
rally, in  autopsy  figures,  bilateral  disease  is  greater.)  Compensatory 
hypertrophy  of  the  sound  kidney  is  frequent. 

Sy:viPTOMS. — The  symptoms  are  (a)  urinary,  (b)  local  and  (c)  general. 
These  may  be  absent  if  the  renal  pelvis  is  intact. 

(a)  Urinary. — The  urinary  symptoms  are  chiefly  those  of  pyelitis 
(q.  V.) .  The  urine  is  acid.  Urination  is  often  difficult  (dysuria)  or  frequent 
(pollakiuria),  so  that  cystitis  is  at  first  suspected;  it  is  a  safe  rule  always 
to  consider  the  iJOSsihUity  of  renal  yhtliisis  in  every  cystitis,  in  which  the 
origin  is  not  clear  and  the  treatment  unsuccessful,  and  in  every  acid, 
sterile,  purulent  urine.  In  62  per  cent,  bladder  symptoms  are  the  first 
to  appear;  they  are  reflex  from  the  kidney  lesion,  or  are  due  to  complicat- 
ing cystitis,  simple  or  tuberculous.  Guyon  describes  an  early  polyuria 
in  which  the  urine  is  clear,  and  a  later  polyuria  in  which  it  is  turbid. 
Hematuria  (q.  v.)  occurs  in  66  per  cent.;  it  may  be  severe  or  slight  and 
its  occurrence  is  more  often  early  than  late;  its  recurrence  distinguishes 
the  "hemorrhagic  type";  it  may  last  one  month  to  four  years.  Pyuria 
occurs  when  the  pelvis  is  invaded,  but  is  absent  if  cortical  foci  do  not 
communicate  withi  the  pelvis,  or  the  ureter  is  occluded;  the  amount  of 
albumin  corresponds  to  the  glistening,  shrunken  and  poorly  nucleated 
pus  cells.  Epithelial  cells,  sometimes  caseous  matter,  elastic  fibers  and 
necrotic  renal  tissue  are  found.  The  sediment  is  often  a  crumbly, 
rapidly  settling  detritus;  tubercle  bacilli  are  found  in  80  per  cent.,  but 
must  not  be  confused  with  the  smegma  bacillus  (t\  page  167);  the  anti 
formin  method  is  most  valuable  (page  167),  and  inoculations  settle  the 
diagnosis.  Sometimes  bacilli  in  the  urine  are  found  in  pulmonary 
tuberculosis  without  disease  of  the  kidneys.  Casts  are  very  infrequent. 
Ureteral  catheterization  determines  which  kidney  is  involved. 

(b)  Local. — Lumbar  pain  sometimes  results  from  capsular  tension;  it 
is  dull,  or  colicky,  and  reflected  to  the  groins  and  testes,  which  may  be 
retracted,  as  in  renal  colic;  colic  is  due  to  the  passage  of  caseous  particles 


TUBERCULOSIS  179 

or  1)1()()(1  clots;  differentiation  from  calculous  disease  (q.  r.)  may  be  diffi- 
cult until  tubercle  bacilli  are  found.  Tumor,  in  tuberculous  pyonephrosis 
or  hydronephrosis,  is  a  small,  tender  enlargement,-  seldom  of  the  size 
attained  in  calculous  or  other  obstructive  disease.  The  kidney  is  palpable 
in  one  out  of  fiA'e  cases.  X-ray  examination  frequently  shows  caseous 
foci  or  calcification. 

(c)  General. — General  symptoms  are  hectic  fever,  malnutrition  and 
other  general  toxemic  symptoms  (see  page  155),  tuberculosis  in  the 
lungs  and  foci  in  the  testes.  The  heart  almost  never  hypertrophies. 
In  60  per  cent,  of  the  cases  operated  on,  the  diagnosis  was  found  correct. 
The  course  is  chronic  and  remittent,  two,  three  or  even  five  years  being 
the  usual  duration;  frequently  there  is  prolonged  clinical  latency;  re- 
covery from  circumscribed  lesions  is  possible;  death  results  from  tuber- 
culous generalization,  less  often  from  sepsis,  perinephritis  or  amyloid 
degeneration,  and  rarely  from  nephritis  or  uremia;  in  Vienna  tubercu- 
lous meningitis  was  present  in  17  per  cent,  as  against  6  per  cent,  in  phthisis. 
The  treatment  is  surgical,  the  first  operation  being  performed  by  Simon 
(1871).  The  operative  mortality  of  nephrectomy  is  3  to  5  per  cent.,  and 
the  end  result,  in  Legueu's  and  Chevassu's  1539  collected  cases,  was  75 
per  cent,  of  recoveries. 

2.  Ureter  and  Bladder. — The  ureter  is  thickened,  infiltrated,  caseous, 
ulcerated  and  often  stenosed;  it  is  involved  in  80  per  cent,  of  cases  of 
renal  tuberculosis.  Secondary  involvement  from  the  kidney  may  be 
limited  to  the  ureter  at  its  vesical  ending.  Bladder  disease  is  almost 
invariably  secondary  per  contigidtatem  or  from  hematogenous  deposits, 
as  seen  by  means  of  the  cj^stoscope.  Israel  noted  tuberculous  cystitis 
in  41  per  cent,  of  cases  of  renal  tuberculosis  {v.  s.),  and  Vignernon  in 
50  per  cent.  Cystitis  of  long  standing  always  suggests  renal  tuberculosis, 
even  with  gonorrheal  or  other  antecedents.  Diagnosis  is  based  on  the 
bacteriology  and  cystoscope.  Rovsing  cauterizes  with  carbolic  acid  and 
Caspar  irrigates  with  bichloride.    Surgical  intervention  is  indicated. 

3.  Male  Genitalia. — The  epididymis  is  more  often  involved  than  the 
testis,  except  in  youth.  (In  early  life  testicular  disease  results  from  general- 
ized tuberculosis;  one-half  of  Jullien's  cases  occurred  under  two  years 
of  age.)  Sometimes  there  is  no  caseation,  as  in  hyperplastic  lymphadenitis, 
and  even  microscopic  confusion  with  sarcoma  is  possible  unless  the  bacilli 
are  particularly  sought.  The  process  is  bilateral  in  50  to  75  per  cent,  of 
cases.  Testicular  tuberculosis  is  most  often  confused  with  syphilis 
(</.  v.),  though  in  the  latter  there  is  less  pain  and  fever  and  more  nodular 
enlargement.  The  seminal  vesicles,  vasa  deferentia  and  urethra  may  be 
invaded  and  a  rectal  examination  should  never  be  neglected.  Recently 
the  prostate,  "the  cross  road  of  the  urinary  and  genital  tracts,"  has 
attracted  especial  attention;  its  primary  involvement  is  disputed  by 
some,  but  the  gland  is  affected  in  65  per  cent,  of  genital  tuberculosis  in 
the  male.  The  lungs  are  invaded  in  primary  genital  tuberculosis  in  70 
per  cent,  and  the  urinary  tract  in  56  per  cent.  Treatment  is  surgical. 
Carl  Rose  found  but  8  records  of  tuberculosis  of  the  penis  (1911),  aside 
from  infection  bv  ritual  circumcision  of  which  41  instances  exist  (Holt, 
1913). 


180  BACTERIAL  DISEASES 

4.  Female  Genitalia. — Local  tuberculosis  occurs  in  2  per  cent,  of 
pulmonary  tuberculosis.  Tuberculous  tubes  are  found  in  1.5  per  cent,  of 
abdominal  operations  (according  to  "W.  Williams,  8  per  cent.).  Xearly 
all  lesions  are  due  to  small  foci  in  the  bronchial  glands.  The  tubes  show 
nodules,  infiltration,  caseation  and  ulceration;  bilateral  involvement  is 
usual  and  its  true  nature  may  be  apparent  only  under  the  microscope; 
tuberculous  salpingitis  may  simulate  tuberculous  peritonitis;  tubal 
disease  may  be  found  in  very  young  children.  The  uterus  ranks  next 
and  is  involved  secondarily.  Ovarian  phthisis  is  always  secondary. 
Tuberculosis  of  the  vagina,  cervix,  vulva  and  female  urethra  is  most 
exceptional. 

]MA:vni^. — Schley  (1903)  collected  65  cases  of  which  12  were  primary; 
tuberculous  lesions  often  cause  nipple  retraction,  tumor  formation  or 
axillary  adenopathy  (66  per  cent.).  "When  cold  abscesses,  fistulse  or 
ulcers  form,  the  diagnosis  is  more  definite.  A  chronic  interstitial  non- 
tuberculous  mastitis  was  described  by  Bedor. 

X.  Tuberculosis  of  the  Upper  Respiratory  Tract. — 1.  Nose. — ^The  nose 
is  seldom  affected,  because  its  irritation  excites  sneezing  and  increased 
secretion,  inimical  to  the  tubercle  bacilli.  Thrasher  (1905)  collected 
125  cases.  In  the  rare  primary  form  there  are  very  few  bacilli  and  an 
exuberant  non-caseous  gro^-th,  which  may  resemble  sarcoma;  there  is 
little  pain  and  the  chief  s^Tuptom  is  a  chronic  corj^za.  In  the  secondary 
form  the  bacilli  are  abundant;  multiple  caseation  and  ulceration  occur 
as  in  other  localizations;  suppressed  coughing,  with  the  mouth  closed, 
is  thought  to  force  germs  into  the  nose.  Nasal  infection  may  occur 
by  picking  the  nose,  and  is  promoted  by  wounds,  ulcers  and  various 
obstructive  processes.  Infection  may  spread  by  the  lymph  vessels, 
especially  in  children,  to  the  cervical  glands  or  even  to  the  meninges. 
In  33  per  cent,  lupus  affects  the  nose  (Bender). 

2.  Nasopharynx. — Primary  involvement  is  infrequent.  Secondary 
disease,  late  in  phthisis,  occurs  in  20  per  cent. ;  it  is  promoted  by  coughing 
with  the  lips  closed.  The  third  tonsil  may  be  affected;  adenoids  are 
tuberculous  in  20  per  cent.  (Dieulafoy). 

3.  Ear. — Tuberculous  otitis  viedia  occurs  chiefly  in  late  phthisis  (32 
per  cent.).  It  is  furthered  by  measles  and  scarlatina,  is  rarely  primary, 
and  often  causes  cervical  hinphadenitis,  and  rarely,  mastoiditis. 

4.  Larsmx. — Laryngeal  phthisis  is  very  rarely  primary.  Louis,  in 
1825,  asserted  that  it  was  secondary  to  lung  disease,  resulting  from 
infection  by  sputum,  which  view  still  holds;  hematogenous  and  lympho- 
genous infection  is  rare.  Lar\Tigeal  tuberculosis  develops  in  25  per  cent, 
of  pulmonary  tuberculosis  in  adults,  and  in  3  per  cent,  in  children. 
Adjuvant  factors  are  inflammation,  fissure  and  syphilis.  In  700  cases 
Krieg  observed  unilateral  involvement  in  39  per  cent.,  of  which  92  per 
cent,  occurred  on  the  same  side  as  the  lung  lesion,  not  from  lymphatic 
extension  but  from  paresis  of  the  vocal  cord  due  to  neuritis  of  the  recurrent 
laryngeal  nerve,  and  to  stagnation  of  sputum  on  the  paralyzed  and 
anesthetic  side.    Unilateral  disease  usually  becomes  bilateral  from  contact. 

Symptoms. — In  those  rare  and  unfavorable  cases  in  which  the  trouble 
begins  icith  laryngeal  symptoms,  the  cough  is  dry  or  brassy;    it  may 


TUBERCULOSIS  181 

develop  under  the  guise  of  simple  laryngitis.  In  cases  foUoiving  ijliiJiisis, 
the  bronchitic  hack  becomes  brassy;  in  the  last  stages  it  becomes  incom- 
plete, ineffectual  or  eructative,  as  the  vocal  cords  cannot  be  apposed. 
Pain  and  hoarseness  are  followed  by  dysyhonia,  aphonia,  dyspnea  and 
distressing  dysphagia. 

Forms. — (a)  Most  commonly  the  ulcers  are  found  in  the  interarytenoid 
region,  on  the  vocal  cords,  posterior  wall  of  the  larynx  and  arytenoids; 
they  are  not  deep  but  are  broad;  their  edges  are  "nibbled,"  and  their  bases 
pale  and  sometimes  caseous.  Particles  aspirated  into  the  lungs,  cause 
tuberculous  or  suppurative  foci.  In  diagnosis,  syphilitic  ulcers  (g.  v.) 
are  more  often  single  and  redder,  have  more  "cut  out"  edges,  frequently 
show  cicatrization,  oftener  involve  the  epiglottis  and  posterior  surface 
of  the  arytenoids,  and  less  often  the  vocal  cords;  show  no  tubercle 
bacilli,  show  no  local  reaction  on  tuberculin  injection  and  respond  to 
mercury,  iodides  and  Wassermann  test.  Ninety  per  cent,  of  all  laryngeal 
necrosis  is  tuberculous.  Perichondritis  may  occasion  sudden  edema 
glottidis,  urgent  dyspnea  and  early  death  unless  timely  tracheotomy  is 
performed.  (6)  In  other  cases  the  submucous  tissues  are  infiltrated  and 
the  mucosa  is  hardened  (pachydermous  form);  the  true  cords  are  less 
involved  than  other  parts;  if  ulceration  develops  it  is  inconspicuous, 
(c)  Caseous  tumors  are  not  frequent;  they  may  precede  the  ulcerative 
form  or  occur  independently  of  it.  (d)  The  vegetative  type  exliibits  small 
excrescences  on  the  ulcers  or  on  the  intact  mucosa. 

Treatment. — Pronounced  lung  changes  exist  and  dysphagia  occasions 
rapid  emaciation.  Besides  general  treatment  (v.  i.),  local  measures, 
as  a  rule,  do  not  modify  the  process.  Insufflations  of  boric  acid,  iodol 
and  painting  with  10  per  cent,  menthol,  10  per  cent,  carbolic  acid  or  20 
per  cent,  lactic  acid  solution  (gradually  increased  to  80  per  cent.),  may 
relieve  the  local  pain;  gr.  |  of  morphine,  hypodermically,  and  10  per 
cent,  cocaine,  locally,  for  a  time  allow  the  patient  to  eat  but  finally  fail 
to  anesthetize  the  wide-spread  ulceration.  The  patient  may  be  able 
to  draw  up  milk  and  water  by  a  tube,  when  the  head  is  turned  over  the 
edge  of  the  bed.  Caustics  are  injurious.  In  Casselberry's  practice,  10 
recovered. 

XI.  Tuberculosis  of  the  Heart  and  Vessels. — (a)  Pericardium:  (v. 
Serous  Membranes),  (b)  Myocardium:  Raviart  (1906)  collected  185 
cases  of  myocardial  tubercle;  miliary  granulations  41  cases,  conglomerate 
tubercles  83,  tuberculous  infiltration  12  and  tuberculous  sclerosis  6 
cases,  (c)  Endocardium:  Norris  found  endocarditis  in  1.4  per  cent,  of 
over  11,000  phthisical  necropsies;  tuberculous  endocarditis  is  vegetative, 
very  rarely  ulcerative  or  caseous;  secondary  infection  causes  some  cases 
complicating  tuberculosis.  Pellegrini  (1912)  cites  120  cases  of  endocardial 
tuberculosis,  of  which  53  showed  tubercle  bacilli,  (d)  Few  cases  of 
primary  disease  of  the  vessels  are  reported;  18  cases  of  tuberculosis  of 
the  aorta  were  collected  by  Simmitsky  (v.  miliary  tuberculosis). 

XII.  Tuberculosis  of  the  Bones  and  Joints.— This  topic  properly 
belongs  to  surgery,  but  its  relations  demand  consideration.  Koch  first 
demonstrated  the  tuberculous  nature  of  caries,  fungus  joint  lesions  and 
tumor  albus,  and    Damsch  determined   this  relation  bv  inoculations. 


182  BACTERIAL  DISEASES 

Konig  and  Orth  found  that  80  per  cent,  of  bone  and  joint  tuberculosis 
was  clearly  secondary  to  pulmonary,  glandular,  genito-urinary  and  other 
tuberculosis.  Probably  all  cases  are  secondary  to  tuberculosis  elsewhere. 
Infection  is  hematogenic  in  the  majority  of  cases,  far  less  often  lympho- 
genic. Experimentation  shows  that  trauma  may  determine  localization 
in  animals  already  infected  with  the  Bacillus  tuberculosis.  Thirty-three 
per  cent,  of  the  cases  occur  in  the  first  decade  of  life,  and  50  per  cent, 
in  the  first  two  decades.  Tuberculosis  in  children  involves  the  bones 
and  joints  in  22  per  cent,  of  cases  (versus  3  per  cent,  of  adult  phthisis). 
Bovine  bacilli  cause  a  certain  proportion  of  tuberculous  osteopathies. 

Localization. — Watson  Cheyne  estimates  that  the  knee  is  affected 
in  16.5  per  cent,  of  cases,  the  hip  in  14,6,  tarsus  and  ankle  in  14.4,  elbow 
in  6.3,  skull  and  face  in  5.5,  sternum,  clavicle  and  ribs  in  5.2,  pelvic 
bones  in  3.5,  femur,  fibula  and  tibia  in  3.5,  spine  in  2.3,  shoulder  in  1.5 
and  scapula,  ulna  and  radius  in  1  per  cent.  Jaffe  finds  involvement  of 
the  spine  in  20,  foot  in  21,  hip  in  13,  knee  in  10,  hand  in  9  and  elbow  in 
4  per  cent. 

1.  Bones. — ^The  spongy  epiphyses  of  the  long  bones  are  the  particular 
seat  of  tuberculous  osteomyelitis  and  periostitis,  whence  infection  easily 
reaches  the  joints;  the  diaphyses  and  flat  bones  are  seldom  involved. 
Involvement  of  the  fingers  and  toes,  less  often  of  the  ulna,  may  cause 
bulging — the  spina  ventosa,  seen  oftenest  at  about  five  years   of   age. 

In  the  bone-marrow  there  develops  a  grayish-red  granuloma  which 
dissolves  the  bone  {caries  sicca) ;  the  trabeculse  necrose  and  are  discharged 
through  fistulse  as  sequesters  or  "bone  sand,"  in  a  caseous,  pus-like  fluid. 
Even  large  foci  may  heal  by  granulating  osteitis.  Infection  may  remain 
semiquiescent  until  aroused  by  mixed  infection  or  trauma.  Cold  abscesses 
are  lined  by  granulation  tissue.  There  may  be  local  tenderness,  stiffness, 
fever  and  nocturnal  pain.  Bore  lesions  are  not  incompatible  with 
otherwise  robust  health.  Landouzy's  camptodactyly  is  a  bending  of 
the  fourth  and  fifth  fingers  which  can  be  flexed  but  not  extended. 

2.  Joints.— Involvement  generally  follows  contiguous  osseous  disease. 
Very  often  there  is  synovial  inflammation  and  proliferation;  far  less 
frequently  there  are  isolated  tubercles  in  a  non-inflamed  synovial  sac. 
Serous  or  serofibrinous  synovitis  (or  the  rice  bodies,  corpora  orzyoidea) 
may  result  from  toxins  in  a  neighboring  osseous  focus,  without  the  actual 
presence  of  tubercle  bacilli.  The  symptoms  of  onset  may  be  acute  or 
insidious.  Pain,  especially  at  night,  contractures  and  fever  may  be 
noted.  In  the  later  stages  of  joint  disease  granulation  tissue  forms  with 
large  caseous  deposits,  hydrops,  empyema  articulorum  or  the  tumor 
albus  (so  named  because  of  the  thickening  of  the  connective  tissue,  the 
edema  and  glistening  appearance  of  the  periarticular  structures).  The 
joint  is  sometimes  disorganized.  Twenty-five  per  cent,  recover  under 
immobilization,  iodoform  injections,  a^-rays.  Bier's  stasis,  heat  and  sea 
air. 

Poncet  first  called  attention  to  a  tuberculous  pseudorheumatism,  which 
closely  resembles  rheumatism  {rheumatisme  tuberculeuse  ankylosante) . 
Poncet  maintains  that  5  to  17  per  cent,  of  active,  and  20  per  cent,  of 
chronic  phthisics  have  pseudorheumatism  and  40  to  50  per   cent,  of 


TUBERCULOSIS  183 

patients  with  chronic  deforming  rheumatism  are  tuberculous.  It  is 
affirmed  that  the  exuded  leukocytes  are  of  the  lymphocyte  type;  inocula- 
tions have  proven  positive  in  a  number  of  cases,  but  toxemia  is  the  most 
probable  cause.  It  is  most  frequent  in  children.  Lejars  found  one  case 
of  primary  tuberculosis  of  the  muscles. 

Xni.  Tuberculosis  of  the  Skin. — 1.  Lupus. — ^Lupus,  the  most  frequent 
form,  in  66  per  cent,  of  cases  is  located  on  the  nose,  lips  and  angle  of  the 
eye.  It  occurs  with  pulmonary  tuberculosis  in  21  per  cent,  and  other 
tuberculosis  in  62  per  cent.  It  is  typical  granulation  tissue  with  true 
tuberculous  tumors,  which  contain  few  bacilli  and  often  advances  on  one 
border  while  it  cicatrizes  on  another. 

2.  Scrofuloderma.- — This  granuloma  appears  as  movable,  painless, 
subcutaneous  nodes,  which  later  become  cold  abscesses  (the  so-called 
scrofulous  gumma,  gomme  scrofuleuse) ;  they  discharge  a  milky  fluid  and 
leave  a  sharply  marked  granulating  ulcer. 

3.  Lichen. — Lichen  scrofulosorum  is  often  tuberculous;  the  eruption 
originates  from  the  follicles  and  is  constituted  of  thick,  oily,  epidermal 
cells  removable  without  bleeding,  and  distributed  in  sharply  marked 
groups  of  yellow-brown  nodules  as  large  as  a  pin-head. 

4.  Tuberculosis  Cutis. — Tuberculosis  cutis  verrucosa  of  Riehl  and 
Paltauf  is  observed  on  the  backs  of  the  hands  and  fingers  and  in  the 
interdigital  folds,  chiefly  in  butchers,  cooks  and  horsemen. 

5.  Postmortem  Tubercles. — Laennec  referred  his  pulmonary  phthisis, 
though  probably  incorrectly,  to  a  postmortem  tubercle.  Gerber  suffered 
from  tuberculosis  of  the  axillary  glands  following  a  tubercle.  They  are 
observed  in  butchers,  veterinary  surgeons  and  pathologists,  especially 
in  those  beyond  middle  life. 

6.  Ulcers. — Tuberculous  ulcers  may  develop  from  cuts  by  broken 
sputum  cups,  bites  of  tuberculous  subjects,  ants  or  flies,  burns,  tattooing, 
skin  grafting,  circumcision  or  vaccination. 

Treatment  of  Tuberculosis.  —  {A)  Prophylaxis.  —  1.  Antibacillary 
PREVENTION  conccms  the  etiological  factors  in  the  dissemination  of  the 
bacillus.  Cleanliness  of  the  skin;  disinfection  of  contaminated  feces, 
urine  or  pus;  confiscation  of  diseased  meat;  and  regulation  of  dairies 
and  inspection  of  cows  are  important;  but  the  destruction  of  infectke 
sindum  is  the  prime  indication.  Tuberculous,  pneumonic,  grippal  and 
other  sputa  must  be  destroyed.  An  appeal  is  made  to  the  conscience 
or  selfishness  of  tuberculous  patients,  setting  forth  the  risks  of  auto- 
reinfection.  Of  all  educators.  Biggs,  of  New  York,  and  Flick,  of  Phila- 
delphia, have  rendered  the  greatest  service.  Patients  should  carry  small 
spit  cups,  of  which  Dettweiler's  and  Major  Appel's  are  the  best;  the 
sputum  should  be  burned  or  boiled  before  it  dries.  Spittoons  are  danger- 
ous. The  patient  should  sleep  alone,  and  kissing  must  be  interdicted. 
The  bedclothes,  linen  and  eating  utensils  should  be  steamed  or  boiled. 
Rooms  should  be  cleaned  with  moist  cloths  and  swept  with  the  windows 
and  doors  open.  The  danger  of  swallowing  sputum  must  be  set  forth, 
and  the  mouth  washed  out  with  some  antiseptic  before  eating,  though  a 
few  bacilli  with  the  food  are  probably  destroyed  by  the  gastric  juice. 


184  BACTERIAL  DISEASES 

In  Germany  the  reduction  of  mortality  by  33  per  cent,  is  clearly  due 
to  an  awakened  public  intelligence.  The  dangers  of  overcrowding, 
public  conveyances  and  foul  air,  are  already  impressed  upon  the  public, 
yet  public  school  ventilation  remains  a  scandal. 

2.  Governmental  Prophylaxis,  less  promising  in  republican  than 
in  autocratic  states,  is  important.  It  comprises:  Education  of  the 
public  by  publication  of  the  dangers  and  preventive  measures  in  tuber- 
culosis; the  establishment  of  sanatoria  for  the  poor,  among  whom  the 
mortality  is  four  times,  and  the  morbidity  many  times  greater  than  in  the 
rich;  the  building  of  separate  wards  for  the  hopelessly  diseased;  the 
reporting  of  the  disease;  and  the  regulation  of  the  air  capacity  of  dwelling 
rooms,  in  tenements,  factories  and  stores.  Aside  from  great  suffering 
and  sorrow  of  thousands  in  every  large  community,  there  is  an  enormous 
economical  waste  in  work  and  wages,  an  enormous  cost  in  hospital  care 
and  a  great  loss  in  live  stock.  The  sociological  damage  is  apparent,  as 
the  ravages  of  tuberculosis  involve  the  working  years  of  life  (15  to  60), 
while  94  per  cent,  of  deaths  from  diphtheria  occur  under  ten  years. 

3.  Individual  Prophylaxis  concerns  increasing  physiological  resist- 
ance and  promoting  sound  development  in  children.  Weakly  children 
should  be  brought  up  and  taught  in  the  open  air,  judiciously  fed,  watched 
during  acute  infections,  sent  into  the  country  during  vacation,  taught 
moderation  and  later,  should  be  informed  as  to  the  danger  of  alcoholism, 
sexual  excesses  and  infections.  Milk  and  cream  should  be  pasteurized 
or  better,  boiled. 

(B)  Hygienic  Treatment. — ^The  three  great  factors  are  fresh  air,  proper 
food  and  rest.  Bodington  (1839),  in  England,  treated  cases  by  fresh  air, 
but  to  Brehmer  (1850),  in  Germany,  is  due  the  credit  of  soundly  estab- 
lishing the  fresh-air  treatment  and  the  curability  of  phthisis.  A  few  of 
his  views  are  untenable,  but  many  of  them  are  the  basis  of  the  modern 
methods  practised  by  McCormack,  Driver,  Dettweiler,  Trudeau,  Knopf 
and  others.  Patients  were  treated  in  sanatoria,  and  those  at  Nordrach 
and  Saranac  and  many  others,  have  given  such  excellent  results  that 
institutions  of  this  class  in  America  number  almost  three  hundred. 
Results  depend  on  (a)  the  extent  of  the  disease;  (b)  the  condition  of  organs 
other  than  the  lungs,  as  the  pleura,  intestines,  larynx  and  heart;  and  (c) 
the  social  status  of  the  case.  Trudeau  brought  about  recovery  in  31 
per  cent,  of  all,  and  in  66  per  cent,  of  incipient,  cases;  Rumpf  followed 
97  per  cent,  of  his  cases :  70  per  cent,  of  incipient  cases  were  able  to  work — 
"the  best  test  of  a  cure";  55  per  cent,  of  those  in  the  second  stage 
and  23  per  cent,  of  those  in  the  third,  recovered.  The  chief  value  of 
sanatorium  treatment  is  that  the  patient  learns  the  lesson  of  living 
properly. 

1.  Fresh  Air. — This  is  the  chief  hygienic  factor  in  treatment,  at 
home,  in  sanatoria  or  in  change  of  climate,  (a)  Treatment  at  home  is 
especially  important,  as  but  5  per  cent,  of  tuberculous  people  are  able  to 
leave  home.  The  patient  should  be  carefully  clothed  and  recline  in  the 
sun  with  the  windows  of  his  room  open,  or  lie  on  a  veranda,  one-quarter 
to  one-half  the  sunny  hours,  according  to  the  season.  At  night  the 
patient's  bed  can  be  brought  to  an  open  window,  from  which  "  a  window 


1 


TUBERCULOSIS  185 

tent"  of  canvas  encloses  the  head  and  leaves  him  ont  of  doors.  Rain, 
snow,  dampness  and  extreme  cold  are  no  contra-indications,  nor  are  fever, 
cough  and  hemoptysis;  but  wind,  dust  and  sudden  variations  in  tempera- 
ture are  to  be  avoided.  Very  thick  clothing,  so  frequently  observed  among 
the  poor,  is  unhygienic.  Acute  caseous  and  advanced  types  generally 
should  be  kept  at  home.  Extreme  care  in  disinfection  is  imperative 
lest  the  home  become  a  menace  to  the  family.  For  those  unable  to  obtain 
sanatorium  treatment,  "classes"  have  proved  of  the  greatest  value 
(Pratt).  (6)  Sanatorium  treatment  offers  the  advantage  of  strict  discipline, 
systematic  living  and  the  constant  regulation  of  the  details  of  every- 
day life  by  a  physician.  Sanatoria  should  be  located  well  outside  of 
every  large  centre  of  population,  (c)  Change  of  climate  w^as  once  con- 
sidered absolutely  indispensable;  now  it  is  said  "to  be  not  without 
influence."  No  climate  is  specific  but  many  offer  advantages  over 
the  northern  climate.  High  altitudes  give  purer  air,  stimulation  of 
breathing,  increase  of  the  chest  dimensions,  growth  of  the  muscles  of 
inspiration,  increase  of  metabolism  and  stimulation  of  the  appetite  and 
blood-making  organs.  Colorado,  Arizona  and  New  Mexico  (4000  to  7000 
feet  elevation)  are  excellent  for  opportunities  to  secure  permanent 
occupation  after  recovery;  because  of  the  emphysema  induced  by 
altitudes,  a  return  to  the  sea  level  should  be  avoided.  St.  Moritz,  Les 
Avants  and  Davos  (5200  feet  elevation)  offer  a  dry,  clear,  cold,  still 
atmosphere,  where  patients  may  reside  summer  and  winter;  it  resembles 
the  climate  of  Colorado,  Montana  and  northern  Wyoming.  There  are 
also  the  Peruvian  Andes  and  numerous  other  altitudes  (see  Solly's 
Climatology).  High  altitudes  are  best  adapted  to  those  with  incipient 
lesions,  slight  cavity  formation  and  little  emaciation,  or  slowly  pro- 
gressing or  torpid  cases.  Slight  fever  and  slight  hemoptysis  are  not 
contra-indications;  emphysema,  weak  heart,  constant  fever,  great 
nervousness  or  repeated  hemoptysis  are  contra-indications.  Moderate 
altitudes  (2000  to  2500  feet)  best  serve  the  majority  of  cases,  as  Asheville 
(2250  feet),  the  Adirondacks  (2000  feet),  Aikin  (2250  feet),  Summer- 
ville,  Thomasville,  etc.  The  climate  of  Minnesota,  Nebraska  and  Dakota 
(1000  feet  elevation)  is  cool  and  dry;  dryness  is  more  desirable  than  lack 
of  variability.  Moderate  elevations  do  not  induce  emphysema,  whence 
return  to  the  sea  level  is  easier.  The  sea  level  is  best  for  the  tuberculous 
aged,  quiescent  cases  with  great  cicatrization  or  extensive  damage,  those 
with  diabetes,  albuminuria,  nephritis,  bone  disease,  marked  anemia, 
repeated  hemoptysis,  emphysema  or  rapid  softening,  incurable  forms, 
thin,  nervous  and  exophthalmic  subjects.  Sea  voyages  are  experimental; 
those  with  incipient  forms,  genito-urinary,  glandular  or  osseous  disease 
or  open  wounds  are  often  helped.  Moist,  warm  climates  at  the  sea  level 
are  especially  adapted  to  laryngeal  disease — as  the  Bermudas,  Florida, 
the  Madeira  or  Canary  Islands;  patients  with  dyspepsia  and  diarrhea 
do  well  in  Corsica,  Palermo  and  Capri.  Warm,  dry  climates,  as  southern 
California,  Egypt,  Algiers  or  the  Riviera  are  good  for  catarrhal  types. 
Climate  alone,  without  reasonable  hygiene,  rarely  benefits.  Direct 
exposure  of  the  body  to  the  sun  (heliotherapy)  is  advocated,  especially 
in  surgical  tuberculosis. 


186  BACTERIAL  DISEASES 

2.  Nutrition. — ^Nlost  physicians  recommend  5  or  6  meals  daily,  but 
better  results  are  often  achieved  by  3  meals,  whereby  the  stomach  is 
allowed  rest.  Feeding  requires  individualization.  The  staple  diet  is 
meat,  eggs,  milk,, cream  and  butter,  fish,  well-cooked  leguminous  vegetables 
(advantageously  given  in  soups),  oil  on  salads,  bread,  pastries  and 
cakes.  If  anorexia  is  of  the  nervous  t\'pe,  patients  must  be  compelled 
to  eat,  but  long  hours  in  the  fresh  air  usually  stimulate  the  appetite. 
With  habitually  light  eaters  caution  is  necessary;  beef-juice,  milk  and 
koumyss  should  be  given;  the  amount  should  be  gradually  increased 
and  other  foods  added.  Wine,  vermouth,  fluidextract  of  condurango 
TTlxv-xxx  or  strychnine,  gr.  -^  in  solution,  half  an  hour  before  meals, 
are  valuable  appetizers.  Raw  beef  (zomo therapy)  was  recommended 
by  Richet  and  Hericourt;  fresh  lean  meat  is  cut,  soaked  in  one-fifth 
its  weight  of  water,  pressed  to  extract  the  blood  and  fluid,  and  adminis- 
tered; it  must  be  freshly  prepared,  as  it  soon  becomes  tainted.  Raw 
eggs  are  often  given  between  or  just  before  meals,  beginning  with  1  and 
increasing  to  4,  three  times  daily,  the  taste  being  disguised  by  orange- 
juice.  Fever  does  not  contra-indicate  full  feeding.  More  than  1|  quarts 
of  milk  induces  gastric  atony;  it  is  given  to  advantage  with  bread, 
crackers  or  toast,  in  order  to  divide  the  curds;  it  may  be  peptonized, 
disguised  with  cocoa  or  cognac  or  given  by  the  rectum  (v.  Gastric  Ulcer)  ; 
cream  and  butter  are  excellent  substitutes  for  cod-liver  oil,  and  buttermilk 
is  indicated  when  the  stomach  is  weak.  Fats  and  carbohydrates  are 
necessary  to  offset   nitrogenous   waste;  the  dark  form  of  cod-liver  oil 

,  {v.  i.),  lipanin  (94  parts  olive  oil  and  6  parts  oleic  acid),  malt,  honey 
and  cocoa  are  valuable.  In  overfeeding  {sur alimentation)  the  tolerance 
of  the  stomach  must  he  considered;  Debove's  method  consists  of  gastric 
lavage  followed  by  the  introduction  through  the  tube  of  three  ounces  of 
powdered  meat,  a  quart  of  milk  and  three  eggs.  Alcohol,  administered 
less  often  and  in  smaller  amounts  than  formerly,  is  frequently  indicated 
symptomatically  {v.i.);  small  amounts  of  red  wine  or  cognac  and  whisky 
in  egg-nogs  are  very  valuable  as  a  food  and  tonic.  Tobacco  should  be 
interdicted;  in  special  cases  a  cigar  or  two  daily  may  be  allowed,  but  the 
smoke  must  never  be  inhaled. 

3.  Rest. — Rest  is  one  essential  in  Dettweiler's  therapy.  Patients 
should  lie  in  the  bright  sunshine  and  fresh  air,  and  active  mental  occu- 
pation should  be  carefully  avoided.  Exercise  destroys  tissue,  induces 
anemia  and  irritates  the  heart;  it  is  distinctly  contra-indicated  by  fever, 
emaciation,  hemoptysis,  rapid  pulse,  nausea  and  coughing.  "Too 
many  cases  of  phthisis  toalk  into  their  graves."  Late  in  the  treatment 
graduated  exercise  may  be  taken.  Pulmonary  gymnastics  and  pneumatic 
difi^erentiation  are  clearly  injurious.  Hardening  and  exercise  should  be 
obtained  by  quick,  dry  rubs  with  a  large,  coarse  towel,  after  which  rapid 
partial,  and  then  general,  wet  rubs  may  be  instituted;  hydrotherapy 
is  shunned  when  there  is  any  tendency  to  hemoptysis. 

(C)  Specifics. — As  yet  there  is  no  specific  for  tuberculosis. 

Tuberculin  Therapy. — (i)  Theory  of  Action. — Tuberculin  is  an  endo- 
toxin and  not  a  toxmi"  Its  injection  causes  an  increase  in  antibodies 
(opsonins,  agglutinins  and  precipitins)  and  an  increased  tolerance  of  the 


TUBERCULOSIS  187 

tuberculin;  unhappily,  however,  increased  tolerance  to  tuberculin  is 
not  identical  with  immunity,  as  is  demonstrated  clinically  at  autopsy 
and  in  animals.  The  immune  substances  may  be  antitoxic  but  possibly 
not  bacteriolytic.  In  treatment  it  is  not  specific  but  merely  accessory, 
(ii)  The  indications  are:  Incipient  subjects  who  are  well  nourished, 
without  fever  and  come  to  a  stand-still  after  some  improvement,  (iii) 
The  contra-indications  embrace  malnutrition,  rapid  wasting,  profound 
toxemia,  pronounced  fever,  acute  phthisis,  rapid  heart  action,  nephritis 
and  great  nervousness,  (iv)  Dosage  is  solely  empirical,  since  there  is 
no  scientific  gauge  of  tolerance  (Wright's  opsonic  index  and  other  methods 
are  open  to  error).  'Carelessly  used,  tuberculin  is  dangerous.  Of  the  "old 
tuberculin"  (O.T.);  the  initial  dose  should  be  0.0000001  gm.;  the  initial 
dosage  for  the  "bacillus  emulsion"  (B.E.)  is  0.00000001  gm.,  increasing 
gradually  toward  the.3ecimal  point,  every  three  days  at  first,  and  later  once 
a  week  between  doses.  The  maximum  dose  of  O.  T.  is  0.0001  and  B.E. 
0.0005;  the  course  is  5  months,  interrupted  when  coryza,  cough,  indiges- 
tion, fever,  emaciation  or  hemoptysis  intervenes,  (v)  Results:  Trudeau 
conservatively  states  that  "tuberculin  immunizes,  prolongs  life,  causes 
the  bacilli  to  disappear  from  the  sputum,  aborts  commencing  infection 
and  also  the  smouldering  fires  of  chronic  infection."  The  subject  is  still 
sub  judice  and  as  one  writer  puts  it,  "a  chaos  of  personal  impressions." 

(D)  Expectant  or  Symptomatic  Treatment. — 1.  Fever. — Rest,  digest- 
ible food,  fresh  air  and  change  of  climate  are  indicated  in  great  preference 
to  drugs.  Strong  wine  may  be  administered  as  the  fever  begins  to  rise; 
arsenic  is  recommended,  but  no  remedy  in  safe  doses  controls  fever. 
Quinine  disturbs  the  digestion.    Sponging  is  efficacious. 

2.  Cough. — ^A  slight  morning  cough,  removing  secretion,  needs  no 
restraint,  but,  if  excessive,  it  begets  coughing  by  congesting  the  lungs, 
and  its  consecutive  exhaustion,  insomnia,  aspiration  and  vomiting 
necessitate  interference.  Fresh  air  and  avoidance  of  dirt,  dust  and 
smoke  are  most  beneficial.  Rest,  especially  after  eating,  should  be  en- 
forced. The  cough  is  somewhat  under  the  control  of  the  will,  as  Galen 
knew;  the  comment  on  its  absence,  especially  at  the  table,  is  universal 
among  observers  of  sanatorium  methods;  slow  breathing,  with  the  head 
slightly  thrown  back,  or  the  sipping  of  warm  water,  with  10  grains  of 
salt,  before  meals  often  aids  in  suppressing  the  emetic  cough.  Creosote 
discovered  by  Reichenbach,  in  1832,  is  not  specific,  but  often  increases 
the  appetite,  modifies  abundant  secretion  from  the  bronchi  (by  which 
the  drug  is  in  part  eliminated),  and  relieves  the  cough.  Administration 
in  the  fluid  form  is  best,  beginning  with  one  drop,  well  diluted,  after 
meals,  and  increasing  to  ten  drops;  full  dosage  often  irritates  the  stomach 
and  kidneys;  it  should  not  be  given  in  febrile  cases  or  in  hemoptysis. 
Creosote  may  be  administered  in  milk,  water,  gentian  or  sherry  wine: 

I^ — Creosoti 3iss 

Glycerini Bss 

Tr.  gentiange  co Siv 

M.  et  S. — One  teaspoonful  after  meals,  well  diluted. 

I^ — Creosoti 3iss 

Mucilag.  acaciae 5iij 

Pulv.  althaese q.  s. 

M.  et  far  pilulas  IC^. 
S. — Oue  after  meals. 


188  BACTERIAL  DISEASES 

Guaiacol  carbonate  is  better  tolerated  and  is  cheaper: 

I^ — Guaiacolis  carbonatis 5iij 

Strychninse  nitratis, 

Arseni  triosidi aa     gr.  iss 

Sparteinae  sulphatis gr.  xlv 

M.  et  fac  chartulas  40. 

Sig. — Odp  powder  after  meals. 

Cod-liver  oil,  first  used  by  Hughes-Bennett,  is  usually  given  in  full  doses 
which  disturb  digestion;  the  first  dose  should  be  10  drops  and  the  amount 
gradually  increased.  It  is  most  valuable  in  tuberculosis  of  the  glands 
and  bones.  Eructations  can  be  avoided  by  administration  one  hour 
after  meals,  when  the  food  leaves  the  stomach.  The  oil  is  readily  absorbed 
because  of  the  bile  contained;  it  is  possibly  alterative  but  is  not  superior 
to  butter  or  cream.  It  may  be  floated  on  whisky,  beer  or  milk,  and 
gulped  do\\Ti.  Its  taste  may  be  partly  disguised  by  using  s\Tup  of 
orange,  capsules,  or  a  "chaser"  of  whisky.  Opiates  may  be  used, 
such  as  paregoric;  codeine  gr.  |  with  aq.  laurocerasi  and  glycerin  aa 
T^.x^'  and  syr.  tolutani  5j  ^.•  i-  d.;  heroine  gr.  -^2  ^•  i-  d.;  even  morphine 
sulp.  gr.  I  with  ac.  hydrocyanici  dil.  ITlij;  myrtol  gr.  ij,  a.m.  and  p.m.; 
terpin  hydrate  gr.  ij-v,  t.  i.  d.;  and  ol.  terebinthinseTTtij.  (See  formulae 
under  Beoxchitis.) 

IJ — Tr.  belladomiEe 5ss 

Spts.  chJoroformi 5  iss 

Alucilag.  acaciiB 5i 

Aquae q.  s.  ad.  Siij 

M.  et  S. — One  teaspoonful  after  meals,  or  as  indicated. 

Expectorants  are  to  be  avoided  because  of  their  nauseating  tendencies. 
Tr.  benzoin  co.,  1  per  cent,  phenol,  and  creosote  may  be  vaporized. 
The  nasopharyngeal  mucosa  may  be  painted  with  iodine,  potas.  iodide 
and  glycerin  in  proportions  of  1,  10  and  100;  or  20  per  cent,  menthol 
applied  locally  {v.  Laryngeal  Tuberculosis). 

3.  Sweats.: — ^The  room  should  be  cool  at  night,  the  bed  not  too  heavily 
covered,  and  the  body  protected  by  a  flannel  night-gown.  A  glass  of 
cold  milk,  with  5ij  of  cognac,  given  at  bedtime,  is  often  beneficial  or 
morphine  when  sweats  are  associated  with  cough  and  msufficient  oxy- 
genation. Atropine  gr.  y^  to  -^,  and  camphoric  acid  gr.  xv  to  xxx, 
at  bedtime,  are  superior  to  aromatic  sulphuric  acid  TTLx  to  xx,  agaricin  gr. 
yV  to  iV,  tr.  nucis  vomicae  TTLxxx,  picrotoxin  gr.  -^  and  muscarin  TTlv 
of  a  1  per  cent,  solution. 

I^ — QuininEe  sulph oss 

Calcii  hj'pophosphitis .      .      oij 

Extr.  nucis  vomicae gr.  v 

M.  et  fac  pilulas  20. 
S. — One  after  meals, 

4.  Hemopttsis. — ^Exertion,  loud  talking  or  singing  and  excesses  in 
alcohol,  venery,  coffee  or  tobacco,  must  be  shunned  in  all  cases.  It 
is  well  to  warn  patients  of  the  possibility  of  hemoptysis,  in  order  to 
prevent  undue  excitement,  if  it  appears.     Eftusive  pleurisy  should  not 


TUBERCULOSIS 


189 


be  tapped  in  recent  bleeding  from  the  lungs,  as  thoracocentesis  has  pro- 
duced fatal  hemoptysis,   The  indications  are  absolute  physical  and  mental 
rest  the  semirecumbent  posture  and  silence;  massage  and  stimulants  are 
contra-indicated;  no  physical  examination  should  be  made  except  by 
auscultation,  as  percussion  is  obviously  dangerous;  and  a  hypodermic 
of  morjMne  should  be  given  to  lessen  cough,  quiet  the  heart  and  allay 
the  excitement  attending  most  hemorrhages.    As  the  tonus  of  the  pul- 
monary vessels  is  beyond    regulation,  ergotin,  tannic  acid  and  other 
hemostatics  are  useless,  though  digitalis  and  fresh  suprarenal  extract 
gr  ii-v  are  sometimes  efficacious.    Salt  3  j  is  a  popular  remedy  and  is 
supposed  to  act  by  stimulating  the  vagus.    An  ice-bag  should  be  placed 
over  the  heart  and  one  over  the  lung,  if  rales  are  heard.    Deep  breathing 
seems  to  lessen  bleeding.    Calcium  lactate  gr.  xv  1. 1.  d.  for  two  days  is 
valuable.    Amyl  nitrite,  recommended  by  F.  Hare,  is  given  at  midnight, 
when  the  vasomotor  centre  is  regaining  its  tone,  lost  during  sleep.     01. 
terebinthiiiffi  lUij-iij    is    considered   the    best   drug   by   FrantzeL      In 
severe  or  recurrent  hemorrhage,  bandaging  of  the  extremities  (Hippo- 
crates), to  lessen  the  return  flow  of  blood,  or  injection  of  horse  serum 
may  be  indicated.     As  a  last  resort  in  hemoptysis,  or  in  cavity^ forma- 
tion, artificial  pneumothorax  has  been  advocated  (Morton,  1833).^ 

5.  Pain.— Pleuritic  pain  is  treated  by  adhesive  straps;  if  muscular 
it  is  treated  by  codeine,  fomentations  or  phenacetin. 

6.  Dyspnea.— If  due  to  stagnant  secretion,  change  of  posture  aids 
in  its  evacuation;  if  asthmatic,  iodide  gr.  iij  is  indicated,  but  with  care 
lest  it  congest  the  lungs;  if  cardiac,  digitalis  or  strychnine  is  indicated. 

7.  Cardiac  Weakness.— Rest,  an  ice-bag  over  the  precordia,  cham- 
pagne, camphor,  strychnine  or  digitalis  are  in  order. 

8.  Insomnia.— The  patient  should  have  fresh  air  night  and  day,  a 
light,  early  evening  meal,  a  glass  of  beer,  porter  or  some  whisky  on 
retiring.    Bromides,  codeine  and  morphine  are  beneficial.  ^ 

9.  Gastro-intestinal  Symptoms.— Nervous  anorexia  is  relieved  by 
fresh  air,  forced  feeding  and  guaiacol  {v.  s.).  Dyspeptic  symptoms  neces- 
sitate a  scant  diet  and  feeding  by  rectum.  In  gastric  atony,  frequent 
meals  of  small  volume,  limitation  of  fluids  and  strychnine  are  indicated. 
For  gas  formation  or  pain  the  following  are  indicated;  phenolmj ;  resorcin 
gr.  iij ;  bismuth  gr.  x;  extr.  belladonnse  or  spts.  chloroformilUxx.  Pyrosis 
may  be  corrected  by  sod.  bicarb,  and  magnesia  carb.  aa  gr.  xxx.  Hyper- 
acidity demands  a  milk  diet,  belladonna,  Carlsbad  water  and  alkalies; 
anacidity  is  relieved  by  easily  digested  foods  and  hydrochloric  acid. 
Vomiting  is  caused  by  the  cough,  overfeeding,  overmedication  or  irrita- 
tion of  the  pharynx  (Lugol's  solution  locally,  or  gargles  1  to  10  of  pot. 
bromide);  small  doses  of  carbolic  acid  are  most  successful  (v.  Typhoid). 
Constipation  (g.  v.)  is  treated  by  the  usual  measures.  Diarrhea  may  be 
dyspeptic,  toxemic,  ulcerative  or  amyloid;  the  following  are  indicated: 

1  Nitrogen  gas  is  injected,  under  manometric  control,  no  gas  being  injected  till  the  column 
oscillates  several  centimeters  with  each  inspiration  (whereby  it  is  claimed  that  gas  embohsm, 
subcutaneous  emphysema  and  pulmonary  perforation  are  avoided);  300-700  c.c.  naay  be 
injected.  Contra-indications  are  bilateral  involvement,  dry  or  effusive  pleurisy,  cardiorenai 
disease  or  great  debility.  In  all  probability,  the  revival  of  this  method  will  i-esult  in  a 
repetition  of  the  former  fiasco.     Some  3000  cases  have  been  treated,  with  some  fatalities. 


190  BACTERIAL  DISEASES 

tannic   acid   gr.   v;    opium  gr.  j;  lead  acetate  gr.  ij;  camphor   gr.  ij; 
tannigen  gr.  vij-xv,  or  bismuth  5i  (see  Typhoid). 

10.  Anemia. — This  is  benefited  by  fresh  air,  change  to  a  high  altitude, 
full  diet,  iron  in  small  doses  and  arsenic. 

11.  Sexual  Symptoms. — Intercourse  must  be  forbidden  in  incipient 
as  well  as  in  advanced  cases.  Three  years  after  recovery  marriage  may 
sometimes  be  allowed;  it  is  generally  less  injurious  to  men  than  to 
women.  Tuberculous  parents  may  rear  healthy  children,  but  tuber- 
culosis (''scrofula")  is  common.  In  66  per  cent,  of  pregnant  tuberculous 
women  the  prognosis  is  bad,  and  laryngeal  tuberculosis  is  almost  in- 
variably fatal  within  a  short  time.  In  severe  cases  abortion  may  be  con- 
templated; Martin  and  Schauta  advise  abortion,  but  in  70  per  cent, 
of  cases  abortion  does  not  alter  the  clinical  course. 

12.  Treatment  of  Other  Complications. — (v.  s.) 


LEPROSY. 

Definition. — A  chronic  incurable  contagion,  caused  by  the  Bacillus 
leprae  and  characterized  clinically  by  nodules,  which  are  observed  ex- 
ternally and  internally  in  many  organs ;  or  by  perineuritis  leprosa,  which 
causes  sensory,  motor  and  other  symptoms. 

Distribution. — The  home  of  leprosy  is  Egypt,  where  it  existed  2400 
or  even  4620  B.C.  The  leprosy  of  Leviticus  probably  includes  other 
diseases.  It  prevailed  in  India  700,  and  in  China  400  years  B.C. 
Just  before  the  Christian  era,  Pompey's  soldiers  brought  leprosy  to 
Italy,  whence  it  spread  over  Europe  and  the  Crusaders  at  the  end  of 
the  thirteenth  century  further  disseminated  the  disease.  In  Europe  there 
were  20,000  asylums,  but  many  cases  were  probably  syphilis;  the  disease 
has  steadily  decreased  since  the  sixteenth  century.  It  is  estimated  that 
at  present  there  are  3,000,000  cases  in  the  world.  Cases  are  found  in 
Europe,  Asia,  Africa  and  America  (New  Brunswick,  Nova  Scotia  and 
British  Columbia) ;  in  the  United  States  (California,  Louisiana,  Minne- 
sota, North  Dakota,  Florida;  in  1912  there  were  146  lepers  in  this 
country,  of  whom  half  were  native  born). 

Bacteriology. — The  Bacilhis  lepras  was  found  by  Hansen  (1871)  and 
fully  described  by  Neisser  (1879).  It  is  a  fine,  narrow  rod,  measuring 
^  to  f  of  a  red  cell,  and  closely  resembles  the  tubercle  bacillus  mor- 
phologically and  in  its  staining  properties;  both  bacilli  contain  fat. 
Inoculation  is  the  surest  differential  criterion.  In  the  internal  viscera 
it  may  exceed  the  dimensions  attained  in  the  skin  and  mucosse  five  or 
six  times.  It  is  motile  and  has  been  cultivated.  It  is  found  in  the 
typical  nodes  and  infiltrations  of  the  skin  and  upper  mucosae,  fresh 
maculae  and  recent  nerve  disease,  sebaceous  and  hair  glands,  lymph 
glands,  bloodvessels,  blood  during  fever  (metastatic  distribution), 
and  in  practically  all  the  viscera,  secretions  and  excretions.  Strickler 
found  it  in  the  nasal  secretion  in  96  per  cent,  of  the  nodular,  96  per  cent, 
of  the  mixed,  and  in  66  per  cent,  of  the  nervous  type.  It  corresponds 
to  all  of  Koch's  criteria;  i.  e.,  it  is  always  present  in  leprosy;  it  can  be 


LEPROSY  191 

cultivated,  and  has  been  inoculated  in  mice,  guinea-pigs  and  monkeys; 
the  value  of  successful  inoculations  on  criminals  under  sentence  of  death 
has  been  justly  criticized,  for  these  cases  developed  in  a  leprous  com- 
munity. Leprosy  is  contagious  only  by  long  and  intimate  contact  with 
lepers.  The  nodular  is  far  more  dangerous  than  the  anesthetic  type. 
Infection  may  be  direct  or  indirect  and  chiefly  through  the  skin  and 
nose,  and  possibly  the  genitalia.  Extension  occurs  more  by  the  lymphatics 
than  the  bloodvessels.  Only  4  per  cent,  of  children  of  leprous  parents 
acquire  the  disease.  More  cases  occur  in  colored  than  in  white  races, 
more  in  men  than  in  women,  more  in  the  poorer  than  in  the  upper  and 
middle  classes  and  largely  between  the  ages  of  fifteen  and  thirty. 

The  incuhation  is  at  least  three  to  five,  sometimes  twenty  years. 

Symptoms. — Visceral  involvement  is  seen  in  every  type;  the  main 
types  are  nearly  always  somewhat  blended. 

1.  Nodular  Type  {Lepra  tuberculosa) . — The  prodromal  toxemic  symp- 
toms indicate  an  infection  already  established,  but  escaping  recog- 
nition; they  are  depression,  formication,  sweats,  pains,  vertigo,  digestive 
disturbance  and  temperature.  After  months  or  years,  maculce  appear 
on  the  face  and  extremities;  they  may  disappear,  leave  pigmentation  or 
metamorphose  into  nodules,  which  are  present  in  75  per  cent,  of  all 
cases.  The  nodule  or  leproma,  is  a  granuloma  similar  to  the  tubercle 
or  gumma,  highly  vascular  and  formed  of  a  scanty  reticulum,  in  which 
lie  emigrated  leukocytes,  small  epithelioid  cells  and  the  larger  multi- 
nucleated lepra  cells  of  Virchow,  which  contain  close  clumps  of  bacilli. 
The  nodes  by  fusion  form  gelatinous,  glistening  and  yellowish-red  infil- 
trations. The  nodes  vary  from  the  size  of  a  millet  seed  to  a  hazel-nut  or 
walnut;  in  the  skin  they  are  dark  red  and  later  yellowish-brown,  glisten- 
ing, vascular,  slightly  desquamating  and  at  first  soft  but  later  harder. 
Sensation  is  always  disturbed  in  their  vicinity.  They  are  most  conspicuous 
on  the  face  and  hands,  but  also  appear  on  the  extensor  surfaces  and 
very  seldom  on  the  soles,  palms,  scalp  or  penis.  The  forehead,  nose, 
cheeks,  chin,  lips  and  ears  are  thickened,  the  nose  becomes  flatter,  the 
eyebrows,  lashes  and  beard  are  shed.  The  eyes  are  involved  in  over 
90  per  cent,  of  the  cases;  the  expression  is  leonine  (leontiasis) ,  or,  as  the 
ancients  called  it,  faun-like  (satyriasis).  The  nodes  grow  and  extend 
slowly,  and  the  lymph  vessels  and  glands  become  enlarged  and  tender. 
Sometimes  the  progression  is  intermittently  acute,  with  fever  and  an 
eruption  resembling  erysipelas.  They  often  necrose  and  ulcerate.  At 
the  same  time  or  later,  nodules  which  are  prone  to  early  ulceration  and 
infiltration  occlude  the  nose,  roughen  the  voice,  distort  the  larynx  and 
throat,  and  impede  mastication,  swallowing  or  respiration.  Cicatrization 
of  the  face  causes  added  deformity. 

2.  Nervous  Type  {Lepra  nervorum,  anesthetica,  mutilans). — ^The 
most  common  prodromes  are  fever,  neuralgia,  paresthesia,  hyperesthesia 
and  cerebral  congestion.  Maculce  develop  on  the  face,  trunk  or  limbs; 
they  are  pale  or  dark  red,  slightly  raised,  growing  peripherally  and 
paling  centrally  and  present  a  glistening  or  powdered  aspect.  Histo- 
logically they  are  identical  with  the  nodules,  but  contain  fewer  bacilli, 
contain  no  large  cells  and  tend  more  toward  fibrous  change.     Their 


192  BACTERIAL   DISEASES 

distribution  is  asymmetrical,  like  that  of  the  underlying  nerve  lesions; 
they  are  often  oversensitive,  sometimes  pigmented  ^ lepra  nigra)  or 
leukoderma-Iike  {lepra  alba). 

Sensory  disturhances  are  due  to  lesions  in  the  nerve  trunks,  -^vhich 
are  the  seat  of  a  perineuritis  and  interstitial  neuritis  which  slowly  com- 
press the  nerve  fibers.  The  connective  tissue  and  the  bacilli  differentiate 
this  from  the  pa^ench^^natous  neuritides.  Unlike  ordinary  neuritis, 
leprous  neuritis  affects  the  sensory  more  than  the  motor  filaments.  There 
is  an  irregular  dissociated  anesthesia  in  which  the  perception  of  pain 
and  temperature  is  usually  more  dulled  than  other  forms  of  sensation, 
mostly  in  the  peripheral  branches  in  the  arms  and  legs.  Sensation  may  be 
perverted  or  retarded  and  sudden  anesthesia  is  considered  rather  char- 
acteristic. Pain  may  be  slight  or  agonizing,  as  in  a  personal  case  of  ten 
years"  duration.  The  nerve  truiilcs  are  palpable  and  tender  in  many  cases; 
in  the  case  cited  the  ulnar  nerve  was  thicker  than  a  lead-pencil:  the 
auricular  nerve  is  felt  m  90  per  cent.  ]\Iotor  weakness  and  atrophy 
are  less  common  and  rarely  extreme ;  the  oral,  sometimes  the  masticatory 
and  ocular  muscles  are  paretic;  ulnar  and  peroneal  implication  causes 
the  ''claw-hand"  and  "claw-foot";  facial  paralysis  occurs  in  9  per  cent. 
of  cases.  The  tendon  reflexes  are  often  increased,  sometimes  normal 
or  decreased;  there  is  often  fibrillation  and  increased  myotatic  irrita- 
bility. Trophic  changes  include  edema,  glossy  skin,  "  mal  perforanf 
(26  per  cent.),  loss  of  hair  or  nails,  bone  resorption,  rheumatoid  swellings, 
ankylosis  and  pigmentation.  Great  trophic  changes  mark  the  lepra 
mutilans. 

3.  Mixed  Type. — This  is  a  combination  of  the  nodose  and  anesthetic 
tj'pes.  In  all  developed  forms  the  internal  tissues  are  invaded:  the  liver, 
spleen  and  lymph  glands  are  enlarged;  the  lungs  show  peribronchial 
foci,  cavities  or  induration;  and  the  intestine  is  infiltrated.  The  sexual 
functions  are  decreased  or  lost.  Infantilism  results  in  cases  developing 
before  puberty.  Cachexia,  sensitiveness  to  cold,  low  temperature  and 
heart  weakness  develop. 

Course  and  Prognosis. — The  course  is  slow  and  progressive,  the  outcome 
invariably  fatal.  The  nodular  type  covers  eight  to  twelve  years,  the 
anesthetic  form  fifteen  to  twenty  years,  but  either  variety  may  endure 
seven  decades;  38  per  cent,  of  cases  die  of  leprosy  ("exhaustion,  diarrhea, 
cardiac  weakness),  22  of  chronic  nephritis,  17  of  lung  disease  (oftener 
leprous  than  tuberculous),  10  of  diarrhea  (leprous  infiltration  of  the  gut), 
and  the  remaining  13  per  cent,  die  of  erysipelas,  sepsis,  amyloidosis  and 
interctirrent  disease. 

Diagnosis. — The  diagnosis  is  based  on  the  history  of  residence  and 
exposure  which  is  often  suppressed  by  the  patient,  on  the  macules  or 
leukoderma  found  in  90  per  cent.,  on  the  anesthesia,  amyotrophy  and 
multilation,  and  on  the  finding  of  the  bacillus  in  the  nasal  secretion, 
nodes  and  mactiles.    In  some  reports,  a  positive  Wassermann  is  given. 

Treatment. — 1.  Prophylaxis. — All  suspicious  cases  should  be  registered 
and  all  clear  cases  sequestrated. 

2.  Therapy. — ^Few  drugs  are  helpful.  (a)  Gurjun  oil  oss-ij  in 
water  or  lime-water;  (h)  chaulmoogra  oil,  in  milk,  beginnino:  with  a  few 


ACTINOMYCOSIS  193 

minims  and  increasing  to  5j-iij;  i^)  salves  of  5  per  cent,  pvrogallol  or 
10  per  cent,  chrysarobin;  (d)  Calamette's  antivenin,  20  to  30  c.c;  (e) 
arsenic,  nastin,  salvarsan,  carbon  dioxide  snow  and  .i-rays  are  recom- 
mended. 


NON-BACTERIAL  FUNGUS  INFECTIONS. 

ACTINOMYCOSIS. 

Definition. — A  chronic  infection  caused  by  the  actinomyces  (hterally 
"ray  fmigus");  mostly  sporadic  in  cattle  and  occasionally  in  man; 
and  characterized  by  chronic  inflammation  in  the  mouth,  head  or  neck, 
lungs  or  intestines  or  abdomen. 

History. — Yon  Langenbeck  (1845)  and  Davaine  (1850),  observed 
the  peculiar  sulphur  granules  in  the  pus.  Bollinger  (1877)  first  scien- 
tifically described  the  fungus  in  cattle,  and  J.  Israel  (1878)  found  the 
parasite  in  human  cases,  but  to  Ponfick  (1879)  is  due  the  credit  of 
identifying  the  bovine  and  the  human  types. 

Etiology. — Statistics  in  Berlin,  Breslau  and  Vienna  show  large  numbers 
of  cases;  there  are  more  in  Scotland,  Denmark,  Italy  and  Russia  than  in 
America,  where  up  to  1902,  100  cases  were  observed.  Seventy  per  cent, 
of  the  cases  occur  in  males  and  33  per  cent,  between  twenty  and  thirty; 
82  per  cent,  between  ten  and  fifty.  The  fungus  enters  chiefly  by  the 
mouth,  in  which  ragged  teeth,  abrasions,  etc.,  favor  its  access.  Israel 
and  Lord  believe  it  inhabits  the  tonsils  and  carious  teeth.  Though  little 
is  kno"WTi  of  it  outside  of  the  body,  it  probably  exists  in  the  intestines  of 
herbivora.  ]Most  cases  occur  in  young  cattle  at  dentition  and  89  per 
cent,  in  the  last  half  of  the  year,  when  the  ingested  grain  is  dry. 

Bacteriology. — The  parasite,  classified  as  a  streptothrix  is  found  in 
small  granules  which  measure  0.15  to  0.75  millimeters,  usually  ovoid 
or  "radiate"  when  squeezed  under  the  cover-glass.  The  younger  forms 
are  transparent,  sago-like,  whitish-gray  bodies  which  may  be  easily  over- 
looked; the  older  sidphur-Iike  granules  consist  of  threads  and  coccoid 
bodies  which  some  consider  spores.  Clubbing  is  considered  a  degenerative 
change.  The  threads  divide  and  branch.  The  fungus  is  therefore 
pleomorphic.  It  stains  with  the  usual  dyes  and  Gram's  method.  Cul- 
tures are  successful  in  50  per  cent,  of  the  cases,  by  mixing  the  granules 
with  softened  gelatin  and  bouillon.  The  colonies  are  thick,  folded, 
membranous,  resistant  and  at  first  have  a  mucoid  or  crystalline  appear- 
ance. Infection  is  very  rarely  direct  either  from  animals  to  man  or  from 
one  person  to  another.    The  virulence  is  therefore  of  low  grade. 

Forms. — Incubation  averages  four  weeks.  Clinically  there  are  three 
main  forms:  (1)  That  of  the  head  and  neck;  (2)  the  lower  digestive 
tract;  and  (3)  the  respiratory  tract. 

1.  Head  and  Neck. — This  form  constitutes  50  per  cent,  of  actinomy- 
cosis. The  atrium  is  the  mouth  and  throat.  The  fungus  is  surrounded 
by  a  massive  accumulation  of  round  cells  which  soon  degenerate  centrally. 
13 


194  NON-BACTERIAL  FUNGUS  INFECTIONS 

The  connective-tissue  reaction  is  marked  and  the  proUferation  shows 
numerous  round  or  polygonal  cells  with  large  nuclei — the  epithelioid 
cells.  Giant  cells  also  form.  The  process  is  considered  chronic  inflam- 
mation by  Bostroem,  and  by  Israel  an  infective  granuloma,  resembling 
the  tuberculous  or  syphilitic  process.  The  destiny  of  the  granulations 
is  modified  by  the  resistance  of  the  tissues  and  by  the  animal  diseased: 
(a)  In  man  the  granulation  wall  melts  into  a  mucoid,  creamy  fluid, 
in  which  there  are  oil,  fibrin,  blood,  pigment  and  actinomycotic  cocci 
and  threads;  the  "cold"  abscess  is  formed  by  the  fungus  itself  which, 
unaided  by  pj^ogenic  organisms,  burrows  to  the  surface  by  circuitous 
fistulcB;  it  discharg'es  a  thin,  puriform  secretion  like  that  of  tuberculous 
glands  but  contains  the  sulphur-Iil~e  grains,  (h)  hi  cattle  and  horses 
the  granulation  tissue  is  more  effectually  limitative  and  develops  hard, 
board-like  or  ligneous  tumors  ("lumpy  jaw,"  "wooden  tongue");  sup- 
puration and  miliar}'  dissemination  are  less,  and  calcification  is  more 
frequent  than  in  man.  In  human  subjects  the  infiltration  may  involve 
the  neck,  face,  tongue,  pharynx,  tonsils,  larjnix  and  thyroid  gland. 
There  is  frequent  inflammation  of  the  soft  tissues,  especially  submaxillary 
or  submental  infiltration  and  superficial  invasion  of  the  bones.  In  a 
few  cases  the  maxillse  may  be  primarily  invaded.  Sarcoma  and  caries 
may  be  simulated.  It  may  spread  regionally  to  the  base  of  the  brain 
and  meninges;  along  the  spine  causing  vertebral  erosion;  and  behind 
the  sternum  with  mediastinal  infiltration. 

Sym-ptoms. — The  fever  is  irregular.  Pain  and  tenderness  are  not 
marked,  for  the  process  is  indolent  or  chronic.  In  26  cases  of  involvement 
of  the  tongue,  its  forms  were  a  hard  tumor,  localized  abscess  or  diffuse 
suppuration;  it  causes  less  pain  and  adenitis  than  does  cancer.  Dys- 
phagia accompanies  retropharyngeal  involvement,  edema  occurs  in  laryn- 
geal localization  and  other  local  interference  such  as  venous  obstruction 
is  frequent.  The  WTiter  observed  trismus  and  severe  unilateral  trifacial 
neuralgia  from  a  primary  focus  at  the  base  of  the  skull,  recovering 
after  operation.  Besides  the  above  regional  invasion,  hematogenous 
extension  by  metastasis  may  occur  in  this  type  as  well  as  in  the  others 
to  be  described  later.  Trauma  may  initiate  generalization.  Unlike 
tuberculosis,  extension  to  the  lymphatics,  or  general  dissemination  by 
them,  is  unusual.    In  the  head-and-neck  form  the  mortality  is  10  per  cent. 

2.  Digestive  Tract. — The  digestive  tract  ranks  next  in  frequency 
of  infection  (25  per  cent.) ;  50  per  cent,  occurs  in  the  region  of  the  ileum, 
cecum  and  appendix  {perityphlitis  actinomycotica) ;  of  200  instances  of 
inflamed  cecum,  4  per  cent,  were  actinomycotic.  Local  pain,  tender- 
ness, induration  and  adhesions  follow  the  primary  lesion  in  the  intestine, 
which  in  rare  instances  remains  superficial  (enteritis  actinomycotica  super- 
ficialis).  Small  nodes  develop  in  the  submucosa,  followed  by  softening 
and  the  development  of  small  ulcers,  the  undermined  edges  and  uneven 
bases  of  which  resemble  tuberculous  ulcers.  Secondary  pyogenic  infec- 
tions are  frequent.    The  ulcers  may  cicatrize  or  fuse  into  larger  ulcerations. 

Symptoms. — The  signs  were  those  of  appendicitis  in  150  cases  on  record. 
Colic  and  vomiting  are  often  present  and  constipation  is  more  frequent 
than  diarrhea,     Extension  of  the  process  downward  involves  the  iliac 


ACTINOMYCOSIS  195 

bone  and  occasionally  the  hip,  bladder,  ovaries,  vagina  or  rectum;  the 
ray  fungus  is  voided  in  the  urine  and  feces;  and  anteriorly,  preperitoneal, 
suprapubic  or  muscular  infiltrations  occur,  with  external  fistulse.  The 
process  then  extends  backward  into  the  retroperitoneal  cellular  tissue,  in 
which  it  may  burrow  around  the  kidneys  or  into  the  chest — perineph- 
ritis, peripsoitis,  parametritis  or  peripleuritis.  In  rare  cases,  freely  mov- 
able operable  tumors  may  develop.  Vascular  metastases  may  occur;  liver 
abscess  is  the  most  frequent  development,  and  is  secondary,  though  some- 
times apparently  primary  (40  cases  reported).  In  70  per  cent,  death 
results  from  exhaustion,  mixed  infection  or  amyloidosis.  Diagnosis  is 
made  from  the  yellow  granules  or  microscopic  recognition  of  the 
fungus. 

3.  Respiratory  Tract. — Respiratory  involvement  is  less  frequent 
(20  per  cent.).  It  is  (a)  secondary  to  regional  extension  from  the  neck 
or  abdomen,  or  to  infarcts,  or,  still  less  frequently,  (h)  primary  in  the 
lungs  (very  rarely  as  a  fibrinous  or  actinomycotic  bronchitis).  Most 
often  it  invades  the  alveoli.  The  lower  lobes,  its  usual  seat,  show  a  gray 
hepatization  with  the  ordinary  actinomycotic  changes.  Fusion  of  the 
usually  small  foci  may  involve  large  portions  of  tissue,  but  demarcation 
is  usual  in  the  lung.  The  clinical  picture  varies:  (i)  In  some  instances 
cavity  formation  is  obvious,  with  hectic  fever,  a  harassing  cough  and 
malnutrition;  the  sputum  is  puriform,  sometimes  fetid  and  stained 
with  altered  blood  like  raspberry  jelly  and  often  reveals  the  actino- 
mycosis rays,  (ii)  Induration  may  occur  from  cicatricial  development, 
(iii)  Pleurisy,  peripleuritis,  pericarditis  or  mediastinitis  may  be  the 
dominant  finding.  There  may  be  much  luxation  of  the  intrathoracic 
contents,  with  dyspnea,  dilatation  and  hydrops.  Penetration  may  occur 
through  the  chest  wall  with  characteristic  discharge  from  the  sinuses 
which  run  along  the  spine  and  iliopsoas  muscle,  or  into  the  abdomen. 
Hematogenous  generalization  occurs  as  in  other  forms.  In  25  per  cent, 
of  cases  the  ray  fungus  is  seen  in  the  sputum  and  tuberculosis  is  excluded 
by  absence  of  tubercle  bacilli  and  elastic  fibers;  differentiation  may  be 
impossible.  The  course  is  usually  subchronic  (averaging  under  a  year), 
less  often  chronic  (two  or  three  years)  and  very  rarely  acute.  Only  6 
recoveries  are  reported. 

4.  Other  Localizations  are  rare;  23  primary  skin  cases  are  reported. 
They  may  resemble  lupus  or  tubercle.  Primary  brain  lesions  may 
simulate  brain  tumor  or  cause  cortical  epilepsy.  Very  few  cases  of 
primary  genito-urinary  infection  are  recorded.  The  lachrymal  duct  or 
middle  ear  is  very  rarely  the  primary  focus. 

Diagnosis. — Similar  fungi  may  cause  difficulty  in  diagnosis  (v.  i.). 
Treatment. — 1.  Prophylaxis. — Care  is  necessary  in  regard  to  picking 
the  teeth  with  straws.    Thorough  cooking  of  cereals  is  essential. 

2.  Surgical  Extirpation. — A  sharp  spoon  is  used  to  clean  accessible 
foci  and  fistulfe,  which  are  then  packed  with  iodoform  or  sublimate 
gauze.  Injections  of  bichloride  of  mercury  (0.5  per  cent.)  are  recom- 
mended.   Recurrence  is  frequent  in  abdominal  types. 

3.  Potassium  Iodide. — In  cases  inaccessible  to  the  knife,  potassium 
iodide  is  excellent.     It  is  not  parasiticidal,  but  large  doses  soften  the 


196  NON-BACTERIAL  FUNGUS  INFECTIONS 

tissues,  prepare  operable  cases  for  surgical  measures,  inhibit  growth 
and  minimize  metastasis;  53  per  cent,  of  bovine  cases  recover  under  its 
use.  Rydygier  injects  large  quantities  of  a  1  per  cent,  solution  into 
the  affected  tissues.  Tuberculin,  vaccine  therapy  and  the  internal  use 
of  copper  sulphate,  J  to  1  grain  are  recommended. 

NOCARDIOSIS. 

J.  H.  Wright  describes  nocardia  as  an  acid-fast,  branching  streptothrix, 
differing  from  actinomycosis  in  that  it  does  not  occur  in  compact  struct- 
ures, does  not  radiate  or  form  club-bearing  granules  and  never  is  local- 
ized about  the  mouth  and  jaw.  "Wright  collected  a  dozen  cases  in  which 
the  lesions  and  symptoms  resembled  pulmonary  tuberculosis  or  septico- 
pyemia (abscesses  in  the  skin,  brain,  etc.).  The  prognosis  is  unfavorable, 
although  iodides  sometimes  help. 

SPOROTRICHOSIS. 

Schenk  (1896)  discovered  the  Sporotrichum  Schenkii,  a  fungus  with 
branched  mycelia  and  numerous  spores.  Over  200  cases  are  reported, 
largely  in  farmers,  in  whom  trauma  probably  opens  the  way  for  cutaneous 
infection.  Its  toxin  produces  little  fever.  The  serum  exhibits  specific 
agglutination.  Infection  follows  the  lymphatics.  The  hard  nodules 
may  resemble  a  chancre;  other  hard  nodes  produce  subcutaneous  ab- 
scesses; still  others  resemble  cutaneous  gumma  or  tuberculoma  his- 
tologically and  clinically.  Lesions  may  appear  in  the  mucosae  or  general- 
ization may  ensue  with  lesions  in  the  bones,  joints,  muscles,  lungs,  etc., 
by  way  of  the  blood  stream.    Surgery  and  iodides  are  indicated. 

OIDIOMYCOSIS. 

Coccidioidal  granuloma  is  a  specific,  subacute  or  chronic  infectious 
disease.  Twenty -four  cases  have  been  recognized  in  various  parts  of  the 
western  hemisphere,  most  of  them  in  California.  The  histological  changes 
in  the  lesions  closely  resemble  those  of  tuberculosis.  Differential  diag- 
nosis depends  on  finding  the  specific  microorganism,  Coccidioides  im- 
mitis,  a  species  of  mould  belonging  to  the  Ascomycetes.  In  the  animal 
body  it  exists  as  spheres  enclosed  in  doubly  contoured  capsules  and 
multiplies  by  endogenous  spore  formation.  As  to  hlastomycosls,  caused 
by  the  Cryptococcus  dermatidis,  Bro^Aii  and  Cummins  point  out  well- 
defined  dift'erences  in  the  pathogenicity  of  the  two  diseases,  coccidioidal 
granuloma  being  alw^ays  and  often  rapidly  fatal  in  man,  while  blasto- 
mycosis is  commonly  not  so,  except  for  the  systemic  cases.  The  clinical 
and  pathological  aspects  of  coccidioidal  disease  are  those  more  closely 
resembling  tuberculosis,  as  there  is  a  greater  predilection  for  the  lym- 
phatic system  than  in  blastomycosis,  and  cutaneous  lesions  are  likely 
to  be  more  ulcerative.  There  appears  but  one  reported  case  of  coccidioidal 
disease  in  the  female  sex,  whereas  there  have  been  many  of  blastomycosis. 


SYPHILIS  197 

Iodides  have  temporarily  benefited  many,  and  apparently  cured  a  few, 
blastomycosis  patients,  whereas  they  have  had  no  effect  on  the  rapidly 
progressive  lesions  and  toxemia  of  coccidioidal  granuloma.  Morpho- 
logically, in  pus  and  solid  tissues  they  are  dift'erentiable  by  the  endo- 
sporulation  in  the  one  and  budding  in  the  other.  Generalization  may 
occur  in  the  bones,  joints,  meninges,  etc.  Iodides,  a:-rays,  radium  and 
vaccines  are  indicated. 

MYCETOMA. 

Madura  foot,  first  described  by  Kaempfer  (1712),  is  largely  seen  in 
India;  seven  American  cases  are  reported.  Infection  of  the  foot  occurs 
usually  in  those  going  bare-footed — by  the  Streptothrix  madurse;  its 
varieties  are  the  red,  black  and  yellow.  A  nodule  on  the  sole  forms, 
softens,  ruptures,  and  by  extension  leads  to  enlargement  of  the  foot, 
sinus  formation  and  involvement  of  all  structures  of  the  part,  muscles, 
bones,  etc.    Amputation  is  required. 


ASPERGILLOSIS. 

Aspergillus  fumigatus  infection  may  occur  as  a  primary  or  secondary 
disease.  As  birds,  cattle  or  even  dogs  may  be  affected,  the  disease  may 
occur  in  pigeon-feeders  or  in  hair-sorters,  from  rye-flour  dust  employed 
to  remove  grease  from  the  hair.  Bronchopneumonic  patches  develop, 
from  which  induration  or  necrosis  ensues,  resembling  phthisis  and  gener- 
ally ending  fatally. 


PROTOZOAN  INFECTIONS. 

SYPHILIS   (POX,  VARIOLA  MAGNA,  LUES  VENEREA). 

Syphilis  is  an  ancient  disease,  as  indicated  by  syphilitic  bones  belong- 
ing to  the  stone  age.  Nusi  King  described  syphilis  in  China  2600  B.C. 
The  first  clear  outbreak  occurred  in  1494  among  the  troops  of  Charles 
VIII.  Fracastorius  in  1530  called  the  disease  Siphilus  (a  shepherd  smit- 
ten with  the  disease  by  Apollo  because  of  .blasphemy).  A  full  account 
of  this  disease  will  be  given  because  of  its  collossal  importance. 
Metchnikoff's  historical  sketch  distinguishes  three  epochs:  First,  the  era 
of  superstition,  in  which  the  only  discovery  was  mercury;  the  second 
empiric  period  concerned  the  clinical  pathology  and  the  differentiation 
of  gonorrhea  and  chancroid;  the  third  dates  from  1905,  since  when  the 
cause,  experimental  inoculation  of  syphilis,  its  serodiagnosis  and  the 
cultivation  of  the  treponema  have  been  determined. 

Definition.^ — A  specific  chronic  infection,  caused  by  the  Treponema 
(Spirochete)  pallidum,  and  found  in  man  only,  either  hereditary  or 
acquired  by  inoculation,  in  the  seat  of  which  a  primary  lesion  or  hard 
chancre  develops,  followed  in  two  or  three  months  by  secondary  lesions 


198  PROTOZOAX  IXFECTIOXS 

in  the  skin  and  muco5£e.  After  months  or  years,  tertiary  lesions  or 
gummata  develop  in  the  \'iscera,  bones  and  skin,  followed  in  some  in- 
stances by  the  so-called  parasyphilitic  manifestations,  as  tabes  dorsalis, 
dementia  and  aneurysm. 

Stages  According  to  Ricord. — The  Pebiaey  Stage. — (1)  Incubation 
lasts  until  the  chancre  appears,  when  s^'philis  is  already  a  general  disease; 
(2)  the  chancre  develops,  the  lymph  vessels  and  adjacent  glands  enlarge, 
and  there  is  a  period  of  latency,  the  second  incubation. 

The  Secoxdaey  Stage. — (1)  SAmptoms  prodromal  to  the  eruption, 
as  fever  or  anemia,  develop  and  then  (2)  the  eruption  appears  on  the  skin 
and  mucosae,  vrith  headache,  "rheumatism,"  iritis,  or  sometimes  jaundice, 
albuminuria  and  splenic  tumor. 

The  Tertlary  Stage. — ^This  may  follow  very  closely  upon  the  second- 
aries or  appear  with  them  (syphilis  maligna  and  hereditary  forms) 
but  usually  is  not  manifest  for  three  or  four  years  (even  fifty  or  sixty). 
Tumor-like  gummata  occur  in  the  skin  and  viscera,  especially  in  the 
liver,  scrotum,  braui  and  cord.  Unlike  secondary  manifestations,  they 
are  asymmetrical,  persistent,  recurrent  and  less  contagious.  There  is 
a  close  histological  resemblance  between  the  primary,  secondary  and 
tertiary  lesions. 

The  quaterxaey  oe  p.arasyphilitic  stage  of  Fournier,  Sigmund, 
Lancereaux  and  Baiimler  is  not  mcluded  in  Ricord's  division.  In  this 
group  of  affections,  the  spirochete  is  also  found,  as  in  paresis. 

I.  Acquired  Syphilis. — Etiology. — 1.  Traxsmissiox  by  Sexual  Ixter- 
couESE. — This  causes  the  great  majority  of  cases,  but  the  term  lues 
venerea  is  often  maccurate  and  unjust  since  syphilis  may  occur  in 
the  innocent  (sA'philis  insontiumj;  in  certain  districts  in  Prussia  70 
per  cent,  of  syphilis  is  innocent.  In  1905  Schaudinn  and  Hoffmann 
described  a  treponema  or  spirochete  pallida,  so  named  because  of  the 
difficulty  in  staining  it.  It  is  long,  delicate,  thread-like,  refractile,  ac- 
tively motile,  pointed  at  its  ends  and  t^\'isted  like  a  corkscrew;  it  measures 
4  to  20^  in  length;  it  lies  free  and  not  iu  the  cells;  it  resembles  the 
spirochete  of  relapsing  fever  and  is  a  flagellated  protozoon.  It  is  present 
in  all  cases,  stages,  types  and  tissues  of  s\'philis.  It  has  been  inoculated 
in  monkeys  from  man,  from  monkeys  to  rabbits  and  then  to  monkeys 
again  through  many  generations.  AYith  Giemsa's  stain  the  spirochetes 
are  a  delicate  violet  and  the  leukocyte  nuclei  deep  red.  The  spirochete 
refringens,  found  in  the  mouth,  ulcers,  smegma  and  venereal  warts,  is 
differentiated  by  its  bemg  more  quickly  stained,  its  greater  size  and, 
particularly,  by  its  broader  and  more  wave-like  undulations.  (See 
Plate  VII.)  It  was  cultivated  by  Schereschewsky  but  first  by  Xoguchi 
in  pure  cultures,  thus  fulfillmg  all  of  Koch's  postulates. 

The  sound  skin  and  mucosae  resist  infection,  and  hence  a  raw  surface, 
erosion  or  wound  is  necessary  for  infection.  SA^hilis  not  only  has  a 
certain  choice  of  place  in  its  inoculation,  but  persists  with  peculiar 
obstinacy  in  certain  localities,  notably  about  the  genitalia,  breasts, 
axillae,  navel,  toes,  angles  of  the  mouth,  tongue,  iris,  palate  or  tonsils, 
because  of  irritation  by  secretions,  clothuig,  trauma,  smoking,  etc. 
These  foci  are  of  sreat  moment  in  the  recrudescence  of  the  disease. 


PLATE  VII 


Spirochetes  of  Syphilis.     (Simon.) 
a,  S.  refringens;  b,  S.  pallida.      (Stained  with  Giemsa's  stain.) 


SYPHILIS  199 

Sj^philis  is  called  a  disease  of  cities;  though  more  common  in  cities, 
syphilis  very  frequently  escapes  recognition  in  the  country. 

2.  Accidental  Infection. — ^Accidental  infection  occurs  in  surgical 
practice,  skin-grafting,  postmortem  infection  (2  cases  of  personal 
observation),  ritual  circumcision,  nursing,  vaccination,  kissing  (as  in  the 
epidemic  recorded  by  Shamberg),  from  use  of  pipesy  in  shaving,  by 
scratches,  from  instruments  used  in  glass-blowing,  or  from  catheters. 
Bardinel  describes  infection  of  over  100  women  by  one  midwife. 

Symptoms. — 1.  Primary  Stage. — ^After  an  incubation  of  two  or  three 
weeks,  the  initial  lesion  occurs  (the  ulcus  durum,  Hunterian  chancre  or 
initial  sclerosis).  Multiple  lesions  occur  in  25  per  cent.  The  induration  is 
usually  oval,  always  sharply  localized,  of  variable  or  even  cartilaginous 
hardness,  freely  movable,  and  usually  papular  and  copper-colored.  Hard- 
ness is  the  most  constant  characteristic  of  the  chancre,  which  heals  only 
when  the  hardness  disappears.  It  is  most  characteristic  in  the  third  or 
fourth  week,  when  the  adjacent  glands  enlarge.  Retrogressive  ulceration 
or  necrosis  is  frequent.  The  ulcer  is  round,  elliptical,  slit-like  or  irregular; 
it  is  hard,  painless,  with  even  surface,  seldom  with  elevations  or  excava- 
tions; it  has  no  areola,  but  a  smooth,  glistening  base  with  thin  secretion 
containing  the  spirochete.  Contact  ulcers  around  the  corona  are  hard. 
The  sclerosis  may  resemble  herpes;  an  herpetiform  chancre  becomes 
indurated  in  about  sixteen  days,  while  simple  herpes  lasts  but  three  or 
four  days;  herpes  may  be  the  atrium  for  syphilitic  inoculation.  If  the 
sclerosis  occurs  on  a  mucous  surface  there  is  little  elevation;  maceration 
and  bleeding  readily  occur,  (a)  The  genital  sclerosis  in  men  occurs  on 
the  urethral  orifice;  in  the  fossa  navicularis;  on  the  glans,  often  as  an 
erosion,  and  difficult  to  diagnosticate  because  of  the  hardness  of  the 
glans;  on  the  corona,  circular  and  hard;  on  the  (broken)  frenulum  or 
in  the  sulcus  coronarius,  usually  with  much  induration,  giving  the  "  split 
pea"  appearance,  one-half  lying  on  the  glans  and  the  other  half  on  the 
prepuce;  on  the  prepuce,  often  with  phimosis;  or  on  the  dorsum.  (6) 
The  genital  sclerosis  in  women  occurs  mostly  on  the  labia;  on  the  labia 
majora,  as  large,  readily  ulcerating  contact  ulcers  with  inflammatory 
edema;  on  the  labia  minora  as  small,  hard  and  circumscribed  nodes; 
on  the  prepuce  as  hard  fissures;  in  the  urethral  orifice  with  induration 
felt  from  the  vagina;  on  the  posterior  commissure,  as  erosions,  which 
are  especially  prone  to  infect  during  coitus;  on  the  hymen  relics,  as 
fissures,  or  large,  hard  ulcers  reaching  into  the  vagina;  rarely  in  the 
vagina,  because  of  its  paucity  in  glands  and  its  thick  epithelium;  in 
the  vaginal  portion  of  the  cervix,  usually  in  women  who  have  been 
pregnant,  in  which  location  it  is  difficult  to  differentiate  from  erosions. 
(c)  The  perigenital  sclerosis  occurs  on  thie  scrotum,  mons  veneris  or  inner 
thigh,  (d)  Extragenital  scleroses  (5  per  cent,  of  chancres)  are  especially 
dangerous  in  midwives,  physicians  and  wet-nurses.  They  occur  on  the 
scalp,  conjunctiva,  nose,  eyelids,  lips,  tongue  and  tonsils  (from  sexual 
perversion),  cheeks,  fingers,  arms  and  mammae.  In  rare  cases  of  accidental 
syphilis  the  chancre  may  not  be  found.  Among  9058  extragenital 
chancres,  1863  occurred  from  vaccination,  745  from  cupping  or  phle- 
botomy, 179  from  circumcision,  and  82  from  tattooing  (Bulkley). 


200  PROTOZOAN  INFECTIONS 

The  primary  sclerosis  is  inoculated  from  an  individual  with  a  chancre 
or  secondary  syphilis;  Williams  reports  41  infections  from  gummata. 
When  the  sclerosis  is  recognized,  the  blood  is  already  infected. 

Histology  of  Chancre. — The  round  cells  increase  the  vessel  walls  tenfold, 
and  the  vessel  lumen  is  narrowed  from  pressure  and  endothelial  pro- 
liferation, even  to  obliteration,  when  ulceration  ensues.  Epithelioid 
and  giant  cells,  and  proliferation  of  the  connective  tissue  in  and  about 
the  vessels  are  noted.    The  Spirochete  pallida  is  present. 

Course. — Usually  induration  disappears  in  thirty  to  ninety  days, 
generally  with  scar  formation.  In  exceptional  cases  (1)  relics  of  the 
sclerosis  may  be  found  after  years  (even  50)  due  to  permanent  vascular 
injury;  (2)  acute  or  (3)  phagedenic  inflammation  sometimes  intervenes. 
Chancre  and  chancroid  are  separate  affections — the  dualistic  doctrine  of 
Bassereau,  Layroyenne  and  Ricord. 

Diagnosis. 

Chancre  or  Sclerosis — vs. — Venereal  Ulcer  or  Chancroid 

Incubation:  two  or  three  weeks.  Three  daj^s. 

Forin:  indurated  erosion,  ulcer,  nodule.  Pustule,  ulcer,  etc.,  without  induration. 

Number:  single  in  75  per  cent.,  rarely  sue-  Often  multiple  at  beginning  or  successively 

cessively  inoculated.  inoculated. 

Depth:  superficial,  flat,  rarely  deep  excava-  Through  entire  cutis  or  mucosa ;    "punched- 

tions.  out"  appearance. 

Border:  gradual  descent.  Abrupt,  sharp,  indented,  undermined. 

Surface:  red,  livid.  White,  gray. 

Induration:  marked,    cartilaginous,    sharply  No  basal  induration;    not  sharply  outhned; 

outlined,  movable,  sometimes  thin,  last-  merges    gradually    into    adjacent    tissue; 

ing  weeks  or  months.  short  duration. 

Secretion:  scanty,    serous;    autoinoculation  Rich,      purulent;      autoinoculation      easy; 

difficult;  spirochetes.  Bacillus   cancri  mollis,   pseudodiphtheria 

bacilli  or  staphylococci. 

Pain:  Kttle.  Much. 

Destruction:  rarely  phagedenic.  More  often  phagedenic;    diffuse. 

Reinfection:  extremely  rare.  Frequent. 

Lymph  glands:   regional,!    ndolent,  swelling  Often  absent  or  acute  inflammatory  swell- 
hard,  painless,  movable;    rarely  pus  for-  ,  ing;     often    pus    formation,    capable    of 

mation.  autoinoculation. 

Nature  of  the  disease:  constitutional.  A  local  infection. 

Wassermann  reaction:  positive  soon.  Negative. 

Mixed  infection  may  occur,  whence  the  now  abandoned  idea  of  the 
unity  of  all  venereal  ulcers;  the  practical  lesson  from  this  doctrine  is 
diagnostic  resenmtion  in  doubtful  cases. 

Lymijhangitis  syphilitica  is  marked  in  70  per  cent.  The  lymph  vessels 
may  become  as  thick  as  a  lead-pencil,  bulging  at  their  valves  (bubonulus), 
hard,  painless,  and  narrowed  in  their  lumen  from  endothelial  proliferation. 
They  are  best  seen  on  the  dorsum  penis.  Resorption  occurs  in  three  to 
eight  months.  Lymphangitic  edema  is  particularly  suggestive  in  women 
when  the  initial  lesion  cannot  be  found.  Local  lymphadenitis  is  present 
in  97  per  cent,  of  cases,  appears  in  three  or  four  weeks,  and  in  six  weeks 
reaches  the  contralateral  inguinal,  iliac  and  lumbar  groups,  in  seven 
weeks  the  cubital  glands,  and  just  before  the  secondary  eruption,  the 
other  glands. 


SYPHILIS  201 

2.  Secondary  Stage. — Secondary  symptoms  appear  in  eight  weeks. 
(fl)  General  infection.  Fever  occurs  in  20  to  33  per  cent.  It  is  far  more 
common  in  secondary  syphilis  ("fever  of  syphihtic  invasion")  than  in 
primary  or  tertiary.  It  often  just  precedes  the  eruption,  mostly  in  the 
pustular  variety.  It  may  be  continuous,  remittent  or  intermittent, 
resembling  typhoid,  malaria  or  phthisis.  Other  toxemic  sjTiiptoms  are 
anemia,  headache,  nocturnal  hone-aches,  neuralgias,  palpitation,  night- 
sweats,  polydipsia,  digestive  disorders,  synovitis  and  icterus;  swollen 
tonsils,  spleen  or  liver,  and  albuminuria  may  occur  as  prodromata. 

(b)  The  exanthem  is  polymorphous,  sharply  marked,  frequently  grouped 
in  a  circular  arrangement  and  without  pain  or  itching;  it  is  highly 
infective  and  is  copper-colored,  a  fact  recognized  in  the  fifth  century;  it 
appears  where  other  eruptions  are  rare,  as  on  the  forehead  or  nasolabial 
fold;  recurrent  crusts  may  develop  on  an  infiltrated  basis.  The  most 
frequent  form  is  the  macule,  next  the  papular  syphilide,  and  then  types 
resembling  pustules,  varicella,  pemphigus  or  impetigo.  In  folds  or  damp 
parts  of  the  skin  mucous  paiches  appear,  as  at  the  angles  of  the  mouth, 
the  groin  or  perineum. 

(c)  The  enanthem  on  the  mucous  membranes  is  observed  on  the  tongue, 
lips  and  cheeks  {mucous  patches),  often  with  pharyngitis. 

(f/)  The  lymphatic  enlargement  becomes  general.  "  Rheumatism," 
bone-aches,  iritis,  etc.,  are  treated  under  special  symptomatology. 

Late  secondary  sympAoms  occurred  after  two  to  thirty  years  in  5.8 
per  cent,  of  Fournier's  19,000  cases  ("recurrent  syphilis"). 

3.  The  Tertiary  Stage. — This  develops  in  10  per  cent,  of  luetics 
and  is  characterized  by  the  gumma  which  occurs  in  many  tissues.  It 
is  not  known  what  determines  tertiary  development;  in  2396  tertiary 
lesions,  78  per  cent,  of  the  cases  were  not  treated  at  all,  19  per  cent, 
moderately  and  only  3  per  cent,  well  treated  (Fournier).  The  topical 
symptomatology  of  gumma  -uill  be  described  below.  The  gumma  may 
be  microscopic,  or  an  inch  or  more  in  diameter.  On  section  it  is  usually 
hard,  grayish-yellow,  homogeneous,  centrally  caseous  and  peripherally 
fibrous.  Tertiary  syphilis,  particularly  of  the  viscera,  may  be  attended 
by  fever.  In  30  per  cent,  of  tertiary  syphilis,  no  evidence  of  earlier  lesions 
can  be  found. 

Special  Symptomatology  of  Syphilis. — Lues  affects  different  tissues 
variously:  Some  organs  are  very  vulnerable,  as  the  liver  or  brain;  other 
organs  are  comparatively  invulnerable,  as  the  spleen  or  bone-marrow, 
in  which  the  parasite  may  linger  for  years  without  causing  particular 
trouble;  and  in  still  other  tissues,  if  affected,  the  parasite  dies  off  rapidly. 
(These  facts  have  a  bearing  on  the  Wassermann  reaction,  v.  %.).  Gen- 
eralization of  the  parasite  occurs  chiefly  in  the  early  septicemia,  and  its 
localization  in  a  given  tissue,  governed  perhaps  by  the  strain  of  parasite, 
seems  to  inhibit  somewhat  its  localization  in  other  tissues. 

1.  The  Skin. — The  macular  {roseolous)  syphilide  is  the  most  frequent 
secondary  erupAion.  The  spots  are  hyperemic  at  first  and  later  somewhat 
infiltrated;  the  macule  develops  rapidly,  lasts  eight  to  ten  days,  varies 
from  a  lentil  to  a  dime  in  size,  and  comes  out  more  clearly  by  chilling 
the  skin,  and  after  administration  of  mercury  (Herxlieimer  reaction).    It 


202  PROTOZOAN  INFECTIONS 

occurs  mostly  on  the  trunk.  The  face,  hands  and  feet  are  usually  free 
except  in  severe  cases.  It  is  symmetrical,  mostly  on  the  flexor  surfaces, 
more  frequently  recurrent  than  any  other  variety  and  prognostically 
favorable. 

The  papular  syphilide  presents  various  forms:  (a)  The  small  miliary 
lichen  syphiliticus  usually  develops  on  the  forehead,  chin,  nose,  shoulders, 
buttocks,  back  and  flexor  surfaces  of  the  extremities.  At  first  red,  it 
rapidly  becomes  brownish-red.  Fine  scales  or  crusts  may  form,  which 
on  falling,  leave  a  lacquered  appearance.  Recurrences  are  infrequent. 
It  must  be  differentiated  from  psoriasis,  the  development  of  which  on  the 
scalp,  ear  and  extensor  surfaces  is  not  observed  in  syphilis,  where  the 
scales  are  smaller,  thinner  and  less  glistening.  On  the  palms  and  soles 
differentiation  may  be  difficult,  but  in  syphilis  the  centre  of  the  papule 
is  likely  to  be  sunken,  (b)  The  large  papular  syphilide  is  often  associated 
with  fever,  constitutional  disturbance  or  synovitis,  and  may  occur  on 
all  parts  of  the  body,  as  the  corona  veneris  on  the  forehead,  around  the 
nose,  dorsum  of  the  hand,  furrows  of  the  chin  and  neck  or  the  junction 
of  the  skin  and  mucosa;  its  polymorphism  is  pronounced,  as  psoriasis 
palmaris,  rhagades,  onychia  or  verrucose  forms,  (c)  The  condyloma 
latum  or  mucous  patch  is  the  papule  altered  by  secretions  or  excretions, 
and  is  found  about  the  genito-anal  region,  axillfe,  etc.  It  is  the  most 
important  syphilide  in  the  propagation  of  syphilis;  it  is  flat,  dirty,  ill- 
smelling,  and  produces  a  spirochete-laden  secretion,  {d)  The  pustular 
syphilide  includes  the  acne  form,  the  varioloid,  varicelliform  and 
impetiginous  forms;  a  bro^\Ti  pigmented  scar  usually  results. 

The  general  characters  of  secondary  eruptions  are:  (i)  Their  circular 
form  and  circular  groupings;  (ii)  slow  evolution;  (iii)  sjTQmetry  of  dis- 
tribution; (iv)  polymorphism;  (v)  induration;  (vi)  copper-color;  and 
(vii)  diffuseness. 

Gummata  of  the  skin  are  asymmetrically  disposed;  are  cutaneous 
or  subcutaneous,  involving  deeper  structures;  are  non-infective;  are 
prone  to  develop  at  the  site  of  secondary  involvements;  occur  in  the 
skin  more  than  in  all  other  localities  combined;  are  promoted  by  in- 
complete mercurial  treatment,  vicious  habits  and  constitutional  diseases; 
and  are  seen  in  10  per  cent,  of  cases,  most  frequently  in  the, third  year 
after  infection.  Small  gummata  may  resorb  by  fatty  degeneration,  but 
the  larger  ones  caseate,  ulcerate  and  leave  a  kidney-shaped  scar  with 
deformation.  Gummata  are  differentiated  from  malignant  ulcerations 
by  the  absence  of  adenopathy,  by  their  slow  growth,  painlessness  and 
multiplicity,  and  by  the  results  of  therapy.  In  gumma,  ulceration  is  more 
rapid  than  in  lupus;  it  is  deeper,  less  sharply  marked,  redder  and  less 
symmetrical;  recurrence  after  cicatrization  is  less  frequent;  the  scars 
are  less  flat  and  smooth,  and  the  bacteriological  findings  of  lupus  are  absent. 

Leukoderma  syphiliticum  is  observed  after  macular  or  lenticular 
syphilides  as  white  spots  with  peripheral  browm  pigmentation,  mostly 
on  the  face  and  neck;  it  occurs  in  4  per  cent,  of  syphilitic  men  and  45 
per  cent,  of  syphilitic  women  and  fades  in  a  few  years. 

The  hair  falls  out  except  from  the  crown  of  the  head,  during  the  second- 
ary stage,  proportionately  to  the  intensity  of  the  eruption.    It  is  greater 


SYPHILIS  203 

in  poorly  nourished  cases,  and  its  regrowth  is  usually  good.    In  the  bald 
areas,  there  are  no  broken  hairs. 

Onychia  syphilitica  occurs  particularly  in  women.  The  nails  may 
hypertrophy,  fall  out  or  fail  to  grow.  Peri-  or  paronychia  rarely  causes 
pain,  ulceration  or  suppuration. 

2.  Lymph  Glands. — ^The  inguinal  glands  are  first  enlarged  because 
they  are  nearest  to  the  most  common  genital  chancre.  Adenopathy  of 
any  particular  group  is  not  pathognomonic  of  syphilis.  The  posterior 
cervical  glands  are  involved  more  than  the  anterior.  Next  in  frequency 
are  the  axillary,  epitrochlear  and  pectoral.  Dietrich  observed  that  99 
per  cent,  of  healthy  individuals  have  palpable  glands.  Inflammation, 
pain  and  suppuration,  from  mixed  infection  occur  in  but  3  per  cent. 
In  extragenital  sclerosis,  other  glands  are  enlarged  first,  e.  g.,  the  an- 
terior cervical,  from  chancre  of  the  lips.  The  glands  are  freely  movable 
and  are  not  usually  larger  than  a  hazel-nut,  but  occasionally  become 
massive,  resembling  Hodgkin's  disease. 

3.  G ASTRO-INTESTINAL  Tract. — On  mucous  membranes  the  eruption 
(enanthem)  is  less  frequent  and  is  less  polymorphous  than  the  exanthem, 
with  which  it  is  synchronous. 

Mouth. — This  is  more  involved  than  any  other  part  except  the  skin  and 
recurrence  is  very  frequent,  (a)  Erythema  may  occur  as  diffuse  or  cir- 
cumscribed, dark  red  maculae,  especially  on  the  cheek,  pharynx,  uvula, 
palate  and  swollen  tonsils — the  acute  syphilitic  angina;  it  ceases  sharply 
at  the  border  of  the  soft  and  hard  palate.  Infiltration  or  fissures,  with  a 
slightly  granulated  and  vesicular  appearance  may  develop.  Erosions 
may  last  long  in  users  of  tobacco  and  alcohol. 

(h)  Mucous  patches,  which  are  papules  modified  by  moisture,  develop 
with  the  exanthem,  mostly  on  the  tonsils,  cheeks  and  lips.  They  are 
elliptical  or  irregular,  flat  or  slightly  elevated,  circumscribed  patches, 
of  variable  color.  On  the  lips  they  may  measure  6  to  17  millimeters. 
The  course  is  usually  chronic;  the  patches  swell,  become  granular, 
ecchymotic  and  often  ulcerated.  On  the  tonsils  they  may  simulate 
diphtheritic  patches,  and  in  smokers  a  cure  cannot  be  effected  until  the 
habit  is  stopped.  They  are  the  most  important  syphilide  because  so  highly 
contagious. 

(c)  Chronic  angina  is  of  a  granular  appearance,  accompanied  by  hyper- 
emia, edema  and  erosion,  a  gray  coating  on  the  swollen  tonsils,  and  the 
appearance  of  pharyngitis  granulosa. 

{d)  Pachydermia,  ichthyosis  and  leukoplakia  occur  on  the  mucosa 
of  the  cheeks,  and  on  the  angles  of  the  mouth,  lips  and  tongue,  but 
are  not  always  syphilitic.  They  are  swellings  with  fissures,  are  gray  in 
color,  irregular,  vary  in  shape  and  size  and  are  thick  and  scar-like.  They 
occur  especially  in  users  of  tobacco  and  alcohol.  Leukoplakia  in  tobacco 
users  usually  occurs  on  the  tongue,  lip  or  palate,  while  in  syphilis  it  is 
mostly  on  the  cheek.  Psoriasis  linguae  presents  elliptical,  red,  flat  spots, 
with  thread-like  coating;  fissures  are  frequent  on  the  edges  of  the  tongue, 
from  the  use  of  tobacco  and  from  bad  teeth. 

(e)  Gummata  of  the  oral  cavity  occur  without  glandular  swelling, 
(iummata  of  the  tongue  are  most  frequent,  occurring  (a)   as  a  diffuse 


204  PROTOZOAN  INFECTIONS 

glossitis  with  later  cirrhotic  shrinkage  or  (h)  as  circumscribed  nodes  or 
ulceration,  without  pain  or  adenopathy.  Gummata  of  the  palate  or 
pharynx  are  mostly  multiple.  They  are  frequently  diffuse,  deep 
or  phagedenic;  they  destroy  the  uvula,  produce  adhesions,  obliterate 
the  posterior  nares  or  Eustachian  tube,  stenose  the  pharynx  or  draw 
the  tongue  back,  stenosing  the  respiratory  passages  or  reaching  the 
spine  or  brain.  In  the  tonsils  they  may  erode  the  carotid  or  palatine 
artery.  Differentiation  is  required  from  tuberculosis  and  epithelioma 
in  which  the  glands  are  usually  involved.  The  diagnosis  ex  juvantihus 
and  Wassermann  test  are  important. 

Esophagus. — Strictures  result  from  deep  gummata,  ulcerations  in  the 
larynx,  or  extension  from  the  bronchial  glands.  Differentiation  is 
required  from  tumor  of  the  mediastinum,  aneurysm,  carcinoma,  round 
ulcer  and  cardiospasm.     Diverticula  may  result. 

Stomach.  —  (a)  Acute  catarrhal  gastritis  in  the  secondary  stage  is 
usually  toxemic — rarely  organic.  (6)  Chronic  gastritis  is  more  com- 
mon, in  part  explaining  the  anemia  and  malnutrition  and  differing 
from  vulgar  gastritis  only  in  the  influence  of  treatment.  Amyloid  and 
glandular  wasting  are  infrequent,  (c)  Ulcers  of  the  stomach  may 
result  from  syphilitic  arteritis;  Garre  collected  30  cases,  {d)  Gummata 
are  rare.  They  begin  in  the  submucosa,  are  usually  multiple,  leave 
radiate  scars  and  differ  from  the  ordinary  round  ulcer  in  that  they  are 
not  funnel-shaped,  have  undermined  edges  and  are  broader  at  the  base, 
(e)  Hemorrhages  from  the  stomach  are  most  rare  and  Hayem's  case  is 
almost  unique.  They  may  result  from  cardiac,  splenic,  hepatic  or  renal 
lesions. 

Intestines. — Little  is  known  of  small  intestine  syphilis  in  the  adult, 
(a)  Acute  catarrhal  enteritis  may  induce  icterus;  it  resists  treatment 
other  than  specific.  (6)  Chronic  enteritis  in  the  sj^hilitic  newborn,  is 
manifested  by  the  viscid  meconium.  Obstinate  diarrhea  and  stenosis 
may  follow,  (c)  Ulceration  may  result  from  enteritis  in  secondary 
syphilis  or  from  gummatous,  diphtheroid  and  amyloid  changes  in  the 
tertiary  stage.  Meschede  collected  54  cases  of  ulcer  in  the  small  intestines. 
They  occur  around  the  axis  of  the  intestine  and  are  characterized  by 
spirochetes  and  productive  inflammation  which  prevents  perforation 
but  leads  to  stenosis,  (rf)  Intestinal  amyloid  disease  is  associated  with 
amyloid  liver,  spleen  and  kidneys.  The  gut  is  pale,  smooth,  waxy, 
thick  and  rigid  and  there  are  obstinate  diarrhea,  stinking  stools  and 
hydrops.  It  is  most  frequent  in  the  small  intestine  and  is  essentially  a 
vascular  change.  Amyloidosis  in  general  occurs  in  67  per  cent,  of  tuber- 
culosis and  in  21  per  cent,  of  syphilis. 

Rectum. — Ulceration  may  occur  in  papules  or  fissures  near  the  anus. 
Rectal  disease  is  usually  secondar^^  by  contiguity,  (a)  Irritative  proctitis 
is  usually  chronic,  attended  by  evacuations  of  pus,  itching,  tenesmus  and 
external  excoriations,  (b)  Syphilitic  ulcers  are  tertiary.  They  occur 
high  up,  extend  to  the  colon  and  often  produce  stenosis.  Perforation 
is  rare.  The  periproctal  tissues  are  invaded.  Fistulse  may  develop,  but 
the  symptoms  are  less  marked  than  in  cancer  or  tuberculosis.  The  feces 
are  covered  with  mucus  and  blood.    Diarrhea  from  catarrh  of  the  colon. 


1 


1 


SYPHILIS  205 

myositis  of  the  sphincter,  involuntary  evacuations,  burrowing  of  pus  and 
sepsis  necessitate  a  long  course.  Tuberculous  ulcers  rarely  occur  in  the 
rectum  alone,  and  are  marked  by  the  tubercle  bacillus.  In  dysentery 
the  involvement  is  higher  up,  colic  is  more  frequent,  diarrhea  is  more 
profuse,  and  the  resulting  stenosis  is  higher  in  the  intestine.  In  car- 
cinoma, age,  cachexia  and  local  appearances  are  suggestive  criteria; 
the  stricture  is  higher  and  adhesions  are  more  common. 

Pancreas. — Acute  svphilitic  pancreatitis,  interstitial  inflammation  with 
cirrhosis  (rarer  in  acquired  than  in  hereditary  syphilis)  and  gumma 
are  recorded.  The  peritoneum  sometimes  participates  in  syphilitic  dis- 
ease of  the  organs  it  envelops,  e.  g.,  perisplenitis,  perihepatitis,  etc.;  it 
is  extremely  rare  as  an  independent  gummatous  peritonitis. 

4.  Spleen. — (a)  Acide  splenic  tumor  occurs  in  31  per  cent,  of  acquired 
and  61  per  cent,  of  congenital  syphilis,  (h)  Interstitial  splenitis  occurs 
chiefly  with  syphilitic  liver,  marked  by  increased  size,  hardness  and 
pain  from  perisplenitis,  (c)  Gummatous  splenitis  is  very  rare,  (d) 
Amyloidosis  occurs  very  frequently  as  the  "sago"  spleen,  which  is  not 
necessarily  very  much  enlarged ;  or  as  the  diffuse  amyloid  spleen,  which 
causes  considerable  swelling. 

5.  LiVEE. — Syphilis  of  the  liver  occurs  pathologically  in  two  main 
forms,  interstitial  and  gummatous,  which  are  often  associated  with 
perihepatitis,  amyloid  or  fatty  change,  and  sometimes  with  parenchy- 
matous changes,  as  acute  yellow  atrophy,  (a)  Interstitial  hepatitis 
(syphilitic  cirrhosis)  is  twice  as  frequent  in  congenital  as  in  acquired 
syphilis.  The  volume  of  the  liver  is  increased  in  children,  and  sometimes 
decreased  in  adults.  The  surface  is  uneven,  with  furrows  or  nodules; 
the  edge  is  thin,  indented  and  sharp,  whereas  in  other  cirrhoses  it  is 
rounded.  Perihepatic  adhesions  to  the  colon  or  abdominal  wall  are 
frequent,  and  clinically  evidenced  by  lessened  respiratory  excursion. 
Connective-tissue  forms  in  Glisson's  capsule,  follows  the  branches  of  the 
portal  vein  into  the  liver  (peripylephlebitis) ,  and  shows  as  bands  of 
grayish  tissue.  The  liver  cells  are  degenerated  or  destroyed  by  fibrous 
tissue  or  obliterating  endarteritis.  The  atrophy  is  most  marked  anteriorly 
and  in  the  left  lobe.  The  connective  tissue  is  not  only  perilobular,  but 
reaches  more  into  the  lobules  than  in  alcoholic  cirrhosis.  In  acquired 
syphilis  the  liver  is  not  equally  or  completely  diseased,  whence  protruding 
granules  of  sound  tissue  are  noted.  New  bloodvessels  from  the  hepatic 
artery  develop  in  the  connective  tissue  and  thrombosis  may  occur  in 
the  portal  vein  and  its  radicles  (pylephlebitis). 

Symptoms. — The  enlargement  is  at  first  insidious — without  pain 
or  ascites.  The  abdominal  veins  may  be  distended;  the  urine  is  often 
dark  and  albuminuric,  possibly  icteric.  The  splenic  tumor  results  from 
hyperplasia,  stasis  or  amyloid  degeneration.  Ascites  is  less  frequent  and 
less  early  than  in  alcoholic  cirrhosis.  Icterus  develops  in  33  per  cent. 
More  bile  is  present  in  the  stools  than  in  ordinary  cirrhosis.  Gastro- 
intestinal dyspepsia  and  vomiting  of  blood  are  not  infrequent.  This 
form  develops  more  often  in  men;  is  promoted  by  alcoholism;  runs  a 
chronic  course ;  and  its  prognosis  is  better  than  in  non-syphilitic  cirrhosis, 
since  relative,  even  spontaneous  recovery  is  possible.     When  the  liver 


206  PROTOZOAN  INFECTIONS 

shrinks  death  results  from  intercurrent  pneumonia,  cholemia  or  hemor- 
rhagic diathesis. 

(6)  Gummatous  hepatitis  (syphilitic  hepatitis  par  excellence)  is  more 
frequent  than  the  first  form,  and  occurs  oftener  in  acquired  than  in 
congenital  syphilis.  The  gummata  are  either  miliary,  or  large  nodes 
which  may  fill  the  abdomen;  they  vary  from  1  to  50  and  may  be. super- 
ficial or  deep.  The  surface  of  the  liver  is  smooth,  warty,  or  adherent 
to  the  diaphragm  or  colon.  The  liver  is  distorted,  mammillated  or 
lohulated  {hepar  lobatum).  Deep,  irregular,  radiating  furrows  are  fre- 
quent, resulting  from  cicatrized  gummata,  affecting  either  lobe  and 
mostly  on  the  anterior  surface  near  the  suspensory  ligament  or  on  the 
edge.  In  congenital  syphilis  gummata  are  often  observed  at  the  hilum, 
in  the  wall  of  the  portal  vein  or  near  the  bile  vessels. 

Symptoms. — Gummata  are  frequently  latent,  i.  e.,  are  discovered 
only  at  postmortem.  Considerable  pain  occurs  in  the  shoulder,  as  well  as 
pain  on  motion  or  tenderness  on  pressure  in  the  epigastrium  or  hypo- 
chondrium.  Pain  is  due  mostly  to  perihepatitis;  a  friction-rub  is  heard 
when  the  inflammation  is  fresh;  adhesions  and  loss  of  respiratory  ex- 
cursion result,  in  older  cases.  Icterus  is  infrequent  and  results  from 
gummatous  compression  of  the  bile  ducts,  perihepatitis  or  cicatrices. 
The  liver  usually  shows  furrows  and  nodules.  Early  enlargement  is  more 
frequent  than  in  alcoholic  cirrhosis;  ultimate  shrinkage  has  been  observed. 
Ascites  is  rare  except  from  syphilitic  cirrhosis,  amyloid  liver  or  cardiac 
insufficiency,  and  is  usually  terminal  and  often  associated  with  albumin- 
uria. Splenic  tumor  is  infrequent,  except  from  gummata  or  amyloid 
degeneration  in  the  spleen,  coincident  liver  cirrhosis  or  gummata  at  the 
porta  hepatis.  Hemorrhages  and  inflammations  of  the  serous  membranes 
are  not  infrequent. 

Diagnosis. — This  depends  upon  other  evidences  of  syphilis ;  it  is  often 
difficult.  Syphilis  of  the  liver  may  remain  stationary  for  a  time  and  in 
general  a  longer  course  is  expected  than  in  alcoholic  cirrhosis.  In  thirty 
instances  of  apparent  cirrhosis,  the  Wassermann  reaction  was  positive 
in  twenty-two.  Gummata  and  cancer  may  be  confused;  age  is  only  a 
relative  criterion,  yet  most  cases  of  liver  syphilis  occur  under  the  fortieth 
year;  ascites,  icterus,  enlarged  liver  and  cachexia  may  occur  in  both 
diseases,  occasioning  doubt  and  confusion.  The  nodules  of  syphilis  are 
usually  small  but  may  be  larger  than  those  of  cancer.  Rapid  growth 
is  an  indication  of  cancer;  more  constant  size,  of  syphilis.  Albuminuria 
and  splenic  tumor  are  more  common  in  syphilitic  liver;  in  66  per  cent, 
of  hepatic  syphilis,  occult  bleeding  and  marked  gastro-intestinal  symp- 
toms may  simulate  malignancy.  The  safest  rule  is  always  to  think 
of  syphilis  when  cancer  seems  the  obvious  diagnosis.  The  lungs  are 
compressed  in  cancer  more  than  they  are  in  syphilis.  The  smooth  edge 
of  the  liver,  signs  of  fresh  hepatitis,  and  lack  of  respiratory  excursion, 
indicate  syphilis.  Riedel  found  similar  symptoms  in  syphilis  and  gall- 
stones, such  as  pain,  fever  and  tenderness.  Fever  is  not  uncommon  in 
hepatic  syphilis,  which  may  then  be  easily  confused  with  liver  abscess 
{q.  v.),  malaria,  tuberculosis,  typhoid  or  septicemia:  there  may  be  pain, 
tenderness,  rigors,  sweats  and  leukocytosis,  which,  with  the  fever,  readily 


SYPHILIS  207 

lead  to  diagnostic  errors;  the  Wassermann  test  is  invaluable.  (See 
Differential  Table  of  Diseases  of  the  Liver.) 

Amyloid  liver  {q.  v.)  is  most  frequent  in  the  tertiary  or  quaternary 
stage  of  acquired  syphilis;  it  is  rare  in  the  liver  alone. 

Syphilitic  lyylethromhosis  (see  Pylephlebitis). 

Icterus  is  attributed  to  swelling  of  the  portal  lymphatics,  early 
hepatitis,  cholangitis,  injury  to  the  liver  cells  or  to  gastroduodenal 
catarrh. 

Devic  and  Beriel  summarized  21  instances  of  hepatic  hemorrhages, 
due  to  infarction  or  luetic  endarteritis. 

6.  Kidneys. — (a)  Albuminuria  occurs  in  recent  syphilis  from  toxemia 
or  in  the  later  ulceration  from  vascular  changes.  It  is  usually  transitory 
and  nephritis  rarely  follows  it,  but  the  later  in  the  disease  that  albu- 
minuria appears,  the  poorer  is  the  prognosis.  Energetic  (not  moderate) 
mercurialization  may  produce  albuminuria  and  cylindruria.  (6)  Parox- 
ysmal hemoglobinuria  occurs  relatively  often  after  mercurial  therapy. 
(c)  Acute  parenchymatous  nephritis  is  focal  and  cortical.  It  is  early, 
toxemic  and  rare.  The  albuminuria  is  intense.  When  it  develops  late 
from  ulceration,  the  prognosis  is  unfavorable;  anemia,  vomiting  or  other 
sj'mptoms  of  acute  nephritis  may  be  present,  but  uremia  is  rare,  since 
it  is  a  focal  disease,  {d)  Chronic  parenchymatous  nephritis  may  follow 
syphilis  (0.5  per  cent.),  (e)  Chronic  interstitial  nephritis  differs  from  the 
ordinary  form  in  its  disseminated  focal  involvement,  which  leaves  scars. 
Polyuria  is  rarely  great,  casts  and  albumin  are  present  in  greater  amount, 
and  the  course  is  more  rapid  than  the  ordinary  course  of  three  to  seven 
years,  because  of  marantic,  amyloid  and  other  visceral  changes.  It  occurs 
at  an  early  age  when  arteriosclerosis  is  rare.  There  is  said  to  be  no  cardiac 
hypertrophy.  (/)  Miliary  or  large  gummata  are  found  in  the  cortex 
chiefly,  usually  multiple  and  unilateral.  They  coexist  with  amyloid 
kidney  and  chronic  parenchymatous  nephritis.  The  symptoms  are 
indeterminate,  {g)  Amyloid  kidney,  q.  v.,  under  diseases  of  the  kidney. 
(/i)  Syphilis  is  an  occasional  etiological  factor  in  glycosuria.  The  supra- 
renals  are  rarely  involved,  except  in  congenital  syphilis;  fatty  degenera- 
tion, gummata,  inflammation  and  amyloid  changes  in  the  Malpighian 
bodies  have  been  recorded — in  Addison's  disease. 

7.  Circulation. — Heart.  —  (a)  Syphilitic  myocarditis  originates  in 
coronary  arteritis;  interstitial  foci  occur  as  infiltration  along  the  small 
vessels,  especially  in  congenital  syphilis,  into  the  intermuscular  septa, 
and  areas  of  myocardial,  fatty  degeneration,  with  spirochetes.  It  in- 
volves the  front  or  apex  of  the  left  ventricle,  or  the  interventricular 
septum.  In  congenital  syphilis  it  occurs  in  the  right  more  than  in  the 
left  heart.  Resulting  changes  are  cardiac  hypertrophy,  aneurysm  of  the 
heart,  Dittrich's  heart  stenosis  (conus  stenosis)  or  amyloid  change. 
Only  97  (62  perfectly  clear)  cases  of  myocardial  gummata  are  recorded 
(Stockmann,  Goldf rank) .  Gummata  may  attain  great  dimensions  in  the 
interventricular  septum.  The  disease  is  often  latent  until,  in  50  per  cent, 
of  the  cases,  sudden  death  results,  largely  in  persons  between  thirty  and 
forty  years  of  age;  myocardial  alterations  often  occur  in  the  secondary 
stage.     The  heart  action  may  be  incompetent  or  irregular,  and  there 


208  PROTOZOAN  INFECTIONS 

may  be  dyspnea,  angina  pectoris,  heart-rupture  or  cerebral  embolism. 
Hydrops  is  rare. 

(b)  Syphilitic  pericarditis  is  invariably  a  complication  of  myocardial 
syphilis,  occurring  over  the  large  vessels  or  anterior  surface  of  the  heart. 
The  symptoms  are  those  of  disordered  compensation  or  myocarditis, 
its  invariable  associate. 

(c)  Syphilitic  endocarditis  may  cause  valvular  disease  {v.  i.,  Aorta). 
Endocardial  gummata  may  occur. 

Bloodvessels. — Endarteritis  syphilitica,  known  to  Morgagni  and  Pare, 
causes  wide-spread,  often  irreparable  or  fatal  complications,  (a)  The 
usual  fibrous  form  is  the  obliterating  endarteritis  of  Heubner  (see  page  211); 
the  wall  is  thick  and  opaque,  the  intima  and  elastic  tissue  hyperplastic 
and  the  lumen  eccentric.  When  the  muscular  coat  is  not  involved, 
thromboses  occur;  when  both  the  muscular  and  elastic  coats  are  diseased, 
aneurysms  result.  It  may  begin  one  year  after  infection.  (6)  Gum- 
matous arteritis  or  periarteritis  is  very  rare,  (c)  General  arteriosclerosis 
involves  the  vessels  more  widely  than  does  the  syphilitic  arteritis  which 
is  largely  localized  in  the  aorta,  coronary  and  brain  vessels  and  exception- 
ally in  the  other  vessels. 

Aorta. — Syphilitic  aortitis  is  oftenest  seen  in  the  ascending  aorta, 
its  arch  and  thoracic  segment,  and  the  lower  part  of  the  abdominal 
aorta.  The  early  stages  show  gray,  gelatinous  patches  of  productive 
cellular  inflammation  and  spirochetes  in  the  intima;  older  foci  are 
grayish-white,  round  or  oval,  elevated  and  stellate  plaques.  The  process 
sometimes  becomes  deep  and  calcification  occurs  in  the  intima  with 
thrombosis.  It  may  involve  the  aortic  valves.  Three-quarters  of  cases 
of  pure  aortic  insufficiency  {q.  v.)  result  from  luetic  aortitis,  and  two-thirds 
react  to  Wassermann's  test.  (See  Aneurysm.)  Its  origin  may  be  (a) 
in  the  intima,  (6)  in  the  adventitia  and  media  together  (mesaortitis) 
or  (c)  in  the  intima  and  adventitia  (vasa  vasorum) .  It  ultimately  involves 
all  the  walls  in  varying  degrees.  The  resulting  loss  of  elasticity  and 
resistance  promotes  aneurysm.  Symptoms  of  aortitis,  as  precordial 
pain,  paroxysmal  dyspnea  or  substernal  dulness  may  begin  soon  after 
the  secondary  stage,  to  reappear  after  one  or  two  decades  as  typical 
aneurysmal  signs.  The  author  believes  90  per  cent,  of  aneurysms  are 
syphilitic.  Syphilitic  aneurysms  may  be  single  or  multiple  and  usually 
occur  in  the  arch,  and  sometimes  also  in  the  abdominal  aorta  or  its 
branches.  Aortitis  occurs  in  98  per  cent,  of  paretics,  and  in  50  per  cent, 
of  syphilitics.    Only  6  cases  of  gummata  are  on  record. 

Pulmonary  Artery. — Occlusion  of  the  pulmonary  trunk,  its  compression 
by  scars  and  valvular  gummata  are  very  rare.  Syphilitic  aneurysm  of 
the  pulmonary  artery  is  not  known. 

Vein  Syp)hilis. — Thirty-three  cases  of  phlebitis  were  collected  by 
Roussy.  Periphlebitis  originates  in  the  adventitia,  especially  in  heredi- 
tary syphilis.    Gummata  exist  in  the  veins  or  involve  them  secondarily. 

Blood. — Oligocythemia  and  oligochromemia  occur  most  markedly 
when  the  glands  are  w^idely  involved.  The  anemia  disappears  under 
administration  of  mercury,  to  reappear  if  too  much  be  given.  A  count 
as  low  as  1,700,000  mav  be  observed.    The  hemoglobin  is  reduced  15 


SYPHILIS  209 

to  30  per  cent.  The  "  Justus  test,"  based  on  a  10  to  20  per  cent,  reduction 
in  the  hemoglobin  after  a  large  inunction  or  injection  of  mercury,  in  the 
florid  secondary  stage,  is  suggestive  of  syphilis.  The  white  cells  are 
increased,  especially  the  lymphocytes;  the  eosinophiles  are  increased 
but  not  constantly.  Myelocytosis  may  develop  in  the  tertiary  stage. 
The  blood  contains  the  spirochetes  and  by  way  of  the  blood,  syphilis  becomes 
a  sepsis.    The  Wassermann  test  {v.  Diagnosis). 

8.  Respiratory  Tract. —  Nose. — (a)  An  initial  nasal  lesion  is  described 
(only  95  cases  recorded).  (6)  Acute  rhinitis  is  much  rarer  in  adults  than 
in  the  newborn;  it  is  characterized  by  its  persistence,  erythematous 
papular  foci,  hemorrhagic  erosions  and  fetor,  (c)  Gummata  usually 
develop  late,  though  they  have  been  seen  in  the  seventh  month;  they 
begin  in  the  floor  and  septum,  periosteum,  bone  and  secondarily  in  the 
cartilage.  The  diffuse  necrosis  involves  the  cartilaginous  and  membran- 
ous septum  and  cartilages  of  the  alse;  sequestra  may  be  blown  from  the 
nose.  Septal  perforation  may  develop  and  a  long  course  is  usual,  with 
discharge  of  pus  and  crusts ;  the  bone  is  often  denuded  and  may  crepitate 
on  palpation.  The  deformed  "saddle-back"  nose  is  due  to  loss  of  the 
triangular  cartilage  and  vomer.  Differentiation  must  be  considered 
from  noma,  tuberculosis,  carcinoma  and  the  perforating  ulcer  of  Zucker- 
kandl  (beginning  as  a  hemorrhage  and  due  to  streptococcic  or  staphyl- 
ococcic infection).  The  diagnosis  is  best  made  by  Wassermann's  test 
and  ex  juvantibus. 

Larynx. — (a)  Catarrhal  laryngitis  occurs  with  the  eruption,  with 
redness,  swelling,  coughing  and  hoarseness,  (b)  Papular  laryngitis  is 
often  associated  with  ulceration,  infiltration  and  nodes.  The  epiglottis 
is  involved.  Stenosis  of  the  glottis  results  if  ulcers  invade  the  submucous 
tissue,  (c)  Gummata  of  the  larynx  are  usually  multiple,  and  vary  from 
the  miliary  size  to  that  of  a  pigeon's  egg;  sometimes  a  diffuse  infiltration 
occurs.  They  may  produce  dysphonia,  dysphagia,  dyspnea,  hemorrhage 
or  suffocation.    They  always  leave  stenosis  or  deformity. 

Diagnosis. — In  cancer  the  glands  are  usually  enlarged,  the  growth  is 
harder  than  in  syphilis  and  the  microscopic  examination  may  be  final. 
Syphilis  and  tuberculosis  may  occur  together;  the  syphilitic  ulcer 
usually  begins  near  the  epiglottis,  is  rounder  and  larger  and  has 
sharper  edges,  a  redder  border  and  a  whitish-yellow  coating  of  its 
deeper  base,  while  the  tuberculous  ulcer  is  less  red,  less  infiltrated  and 
less  deep. 

{d)  Perichondritis. — Any  cartilage  may  become  excoriated,  necrosed 
and  surrounded  by  edema.  Syphilis  causes  13  per  cent,  of  cases  of 
glottis  edema;  tuberculosis,  9  per  cent.  The  prognosis  is  always  grave, 
yet  the  lower  the  necrosis,  the  worse  is  the  prognosis,  for  deformity  and 
stenosis  occur,  with  dyspnea  or  dysphagia. 

(e)  Syphilitic  vegetations,  due  to  irritating  secretions,  are  sessile  or 
pedunculated  and  cause  dysphonia  or  even  suffocation. 

Trachea. — The  trachea  is  red,  swollen,  sometimes  ulcerated.    Tracheal 

stenosis,  resulting  from  healing  gummata,  is  usually  angular  and  involves 

mostly  the  middle  third.     The  symptoms  are  inspiratory  dyspnea  on 

exertion  or  on  lying  down;  cyanosis;  and  a  cough  resembling  pertussis, 

14 


210  PROTOZOAN  IXFECTIONS 

with  sanguinopurulent  sputum^  which  may  contain  fragments  of  cartliage. 
The  diagnosis  is  made  by  the  larjTigoscope. 

Bronchi. — (a)  Acute  hronchitis  may  be  a  secondary  symptom. 

(h)  Chronic  hronchitis  accompanies  laryngeal,  tracheal  or  bronchial 
affections.  Phthisis  may  be  suggested.  The  breathing  is  disproportion- 
ately disturbed  by  irritation  of  the  vagus  by  enlarged  bronchial  glands. 

(c)  Kidney-shaped  ulcers  may  cause  stenosis  or  perforation  into  the 
vessels,  mediastinum  or  esophagus;  in  Conner's  128  cases  of  bronchial 
and  tracheal  syphilis,  56  per  cent,  affected  the  trachea  alone;  gummata 
occurred  in  15  per  cent.;  ulcers  in  44  per  cent.,  frequently  T\'ith  severe 
hemorrhages;  cicatrices  and  stenoses  in  40;  and  bronchiectasis  in  20, 
peritracheitis  in  6,  and  pulmonary  syphilis  in  7  per  cent. 

Lungs. — Syphilis  may  simulate  pulmonary  tuberculosis.  Patients 
with  tuberculous  signs  should  be  searched  for  syphilis. 

(a)  In  the  white  pneumonia  of  hereditary  syphilis,  the  lung  is  firm, 
heavy,  airless  and  grayish-white,  the  chief  changes  being  infiltrated 
alveolar  walls,  desquamated,  swollen  epithelium  and  spirochetes  in  the 
air  cells  and  miliary  foci  about  the  arteries. 

(h)  Diffuse  infiltration  differs  from  tuberculosis  in  that  it  rarely  occurs 
in  the  apex;  in  Grandidier's  30  cases  the  right  middle  lobe  was  affected 
in  27.  The  lung  is  red,  hard,  large,  airless  and  smooth  on  section  and 
later  becomes  gray,  une^'en  and  nodulated.  Connective-tissue  infiltration 
occurs  about  the  vessels,  impinging  upon  the  air  cells.  Necrosis,  fatty 
change,  caseation  and  later,  cavities  may  result  from  vascular  occlusion. 
Disproportionate  dyspnea  is  present.  Temperature  may  occur  with  or 
without  ulceration. 

(e)  Gummatous  pjneumonia  may  occur  alone  or  with  diffuse  infil- 
tration. Gummata  develop  largely  in  the  lower  lobes  near  the  hilum. 
Difterentiation  from  tuberculosis  is  often  difficult  and  both  lesions  may 
occur  together.  Dulness  and  other  signs  of  consolidation  or  cavity  for- 
mation often  result.  The  sputum  is  mucous,  purulent,  profuse,  blood- 
tinged,  stinking,  and  contains  masses  of  tissue  but  no  tubercle  bacilli. 
The  course  is  usually  chronic,  and  advanced  cases  may  heal  with  appro- 
priate treatment;  Brambilla  (1777)  described  a  supposedly  phthisical 
patient,  who,  by  mistake,  took  mercury  and  recovered.  Tuberculosis 
occurs  more  frequently  in  the  upper,  syphilis  more  often  in  the  lower 
or  middle  lobes.  Rise  of  temperature  is  more  frequent  in  tuberculosis. 
In  syphilis,  actual  hemorrhage  is  rare,  as  the  vessels  are  obliterated,  and 
night  sweats  are  infrequent. 

{d)  In  syphilitic  interstitial  pneumonia  the  lung  may  be  lobulated 
(pulmolobatus)  like  the  lobulated  liver;  marked  induration  dilates  or 
distorts  the  bronchi;  diagnosis  is  impossible. 

(e)  Syphilitic  pleura  disease  occurs  chiefly  with  lung  lesions. 

9.  XERVors  System. — Syphilis  of  the  nervous  system  occurs  eight 
times  more  frequently  in  men,  mostly  between  the  years  of  twenty-fi^'e 
and  forty,  and  after  trauma;  in  brain  workers  or  those  debilitated  by 
worry  or  excesses;  or  in  children  as  perhaps  the  first  symptom  of  parental 
disease. 

In  20  per  cent,  of  cases  there  is  no  history  of  chancre.     It  occurs  where 


SYPHILIS  211 

the  secondaries  have  been  hght  and  ineffectually  treated.  Syphilis 
occurs  in  the  brain  in  16.5  per  cent,  of  syphilitics  and  more  often  than 
in  other  viscera,  excepting  the  liver. 

Fifty  per  cent,  of  brain  syphilis  occurs  loithin  three  years  after  infection. 
Formerly  described  as  occurring  many  years  after  infection,  cerebro- 
spinal syphilis  may  develop  as  early  as  five  weeks  after  infection 
(especially  in  those  advanced  in  years).  Nervous  symptoms  in  the 
secondary  stage  as  headache,  neuralgia,  increased  reflexes  or  fleeting 
paralyses,  are  partly  toxemic  but  largely  anatomic,  as  is  demonstrated 
by  the  pleocytosis  (over  ten  cells  in  the  cell  count),  lymphocytosis, 
Wassermann  and  globulin  reactions  of  the  cerebrospinal  fluid. 

In  general,  the  symptoms  are  marked  by:  (a)  variability  and  incon- 
sistency, due  to  alternate  regression  and  recurrence  in  the  lesions; 
(6)  incompleteness,  as  partial  paralysis  or  disturbance  of  consciousness; 
(c)  the  symptoms  are  partly  tumor-like,  partly  vascular,  or  partly  in- 
flammatory ;  they  are  partly  meningeal,  partly  basal  or  cortical,  and  rarely 
occur  in  the  centre  of  the  brain  except  from  secondary  vessel  lesions  and 
gummata.    Syphilis  produces  no  symptom  not  produced  by  other  disease. 

Types. — 1.  Syphilitic  arterial  disease  is  the  most  frequent  form,  and 
aside  from  neuritis  paralysis,  the  most  frequent  cause  of  syphilitic  paralysis. 
As  prodromal  disturbances,  headache  is  usual;  vomiting,  vertigo,  psychic 
changes,  convulsions,  hemianopsia  and  aphasia  may  occur;  choked  disk 
is  rare.  Thrombosis  and  obliteration  of  the  vessels  are  gradual  in  onset 
and  intermittent — e.  g.,  involving  the  leg  and,  in  a  few  hours  or  days, 
the  arm — and  the  multiple  softening  in  95  per  cent,  of  cases  occurs  in 
the  distribution  of  the  Arteria  fossae  Sylvii. 

Course. — The  first  attacks  are  mild ;  the  later  are  more  severe,  and  occur 
with  somnolence,  bilateral,  alternating  or  crossed  paralysis,  general  or 
rarely  Jacksonian  convulsions,  or  with  partial  aphasia,  mental  changes 
or  progressive  bulbar  phenomena. 

In  diagnosis  the  ordinary  arteriosclerosis  in  over  90  per  cent,  of  cases 
occurs  in  late  life,  its  progress  is  slower,  the  changes  are  more  disseminated, 
all  coats  of  the  vessels  are  involved,  its  fatty  and  calcareous  changes  lead 
more  often  to  widening  than  to  obliteration,  and  hemorrhage  is  more 
characteristic  than  softening;  whereas  in  syphilitic  endarteritis  the  onset 
is  more  acute  and  headache  more  conspicuous,  encephalomalacia  occurs 
at  a  younger  age  (see  Brain  Embolism),  the  changes  affect  chiefly  the 
aorta  and  cerebral  vessels,  the  intima  is  principally  involved,  calcareous 
and  fatty  changes  are  rare  and  obliteration  is  usual;  the  hemiplegia 
occurs  by  "instalments,"  associated  with  meningitis,  apathy,  dementia, 
somnolence  or  delirium;  and  finally  the  symptoms  are  more  diffuse. 
The  Wassermann  test  and  spinal  puncture  are  final.  Without  treatment, 
the  average  duration  is  one  to  three  months. 

Multiple  aneurysms  of  the  basilar.  Sylvian  and  carotid  trunks  are 
generally  tertiary,  but  occasionally  secondary;  their  rupture  produces 
symptoms  of  apoplexy  or  meningeal  hemorrhage.  Otherwise  hemorrhage 
is  rare  in  brain  syphilis. 

AVhile  softening  is  usually  ischemic  (non-inflammatory),  encephalitis 
syphilitica  may  rarely  cause  disseminated  softening  or  indurated  sclerosis. 


212  PROTOZOAN  INFECTIONS 

2.  Basal  gummatous  meningitis,  the  best-known  type,  and  the  next 
most  frequent  form,  begins  in  the  dura,  especially  about  the  optic  chiasm, 
interpeduncular  spaces  or  cavernous  sinus;  less  frequently  in  the  fossa 
of  Sylvius  and  the  cortex;  pathologically  it  consists  of  fibrinous  exudate, 
granulation  tissue,  gummata  and  cicatrices. 

General  Symptoms. —  Headache  is  the  most  important  and  early 
symptom  (in  75  per  cent.).  It  is  paroxysmal,  is  increased  at  night,  sharp, 
boring  and  deep-seated.  Other  symptoms  are  projectile  vomiting,  vertigo, 
somnolence,  semi-intoxication,  motiveless  activity,  nocturnal  automatism 
or  dementia,  alternating  with  delirium,  epileptic  attacks  or  paralytic 
seizures;  the  symptoms  may  resemble  those  of  uremia,  meningitis  or 
typhoid.  Between  attacks,  cerebration  may  be  normal.  Epilepsy 
may  be  typical  or  unilateral,  frequent  or  violent.  Polydipsia,  diabetes 
insipidus  from  disease  in  the  third  ventricle,  or  diabetes  mellitus,  of  which 
Oppenheim  collected  20  cases,  may  occur.    Fever  may  be  present. 

The  cranial  nerves,  especially  the  second  and  third  are  often  affected. 
Involvement  of  successive  branches  is  most  characteristic  (85  per  cent.); 
80  to  90  per  cent,  of  nerve  involvements  result  from  syphilis  of  the  hrain, 
tabes  or  less  frequently,  general  paralysis  and  brain  tumor,  (a)  The 
third  nerve  is  involved  in  65  per  cent,  of  these  cases — "the  sign  of 
syphilis."  (b)  The  optic  nerve  is  diseased  anatomically  in  82  per  cent, 
and  clinically  in  40  per  cent,  of  cases;  choked  disk  (10  per  cent.)  is 
almost  always  bilateral  (see  Plate  IV).  Simple  atrophy,  with  complete 
blindness  (in  6.6  per  cent.),  is  most  frequent  in  tabes  and  next  most 
frequent  in  brain  syphilis  and  general  paralysis.  -a^mSurosis  is  common 
and  often  unilateral.  Hemianopsia  is  homonymous.  Temporal  heterony- 
mous hemianopsia  is  very  often  syphilitic;  the  nasal  form  is  rarely  so. 
Eye  changes,  due  to  meningitis,  bone  disease  or  gumma  are  susceptible 
to  treatment,  (c)  The  fourth,  sixth  and  fifth  nerves  are  next  in  frequency 
of  involvement.  The  fifth  is  unilaterally  affected,  and  more  in  its  sensory 
than  motor  branches.  The  olfactory  nerve  is  rarely  involved.  The  facial 
nerve  may  be  paralyzed,  nearly  always  unilaterally  and  peripherally. 
The  eighth  nerve  is  sometimes  involved,  and  the  resulting  Meniere 
complex  is  ominous.    The  vagus  or  hypoglossus  may  be  affected. 

With  the  above  changes  (i)  gummata  may  grow  into  the  pons,  crus  or 
medulla,  and  cause  hemiplegia  and  crossed  paralyses,  as  hemiplegia 
plus  oculomotor  paralysis  (Weber's  paralysis);  plus  facial  paralysis 
(Gubler's  paralysis)  or  plus  abducens  and  trigeminus  paralysis  (Leyden's 
paralysis) ;  or  (ii)  arterial  phenomena  are  often  noted,  syncope,  apoplecti- 
form attacks,  encephalomalacia,  hemiplegia,  hemianesthesia  and  hemi- 
anopsia, usually  as  later  symptoms.  Syphilitic  meningitis  is  typically 
subacute  with  remissions  and  exacerbations,  and  lasts  rarely  more  than 
half  a  year. 

Differential  Diagnosis. — Carcinoma  and  sarcoma  at  the  base  of  the 
brain,  involving  the  meninges,  run  a  continuous  progressive  course, 
with  definite  localization,  while  in  syphilis  the  course  is  intermittent, 
localization  varies,  and  vascular  changes  are  often  marked.  In  tuber- 
culous meningitis  there  is  less  development  of  connective  tissue,  vascular 
changes  are.  rarer,  the. nerves,  less  frequently  involved,  the  course  more 


SYPHILIS  213 

acute,  febrile  and  progressive,  and  remissions  less  frequent  and  less 
marked.  Mental  obscurity  is  more  marked,  sudden  and  stationary. 
The  initial  irritation  is  followed  by  later  paralysis,  while  paralysis  may 
occur  at  once  in  syphilis.  Tuberculous  meningitis  usually  occurs  before, 
and  syphilis  after,  twenty  years  of  age.  Other  syphilitic  or  tuberculous 
foci,  the  Wassermann  reaction,  lumbar  puncture  and  the  results  of 
therapy  determine  the  differentiation.  Spirochetes  have  been  found 
directly  in  the  cerebrospinal  fluid  only  five  times.  Differentiation  from 
Quincke's  serous  meningitis  is  not  difficult.  The  multiple  7ierve  root 
affection  of  Kahler,  involving  the  seventh  and  third  cerebral  and  the 
cervical  and  dorsal  nerve  roots  causes  neuralgia  and  paralysis.  Periodic 
Ijaralysis  of  the  third  nerve  is  rhythmic  in  its  attacks,  usually  involves 
the  entire  nerve,  occurs  in  young  children  especially,  and  with  attacks 
of  migraine. 

3.  Syphilis  of  the  convexity  is  a  meningo-encephalitis,  with  circumscribed 
symptoms  like  cortical  tumor  or  with  diffuse  manifestations. 

General  Symptoms. —  Headache  is  usually  the  first  and  most  common 
manifestation.  Focal  Jacksonian  attacks  occur  with  mono-  or  hemiplegia, 
develop  by  starts  or  "instalments"  and  occur  without  an  aura.  Ninety 
per  cent,  of  convulsions  in  those  over  thirty  years  of  age,  not  uremic  or 
alcoholic,  are  syphilitic  (Fournier).  The  symptoms  are  more  diffuse 
than  in  vulgar  epilepsy.  The  convulsions  may  number  even  400  in 
twenty-four  hours.  Aphasia  is  frequent,  usually  of  the  transitory  motor 
type  and  occurs  less  often  from  gumma  than  from  vascular  disease. 
Dift'use  meningo-encephalitis  may  resemble  an  acute  psychosis  or  de- 
mentia. Convexity  syphilis  recovers  more  frequently  than  other 
forms. 

4.  Gummata,  the  least  frequent  variety,  occur  usually  in  the  meninges, 
sometimes  in  the  central  ganglia,  cerebellum,  pon  or  crus.  The  symptoms 
are  those  of  brain  tumor,  except  that  there  is  often  regression,  either 
spontaneous  or  therapeutic.  Cortical  gummata,  producing  cortical 
epilepsy  and  monoplegia,  require  difi^erentiation  from  cortical  tumor 
{q.  V.)  in  w^hich  the  pressure  symptoms,  and  slow  pulse  are  more  marked; 
the  disk  changes  follow  focal  signs  and  the  process  advances  less  by 
epochs;  while  in  syphilis  the  pressure  symptoms  are  more  dift'use  and 
rapidly  extensive;  the  disk  is  involved  when  coincident  basal  meningitis 
occurs;  cortical  paralysis  is  often  associated  with  Jacksonian  epilepsy 
(v.  s.);  the  symptoms  are  more  undulatory,  the  Wassermann  test  is 
positive,  and  treatment  is  successful. 

5.  Cerebrospinal  syp)hilis  produces  suggestive  spinal  symptoms:  (a) 
their  asymmetry,  (6)  their  less-pronounced  character,  (c)  their  variability, 
(d)  meningeal  and  nerve-root  symptoms,  (e)  the  cerebrospinal  fluid 
issues  under  pressure  and  exhibits  pleocytosis  (the  normal  number  of 
lymphocytes  being  4  to  6),  Wassermann's  reaction  and  globulin,  and  (/) 
response  to  mercury  and  iodides.  Syphilis  is  never  a  system  disease 
((iowers).  Syphilis  of  the  cord  is  six  times  less  frequent  than  brain 
syphilis. 

The  most  frequent  and  chracteristic  form  is  meningo-encephalomyelitis. 
While  the  symptoms  may  be  strictly  spinal,  cerebral  meningo-enceph- 


214  Protozoan  infections 

alitis  is  frequently  found  anatomically.  Heubner's  arteritis  Is  not  noted. 
Brain  changes  may  mask  the  spinal  symptoms.  The  meninges  are  most 
involved  in  the  cervical  and  upper  dorsal  regions,  as  evidenced  by  pain, 
stiffness  or  girdle  sensation;  while  the  cord  itself  is  mostly  affected  in  the 
lower  dorsal  region,  and  therefore  causes  weakness  in  the  legs,  paresthesia, 
sphincter  disturbance  and  decubitus.  Intercostal  neuralgia,  nocturnal 
pains  in  the  extremities,  spastic  paraparesis,  hemiparaplegia,  triplegia, 
Brown-Sequard's  syndrome,  increased  reflexes  and  sensory  disturbances, 
are  some  of  the  symptoms  of  cerebrospinal  syphilis.  Erb  laid  special 
stress  on  the  spastic  paraplegic  type.  The  so-called  syphilitic  myelitis 
is  often  only  softening — myelomalacia.  Gum.mata  of  the  cord  and 
perineuritis  gummosa  of  the  nerve  roots  are  uncommon. 

In  cerebrospinal  syphilis,  tabes  and  dementia,  the  lumbar  puncture 
is  important  (v,  s.). 

Prognosis  of  Brain  Syphilis. — Only  half  of  the  cases  recover.  The 
later  the  disease,  the  worse  is  the  prognosis.  The  prognosis  is  more  favor- 
able in  meningeal,  i.  e.,  extracerebral  involvement,  when  nerve  symptoms 
or  epilepsy  are  dominant,  or  when  early  and  thorough  treatment  is 
instituted.  The  prognosis  is  less  favorable  in  specific  endarteritis, 
bulbar  forms,  diffuse  involvement,  in  great  psychic  alteration  and  in 
extragenital  infections  and  hereditary  syphilis.  Recovery  is  rarely 
complete  and  recurrence  is  possible. 

6.  Syphilis  of  the  peripheral  nerves  may  cause  facial  and  trigeminal 
paralysis,  even  in  the  secondary  stage.  The  most  frequently  affected 
spinal  nerves  are  the  occipital  and  auriculotemporal.  But  6  reports  of 
luetic  multiple  neuritis  exist  in  the  literature. 

10.  Eye  and  Ear. — Syphilis  explains  3  per  cent,  of  all  eye  diseases 
and  3  per  cent,  of  all  syphilitics  have  eye  disease.  The  uveal  tract  is 
most  involved;  next  in  frequency  come  the  retina,  optic  nerve  and  eye- 
muscles;  the  lens  suffers  only  from  uveal  tract  disease.  The  lids  are 
not  often  involved  (chancre,  condyloma  and  gumma). 

Conjunctiva. — ^Twenty-two  scleroses  have  been  observed,  as  well  as  a 
few  gummata;  catarrh  occurs  in  the  secondary  stage. 

Cornea. — The  cornea  is  frequently  involved:  (a)  As  parenchymatous 
keratitis,  which  is  mostly  observed  in  congenital  syphilis,  and  occurs  even 
in  the  third  generation;  in  acquired  syphilis  it  occurs  in  but  2  per  cent, 
of  cases.  " Hutchinson' s  triad''  in  congenital  syphilis  consists  of  keratitis, 
notched  teeth  and  congenital  or  early  acquired  deafness.  The  cornea  is 
diffusely  clouded  and  milky  (the  ground-glass  cornea) ,  and  on  close  exami- 
nation shows  patches  or  streaks  of  inflammation;  ih)  as  keratitis  inter- 
stitialis,  circumscribed  or  punctate;  (c)  as  gumma,  which  is  infrequent; 
{d)  as  keratonialacia,  observed  in  the  congenital  variety. 

Iris. — Of  all  inflammations  of  the  iris,  75  to  90  per  cent,  are  syphilitic. 
The  symptoms  are  those  of  other  iritides — ciliary  injection,  discoloration, 
slow  reaction  and  synechia  or  occlusion  of  the  pupil.  It  is  plastic,  or 
exudative  with  tiny  papules;  iritis  with  nodules,  if  not  traumatic,  is 
strongly  indicative  of  syphilis.  Iritis  is  usually  secondary,  rarely  tertiary. 
Without  cyclitis  it  is  rare  in  congenital  syphilis.  Atropine  should  be 
administered  early  while  mercury  is  being  given,  for  expectant  treat- 


Syphilis  215 

tnent  results  in  severe  lesions  and  recurrence.  Ciliary  involvement  is 
usually  secondary,  rarely  tertiary.  Injection  and  exquisite  tenderness 
are  characteristic. 

Choroid. — The  choroid  is  involved  in  the  secondary  period,  perhaps 
following  iritis  or  cyclitis.  Its  several  forms  terminate  with  the  same 
appearances — exudative  choroiditis  with  small,  oval  or  irregular  yellowish, 
bluish  or  rose-colored  spots.  Both  the  spots  and  pigment  lie  behind  the 
retinal  vessels,  which  branch  over  them  in  the  ophthalmoscopic  picture 
(Plate  VI).  Disseminated  choroiditis  consisting  of  spots  of  pigment 
especially  in  the  peripheral  eye-ground,  usually  indicates  syphilis.  When 
recurrent,  with  inflammation  of  the  retina  and  choroid,  blindness  may 
result.  The  vitreous  humor  is  rarely  involved  without  lesions  of  the  uvea. 
It  results  in  opacities  or  dust-like  bodies;  in  the  absence  of  myopia  it 
rather  indicates  syphilis. 

Retina. — The  retina  is  involved  chiefly  in  its  anterior  layers,  be- 
coming cloudy  about  the  disk,  with  opacity  of  the  nerve  and  blurring 
of  the  disk  outlines.  The  course  of  the  arteries  is  lost  or  broken  and 
the  veins  are  tortuous  and  engorged.  Most  cases  of  idiopathic  retinitis 
are  syphilitic.  Nodules,  either  papules  or  gummata,  constitute  the 
specific  retinitis.  Recurring  retinitis,  commencing  at  the  macula,  is  of 
great  importance.  Retinitis  with  pigment  formation  occurs  mostly  in 
congenital  syphilis.  The  optic  nerve  is  usually  involved  with  the  retina, 
and  anywhere  from  its  central  origin  to  the  disk.  Sometimes  the  change 
is  simple  blue  atrophy;  again  the  appearance  is  nearly  normal,  or  again 
choked  disk  occurs.  The  causative  lesions  are  gumma  in  the  brain, 
syphilitic  inflammation  of  the  intracranial  tract  or  basal  disease.  Neither 
its  syphilitic  nature  nor  its  location  can  be  diagnosticated  by  the 
ophthalmoscope.  Amblyopia  or  amaurosis  may  result  from  transitory, 
circulatory,  or  permanent  organic  changes.  Hemianopsia  is  often 
central,  results  from  lesion  in  the  optic  tract  and,  in  most  cases,  is 
transitory. 

Eye  Muscles. — The  eye  muscles  are  involved  as  frequently  as  is  the 
iris;  more  than  half  the  paralyses  of  the  eye  muscles  are  syphilitic. 
Ocular  paralyses  may  be  (a)  peripheral;  (6) ' intracranial  as  at  the  base 
of  the  brain;  or  (c)  central  (nuclear,  fascicular  and  cortical).  The 
following  lesions  occur :  syphilitic  meningitis,  basal  gummata,  periostitis, 
cellulitis  of  the  orbit,  diffuse  arterial  disease,  nuclear  disease,  polien- 
cephalitis  and  gummata  of  the  hemispheres  or  cortex.  Other  causes  as 
tabes,  general  paralysis  and  tumor,  must  be  considered.  Thirty-six 
to  50  per  cent,  of  nuclear  paralyses  are  syphilitic.  Syphilis  frequently 
produces  progressive  paralysis  of  all  the  muscles  of  both  eyes.  Total 
paralysis  of  the  ociilomotor  is  rare;  if  it  occurs,  the  lesion  is  usually  at 
the  base,  is  rarely  orbital,  or  may  be  nuclear,  especially  if  one  twig 
after  another  become  involved.  If  it  is  partial,  it  is  usually  nuclear, 
rarely  neural  or  muscular.  Ptosis  is  highly  suggestive  of  syphilis.  Ab- 
ducens  and  trochlear  paralysis  may  occur.  Ophthalmoplegia  interna, 
involving  the  sphincter  iridis  and  the  ciliary  muscle,  produces  mydriasis 
and  paresis  of  accommodation;  36  per  cent,  of  all  mydriases  are  syphilitic 
and  nuclear.    Ophthalmoplegia  externa  may  occur  with  facial  paralysis. 


216  PROTOZOAN  IXFECTIOXS 

involving  the  orbicularis  palpebrarum,  or  with  trigeminal  paralysis 
involving  the  sensory  filaments  of  the  eye. 

Orbit. — Periostitis  is  mdicated  by  deep  tenderness  over  the  eye-ball 
or  edge  of  the  orbit;  by  pain  on  movement  of  the  eye;  more  rarely 
by  blindness,  exophthalmos  and  thrombosis.  Periosteal  gummata  are 
often  mistaken  for  tumors. 

Ear. — Four  instances  of  primary  sclerosis  on  the  external  ear  have 
been  noted;  33  per  cent,  of  children  \\ith  hereditary  s^^hilis  are  deaf; 
otosclerosis  is  specific  in  25  and  nervous  deafness  in  50  per  cent. 
Condylomata,  mastoid  periostitis  or  gumma,  sclerosis  or  gumma  of 
the  Eustachian  tube,  may  be  observed. 

11.  Genitalia. — Some  chancres  occur  in  the  urethra;  gummata  have 
been  observed  in  the  urethra  and  bladder  (23  cases). 

Penis. — Gummata,  at  the  site  of  the  primary  lesion  or  elsewhere, 
often  are  confused  with  chancre,  chancroids  or  carcinoma. 

Testes.- — (a)  Diffuse  interstitial  orchitis  occurs  'ttith  great  pyriform 
swelling  and  flattening  of  the  epididymis;  it  is  often  nodular,  due  to 
periorchitis  or  gummata.  Serous  effusion  and  synechia  occur.  Absorp- 
tion of  this  sarcocele  syphilitica  may  result.  The  connective  tissue 
is  increased  and  the  canals  are  compressed,  fatty  and  infiltrated  with 
round  cells  (b)  Gummatous  orchitis  is  less  frequent,  and  usually  involves 
one  testis.  Great  symmetrical  or  irregular  swelling  may  occur,  and 
frequently  the  entire  testis  is  firm  and  studded  with  gummata,  single  or 
multiple,  hard,  irregular,  painless  nodules.  The  testes  sclerose  and 
atrophy.  The  symptoms  develop  gradually  or  after  trauma.  The  scrotum 
is  infiltrated,  nodular  and  red.  Perforation  is  frequent,  with  a  crater-like 
opening  and  irregular  edges.  Oligospermia,  azoospermia  or  impotentia 
does  not  always  follow,  because  islets  of  functionating  tissue  frequently 
remain;  syphilis  has  been  inoculated  into  rabbits  from  the  sperma. 
Differentiation  is  required  from  gonorrheal  orchitis,  which  is  more  acute, 
painful  and  involves  the  epididymis  first;  plastic  orchitis,  resulting  from 
stricture  and  traumatic  orchitis;  also  from  tuberculous  disease,  which 
is  often  bilateral  or  occurs  in  several  foci,  and  frequently  involves  the 
cord,  vesicles,  epididymis  and  often  causes  perforation  with  pain,  fever 
and  prostration,  in  which  case  tubercle  bacilli  may  be  detected.  Sar- 
coma is  harder,  develops  more  rapidly,  is  more  nodular,  produces 
lancinating  pains  and  frequently  aftects  the  glands,  epididymis  and 
cord,  which  are  less  often  invoh'ed  in  s^'philis.  Carcinoma,  which 
requires  differentiation  from  interstitial  orchitis  does  not  respond  to 
specific  treatment. 

J^as  deferens  and  prostatic  involvements  are  rare. 

Vagina. — Chancres  are  relatively  rare,  because  of  the  thick  epithelium 
and  the  paucity  of  glands;  secondary  eruptions  are  rarely  observed. 
Gummata  occur  infrequently. 

Vulva. — The  vulva  is  very  frequently  the  seat  of  secondary  lesions, 
upon  which  tertiary  lesions  may  develop,  which  may  extend  to  the  urethra 
or  bladder.  Enormous  swelling,  resembling  blisters,  is  a  common  result 
of  lymphatic  involvement.  Gummata  are  readily  differentiated  from 
carcinoma  and  tuberculosis. 


SYPHILIS  217 

Cervix. — Chancre  occurs  in  5  per  cent,  of  cases.  Scars  may  result 
from  gummata,  with  stenosis  and  steriUty. 

Uterus. — SyphiHtic  endometritis  is  frequent;  metrorrhagia  may  respond 
only  to  mercury.  Virchow  described  a  papular  and  a  tuberous  variety. 
Endometritis  may  produce  sterility.  In  clear  cases  of  metritis  large 
tumors  disappeared  under  specific  therapy.  Specific  or  simple  peri- 
metritis is  secondary  to  rectal  disease.  Placental  involvement  and 
abortion  are  discussed  under  Congenital  Syphilis. 

Tubes  and  Ovaries. — Salpingitis,  oophoritis  and  gummata  have  been 
described. 

12.  Bones,  Joints  and  Muscles. — Periostitis  produces  pain,  tender- 
ness and  swelling,  which  is  hard  at  first,  and  later  is  elastic  even  to  fluctu- 
ation. It  occurs  especially  on  parts  subject  to  trauma,  as  the  head,  ster- 
num, ribs,  tibia  or  clavicle.  Fugitive  pains  occur  with  the  secondary 
eruption,  but  the  pain  of  periostitis  is  fixed,  rarely  migrates,  is  boring  in 
character,  appears  at  night — dolores  nocturnoe — and  disappears  at  1 
or  2  o'clock  in  the  morning  with  sweating,  but  otherwise  resembles  the 
common  types  of  periostitis.  In  28  per  cent,  it  occurs  in  the  frontal  or 
temporal  bones,  and  forms  circumscribed,  smooth,  elastic  and  immovable 
tumors.  On  the  ribs,  it  occasions  pain  on  coughing  or  neuralgia  over  the 
sternum.  Tibial  nodes  occur  in  16  per  cent,  of  cases.  Osteophytes 
develop.    Periosteal  changes  last  for  five  or  six  weeks. 

Gummata  of  the  bones,  the  first  well-studied  form  of  gummata,  largely 
occur  on  the  exposed  parts  as:  (a)  Diffuse  subperiosteal  infiltration, 
which  causes  molecular  destruction  of  the  bone.  Sequestra  may  form, 
especially  in  the  femur;  osteophytes  in  the  diaphysis  sometimes  resemble 
arthritis  deformans.  (5)  Circumscribed  gummata,  the  more  important 
form,  develop  in  the  periosteum,  as  elastic,  immobile,  not  especially 
tender  tumors  which  afterward  soften  and,  perhaps  fibrose  and  calcify. 
Gummata  of  the  cranium  are  attended  by  dull  pain,  especially  at  night; 
grow  slowly ;  are  at  first  soft,  and  later  have  a  wall-like,  hard  edge.  They 
rarely  ulcerate  except  from  pyogenic  infection  and  often  disappear 
spontaneously,  leaving  an  elevated  periphery  and  a  deeper  centre.  They 
are  often  mistaken  for  supra-orbital  neuralgia  or  migraine.  Tuberculous 
ulcers  rarely  occur  in  this  location.  Meningeal  symptoms  may  develop 
(perforating  type) .  Gummata  at  the  base,  where  periostitis  is  infrequent, 
occur  chiefly  in  the  middle  fossa  and  involve  the  nerves  or  bloodvessels. 
Dift'use  gummatous  infiltration  develops  very  slowly,  with  little  pain, 
possibly  with  ulcerative  exposure  of  the  bone  and  is  diagnosticated  with 
difficulty.  In  1914  Hunt  collected  100  instances  of  luetic  spondylitis; 
only  44  per  cent,  recovered,  due  to  its  late  recognition;  the  aft'ection  is 
cervical  in  70  per  cent.,  rarely  dorsal,  very  rarely  lumbar,  and  aft'ects  the 
bodies  of  the  vertebrae  less  than  their  processes  and  arches,  in  contra- 
distinction to  tuberculosis.  Pain  and  immobility  are  observed.  The  head 
is  held  in  the  hands,  if  the  atlas  is  involved ;  death  results  from  ulceration, 
pressure  on  the  medulla  or  luxation  (10  per  cent.).  The  humerus,  radius 
and  carpus  are  infrequently  involved.  The  phalanges  may  be  involved, 
usually  one  finger  only,  spina  ventosa,  the  parts  being  swollen  but  soft, 
with  periosteal  thickening,  shining  appearance  and  rarely  pain  or  ulcera- 


2l8  PROTOZOAN  INFECTIONS 

tion.  The  cla^'icle,  from  its  esri^osure  to  trauma,  is  very  frequently 
involved;  the  course  is  slow  and  often  painless.  Ulceration  of  the  sternum 
is  frequent;  of  the  ilium  and  sacrum,  rare. 

Joints. — (a)  Acute  synovitis  occurs  alone  or  with  periostitis  at  the  time 
of  the  eruption;  pain  alone  may  be  observed  or  the  swelling  is  poly- 
articular, with  tenderness,  nocturnal  pain,  immobility,  temperature, 
and  involvement  of  the  muscles  and  tendons.  The  knees  are  most 
frequently  involved  and,  according  to  Fournier,  more  than  three  joints 
are  never  affected.  This  luetic  pseudorheumatism  may  last  weeks  or 
months  and  does  not  involve  the  heart.  In  100  acute  arthritides  among 
negro  laborers  on  the  Panama  Canal,  Baetz  found  63  per  cent,  syphi- 
litic and  28  per  cent,  gonococcic.  (6)  Chronic  synovitis  or  arthritis 
is  usually  monarticular,  indolent,  afebrile,  painless,  a^nd  affects  chiefly 
the  knee  and  elbow,  (c)  Joint  disease  of  late  sj^Dhilis  origmates  in  the  bone 
or  cartilages  (tumor  alhus  syphilitique),  and  affects  chiefly  the  knee,  elbow 
and  ankle.  The  central  portion  of  the  cartilage  is  involved,  and  not  its 
edge,  as  is  the  case  in  arthritis  deformans,  probably  due  to  osseous  gummata 
and  most  frequent  in  congenital  syphilis.  The  onset  is  slow,  with  moderate 
pain  and  swelling;  no  temperature  is  observed.  There  may  be  a  close 
resemblance  to  tuberculous  lesions;  tuberculosis  is  usually  inflammatory, 
incipient  syphilitic  lesions  non-inflammatory;  in  syphilis,  sequestration 
and  ulceration  are  infrequent;  therapy  and  the  seroreaction  are  the 
final  tests.  Syphilis  is  most  prone  to  attack  the  periosteum,  gonorrhea 
the  joint,  and  pyogenic  organisms  the  bone.  The  ^Titer  has  repeatedly 
seen  lues  simulate  arthritis  deformans. 

Muscles. — Early  involvement  may  occur  from  toxemia  or  myositis. 
The  latter  is  a  diffuse  or  circumscribed  infiltration,  which  possibly 
eventuates  in  muscular  contractures,  especially  in  the  arm  and  finger 
flexors,  sphincter  ani,  masseters,  deltoid  and  sternomastoid.  The  course 
is  subacute  or  chronic,  depending  on  treatment.  Gummata  cause  con- 
fusion with  neoplasms;  they  may  be  as  large  as  the  fist,  single  or  multiple, 
usually  with  a  firm  connective-tissue  capsule;  they  involve  the  long 
muscles  of  the  arms  and  neck,  especially  at  their  attachments.  The 
course  is  long,  and  regression  may  occur  with  induration  and  atrophy 
(arterial  disease  and  central  nervous  lesions).  jNIyositis  ossificans  is 
rare.  The  tendons  may  be  involved,  partly  from  changes  in  the  bones  or 
muscles,  (a)  The  early  irritative,  acute  bursitis  or  tendosynovitis  is 
sometimes  confused  with  rheumatism.  It  occurs  most  frequently  in 
sewing  women  and  washerwomen.  There  is  more  tension  than  pain. 
(6)  The  gummatous  form,  occurring  in  the  flexor  tendons,  is  character- 
ized by  indolence,  painlessness  and  benignancy.  Churchman  collected 
26  cases  of  bursitis  (1876-1908). 

13.  M.-ooLE. — (a)  The  diftuse  infiltration,  syphilitic  mastitis,  with 
swelling,  occurs  largely  in  the  secondary  stage,  and  often  resorbs  spon- 
taneously, (h)  Gummatous  mastitis  is  deep-seated  and  is  not  very  sensi- 
tive. Rapid  growth  may  be  observed  with  central  necrosis,  fluctuation 
or  external  ulceration.  It  requires  dift'erentiation  from  adenoma,  fibroma 
and  carcinoma;  it  is  frequently  bilateral,  without  cachexia  or  adenopathy, 
but  possibly  with   gummata   elsewhere,      (c)   206   cases  of  mammary 


SYPHILIS  219 

chancre  are  recorded  (Dimey).    There  is  a  reversion  to  the  abandoned 
idea  that  milk  may  convey  infection. 

Diagnosis  of  Syphilis. — Differentiation  has  been  treated  under  the 
primary  cliancre,  secondary  manifestations  and  special  visceral  pathology. 
The  last  ten  years  have  brought  within  our  reach  special,  we  may  say 
absolute,  diagnostic  helps  for  the  careful  diagnostician,  and  yet  there 
is  a  tendency  to  leap  at  once  to  laboratory  diagnosis  and  to  disregard 
the  frequently  characteristic  clinical  physiognomy  of  the  disease. 

I.  The  Treponema. — In  the  initial  induration,  the  detection  of  the 
parasite  is  invaluable,  employing  the  dark-ground  illumination.  Doubt- 
less cultural  methods  soon  will  be  available  for  practical  use. 

II.  The  Wassermann  Reaction. — Elaborate  studies  of  this  compli- 
cated test,  discovered  in  1906  by  Wassermann,  Neisser  and  Bruck, 
have  showii  its  presence  in  85  to  95  per  cent,  of  syphilitics;  in  the  chancre 
stage,  it  appears  in  90  per  cent,  usually  in  six  weeks;  in  the  secondary 
stage,  in  95  to  100  per  cent,  (in  80  per  cent,  when  no  outward  signs  are 
present);  in  the  tertiary  stage,  in  96  per  cent,  (in  57  to  65  per  cent. 
of  cases  showing  no  obvious  symptoms);  in  the  quaternary  stage,  in 
95  to  100  per  cent,  of  general  paresis,  in  75  per  cent,  of  tabes  and  in  about 
66  per  cent,  of  cases  of  aortic  leakage,  aneurysm  (95  per  cent,  of  those 
under  forty  years  of  age)  and  aortitis.  In  general,  Wassermann's  1982 
cases  of  syphilis  gave  the  reaction  in  90  per  cent,  of  manifest  lues  and  in 
50  per  cent,  of  cases  without  obvious  symptoms.  A  positive  reaction  is 
sometimes  encountered  in  leprosy,  frambesia,  trypanosomiasis,  scar- 
latina, etc. 

The  positive  reaction  is  the  most  common  symptom  of  syphilis,  but 
it  is  only  a  symptom  and  may  be  lacking ;  much  less  significance  attaches 
to  a  negative  reaction,  which,  in  general,'  is  encountered  in  10  per  cent,  of 
cases  undoubtedly  syphilitic.  A  positive  reaction  denotes  the  survival 
in  the  body  of  some  living  spirochetes,  and  99  per  cent,  of  positive  re- 
actions are  absolutely  diagnostic  of  lues.  Mercury  and  arsenic,  pre- 
viously administered,  vitiate  the  reaction,  as  does  also  alcohol  (taken 
within  twenty-four  hours  of  the  test).  The  best  results  follow  the 
original  unmodified  Wassermann  technique.  The  practical  bearings  of 
the  test  are  immense,  e.  g.,  upon  the  questions  of  immunity,  which  is 
merely  latency  of  the  disease,  reinfection,  familial  diseases,  heredity, 
congenital  lues,  prostitution,  marriage,  life  insurance,  and  treatment, 
all  of  which  are  discussed  later.  To  mention  but  a  few  instances: 
Letulle  found  positive  reactions  in  43  per  cent,  of  chronic  obscure  diseases 
and  in  25  per  cent,  of  chronic  nephritides.  Dean  in  one-sixth  of  330 
idiots,  etc.  A  Wassermann  on  the  spinal  fluid  may  be  positive  in  nervous 
lues  when  one  on  the  blood  is  negative;  the  former  is  important  diag- 
nostically  and  also  therapeutically,  since  a  test  of  the  spinal  fluid 
should  be  negative  before  a  case  may  be  declared  cured. 

III.  NoGUCHi's  LuETiN  Test. — ^Luetin  prepared  from  strains  of  spiro- 
chetes, sterilized  from  pure  cultures,  is  injected  as  a  fine  emulsion 
in  doses  of  0.05  c.c.  intradermally.  Luetin  (the  antigen)  elicits  a  cuta- 
neous reaction  or  allergy  comparable  to  v.  Pirquet's  test.  The  positive 
reaction,  obtainable  only  in  syphilis,  begins  as  a  small  erythematous  area 


220  PROTOZOAX  IXFECTIOXS 

surrounding  the  point  of  injection,  ustially  within  twenty-four  hours.  This 
area  may  remain  without  further  change  for  several  days  or  may  become 
papular  or  pustular,  accordmg  to  the  severity  of  the  reaction,  which 
reaches  its  height  in  four  or  five  days.  In  some  cases  a  slight  rise  m  tem- 
perature occurs,  lasting  a  day  or  so,  and  accompanied  by  malaise,  loss  of 
appetite  and  diarrhea.  The  reaction  is  sometimes  torpid,  coming  on 
after  ten  or  more  days  as  a  pustular  eruption.  Xoguchi  concludes: 
(1)  The  luetin  reaction  is  specific  for  syphilis.  (2)  The  reaction  is  present 
in  the  majority  of  cases  of  tertiary  (100  per  cent.),  latent  (96  per  cent.) 
and  hereditary  s^'philis  (96  per  cent.).  (3)  It  is  less  constantly  present 
in  secondary  untreated  and  primary  cases  (50  per  cent.).  (4j  In  treated 
secondary  cases  the  reaction  is  present  in  most  instances,  especially 
when  treated  by  salvarsan.  (o)  In  general  paralysis  and  tabes  dorsalis 
a  positive  reaction  was  obtained  in  60  per  cent,  of  cases.  (6)  In  certain 
cases  of  tertiary  and  hereditary  syphilis  there  may  be  a  considerable 
inflammatory  reaction  at  the  site  of  injection  of  the  control  fluid,  and 
as  strong  as  at  the  luetin  inoculation  site.  The  Wassermann  reaction  is 
more  constantly  present  than  the  luetin  reaction  in  primary  and  second- 
ary s\"philis,  especially  when  only  a  slight  amount  of  treatment  or  none 
was  given,  but  the  luetin  reaction  is  more  constantly  present  than  the 
Wassermann  reaction  m  cases  of  tertiary  and  latent  syphilis.  Through 
the  treatment  the  Wassermann  and  clinical  symptoms  gradually  are  made 
to  disappear,  while  the  luetin  reaction  becomes  more  distinct. 

IV.  Diagnosis  ex  Jua'axtibus. — r.  i.  Therapy. 

Immunity. — Syphilis  confers  imriiuniiy.  but  this  is  neither  absolute 
nor  life-long,  because  (Ij  reinfection  may  occur;  of  356  instances  in  the 
literature,  only  132  stand  criticism  (F.  John,  1909);  (2)  in  hereditary 
syphilis,  a  later  infection  may  be  acquired  (27  cases  known) ;  (3)  a  soimd 
child  of  syphilitic  parentage  may  acquire  syphilis  (29  cases  reported); 
and  (4)  apes  have  been  reinoculated.  Gitting's  case  with  a  second  chancre, 
occurring  while  the  Wassermann  was  stfll  positive,  may  have  been  a 
recurrence.  In  general,  immunity  means  only  latency  of  the  luetic 
virus.  ^ 

Abnormal  Course  of  Syphilis. — Of  special  importance  is  malignant 
syphilis  C syphilis  precox,  acute  or  galloping  syphilis,  synonymous  with 

1  Levaditi  holds  that  during  the  period  of  incubation  before  the  primary  sore  the  parasites 
invade  the  body,  causing  the  development  of  immune  bodies,  as  manifested  bj'  a  refractors' 
condition  of  the  skin  to  further  infection:  this  resistance  becomes  vreU  developed  at  the 
onset  of  secondarj-  lesions.  During  the  secondary  stage  the  lesions  are  chiefly  inflamma- 
tory, with  e\-idence  of  great  resistance  by  the  tissues,  -n-hich  suffer  little  injurj-,  despite  the 
presence  of  great  numbers  of  parasites.  In  the  tertiarj-  stage,  the  resistance  to  infection  is 
highly  developed,  and  the  lesions  show  great  tissue  destruction  produced  by  comparativelj' 
small  numbers  of  parasites. 

Levaditi  suggests  that  the  resistance  of  the  host  to  the  invading  organism  developed 
during  the  primarj'  stage  maj-  hold  the  parasites  in  check  for  a  time,  until  they  acquire  a 
certain  degree  of  immunity  of  their  own  to  the  antibodies  of  the  host;  they  then  enter 
the  blood  and  set  up  a  generalized  infection,  characteristic  of  the  secondary-  stage;  in 
reaction  to  infection,  greater  quantities  of  antibodies  are  formed,  suppressing  the  parasites 
to  a  large  degree,  although  not  destroj-ing  all  of  them.  The  tissues  themselves  may  become 
hypersensitive,  i.  e.,  a  few  spirochetes  cause  extensive  local  necrosis,  characteristic 
of  gummata.  Gummata,  then,  are  produced  by  parasites,  which  are  refractory  to  the 
antibodies  of  the  patient  and  develop  in  tissues  which  have  grown  sensitized.  Iodides 
operate  by  rendering  the  tissues  less  sensitive  or  anaphylactic. 


SYPHILIS  221 

early  tertiary  de\'elopment) .  The  cause  may  be  increased  virulence  of 
the  spirochete,  or  decreased  physiological  resistance,  as  in  tuberculous, 
alcoholic  and  other  cachexise.  Early  ulceration,  grave  general  symptoms 
and  hemorrhage  are  noted. 

Prognosis. — On  pregnancy  the  disease  exerts  a  malign  influence  and 
mercury  is  less  universally  successful  (i\  Congenital  Syphilis).  Exan- 
thematous  diseases  may  cause  syphilis  to  disappear  temporarily.  The  effect 
of  coincident  measles  and  smallpox  is  unfavorable.  Chronic  diseases, 
as  tuberculosis,  often  induce  ulceration  and  early  tertiary  symptoms. 
Trauma;  in  the  treatment  of  fractures  and  in  plastic  operations  in 
syphilitics,  mercury  is  indicated.  Wounds  may  become  the  seat  of 
specific  ulceration. 

In  life  assurance  the  outlook  is  uncertain;  Leser's  figures  indicate  that 
33  per  cent,  of  luetics  ultimately  die  of  tuberculosis,  paralysis  or  aneurysm; 
other  main  causes  of  premature  death  are  cardiac  disease,  nephritis, 
dementia,  tabes,  thrombosis  and  suicide;  the  chief  contributing  causes 
are  poverty,  worry,  overwork  and  alcoholism. 

Congenital  Syphilis. — Syphilis  descends  only  to  the  first  genera- 
tion; among  the  115  cases  recorded  in  the  second  generation,  many  are 
doubtful. 

It  was  formerly  held  that  a  child  might  acquire  syphilis  from  the 
father,  from  the  mother,  or  that  mother  and  child  might  be  infected 
simultaneously.  Hutchinson  still  adheres  to  the  possibility  of  paternal 
lues  transmitting  the  disease.  The  Wassermann  reaction  and  the  presence 
of  spirochetes  have  revolutionized  our  conceptions  of  congenital  syphilis. 
According  to  Colles's  (or  Beaume's)  law  the  syphilitic  child  is  held  to  make 
the  mother  immune  to  infection;  she  cannot  be  infected  from  her  in- 
fected child;  and  can  nurse  her  syphilitic  child  without  danger.  In  such 
cases,  Fournier  held  that  the  mother  is  already  syphilitic,  and  in  381 
cases,  76  per  cent,  gave  a  positive  Wassermann  reaction,  whence  it  is 
probable  that  all  such  mothers  are  luetic,  the  s^-philis  being  latent. 
Profeta's  law  held  that  (apparently)  sound  children  of  syphilitic  parentage 
possess  an  immunity  against  syphilitic  infection;  Wassermann's  re- 
action proves  that  these  children  have  syphilis. 

The  more  recent  the  parental  syphilis,  the  greater  the  probability 
of  fetal  infection;  in  tertiary  syphilis  of  the  parents,  the  child  may  escape. 
Thus  the  first  product  of  conception  may  be  aborted,  the  second  macer- 
ated fetus  prematurely  delivered,  the  next  die  at  birth  or  shortly  after- 
ward, the  next  viable  though  infected,  and  finally,  as  the  toxemia  wears 
off,  even  sound  children.  Only  28  per  cent,  of  conceptions  in  syphilitic 
mothers  result  in  full-term  infants,  and  of  these  85  per  cent,  die  within 
the  first  year.  Women  who  habitually  abort,  show  the  Wassermann 
reaction. 

It  is  possible  that  excessive  emphasis  has  been  placed  upon  the  sig- 
nificance of  abortion  per  se;  infectious  abortion  is  common  among  mares 
and  cows  and  is  due  to  a  small  bacillus  (Bang,  1895).  Infection  from  the 
mother  is  carried  to  the  fetus  by  way  of  the  placenta,  in  the  fetal  portion 
of  which,  and  usually  also  in  the  umbilical  cord,  spirochetes  are  found, 
although  but  seldom  in  the  maternal  portion  of  the  placenta.    Significant 


222  PROTOZOAN  INFECTIONS 

also  is  the  heavy  placenta  whose  weight  compared  with  that  of  the  syphihtic 
child  is  1  to  5,  4  or  3  (normally  1  to  6).  In  the  placental  villi  end-  and 
periarteritis  occur,  which  may  cause,  by  vascular  occlusion,  placental 
necrosis  and  adherence.  Similar  changes  in  the  umbilical  vessels  may 
destroy  the  child.  When  the  macerated  fetus  is  examined,  the  spirochete 
is  found  in  84  per  cent.,  most  often  in  the  adrenals,  next  in  the  liver  and 
lungs  in  the  vicinity  of  the  vessels,  and  often  in  the  heart  alone.  The  ovary, 
testicle,  and  epididjTuis  contain  the  spirochete.  In  living  children 
the  spirochete  was  found  in  the  vesicles  in  cases  of  pemphigus.  A  differ- 
ence exists  between  the  congenital  syphilis  with  signs  at  birth,  and  the 
hereditary  type,  which  develops  later  (possibly  very  late,  syphilis  hered- 
itaria tarda).  Even  when  specific  lesions  are  absent,  pathological  cell 
degeneration,  rhachitis,  slow  intelligence,  neuroses,  psychoses  and  a  high 
percentage  of  mortality  to  all  diseases  may  result. 

Symptomatology. — The  primary,  secondary  and  tertiary  stages  are 
not  discrete  and  lymphatic  infection  does  not  precede  that  of  the 
entire  organism.  Secondary  and  tertiary  manifestations  may  occur 
synchronously.  The  symptoms  are  recognizable  at  birth  or  after  a  few 
days  or  weeks,  and  almost  always  within  the  first  three  months. 

Appearance. — The  atrojjhic  child  presents  a  rather  characteristic 
appearance,  with  relaxed  }'ellowish-gray  skin,  poorly  developed  hair,  bent 
or  undeveloped  nails  (onychia)  and  "the  little  old  man"  appearance 
described  by  Trousseau,  but  not  pathognomonic  of  lues.  The  palms 
and  soles  are  lacquered,  the  voice  and  muscles  are  weak  and  the  child 
does  not  nurse  well.  Such  children,  especially  when  several  are  born  in 
succession,  point  to  syphilis. 

Pathognomonic  Symptoms. — The  exanthevi  is  ijolymorphous,  but 
varieties,  often  severe,  occur  which  are  absent  or  infrequent  in  the 
adult,  such  as  pemphigus,  hemorrhages,  furuncles  and.  diffuse  infihration 
of  the  skin.  The  maculae  are  dirty,  brown-red,  often  confluent,  and  occur 
on  the  face,  body,  extremities  and  genital  regions.  The  papules  occur 
principally  in  the  folds  of  the  joints,  axillae,  groins  and  gluteal  region 
and  tend  to  recur  and  ulcerate;  papules  of  various  ages  coexist  with 
desquamation,  though  never  with  condyloma,  which  is  always  a  sign  of 
acquired  syphilis.  Psoriasis  of  the  hands  and  soles  of  the  feet  is  common. 
Pustular  lesions  occur  in  severe  syphilis  and  are  prognostically  unfavorable. 
They  occur  in  the  immature  fetus;  pemphigus  is  a  subtype  of  the  pustule; 
gangrene  and  necrosis  may  occur.  The  copper-colored  syphilitic  infil- 
tration, especially  on  the  nates  and  lower  extremities,  may  be  mistaken 
for  erysipelas.  Coryza  {"snuffles'')  is  very  characteristic  and  almost 
in\ariable,  the  secretion  being  bloody  and  purulent,  with  crust  formation, 
and  spirochetes  in  20  per  cent.  Fissures  occur  about  the  mouth,  with  an 
infiltrated  base  and  cicatrix  formation.  Papular  eruptions  occur  in  the 
mouth,  especially  on  the  tongue  and  the  palate,  with  a  tendency  to 
necrosis ;  atrophy  of  the  base  of  the  tongue  occurs  in  most  cases.  Rhagades 
occur  about  the  infiltrated  genital  and  anal  regions. 

Teeth. — Erosions,  furrows  and  notches  may  develop.  The  teeth  are 
small,  often  irregular  and  poorly  developed.  Hutchinson  held  that 
the  semilunar  curving  on  the  free  edge  of  the  upper  middle  permanent 


SYPHILIS  '  223 

incisors  was  pathognomonic  of  tardy  congenital  syphilis,  appearing 
at  the  seventh  year,  but  Hutchinson  s  teeth  occur  in  other  affections, 
and  are  expressions  of  constitutional  derangement  only.  Later  the 
lateral  borders  of  the  teeth  become  curved;  the  teeth  may  become 
peg-like  or  the  notches  grind  off  even.  The  other  associates  of  Hutchin- 
son's triad— deafness  and  the  ground-glass  cornea— are  discussed  on 
pages  214  and  216.  Blue  sclerotics  are  accounted  symptomatic  of  con- 
genital lues,  and  Heine  found  optic  neuritis  in  82  per  cent.  The  Wasser- 
mann  test  is  positive  in  90  to  ICO  per  cent.;  it  may  be  absent  at  first,  to 
appear  as  the  clinical  signs  develop;  in  one  series  it  was  positive  in  298 
out  of  300  cases. 

Bones.— As  in  adults,  there  may  be  periostitis,  tophi  or  perforated 
palate.  Osteochondritis  occurs  especially  in  the  lower  end  of  the  femur; 
the  diaphysis  and  epiphysis  may  be  separated.  There  is  (a)  overgrowth 
of  the  cartilage  of  the  diaphysis  which  produces  the  wavy  line  of  white 
cartilage  cells;  (h)  the  line  of  cartilage  cells  becomes  thick  and  foci 
of  decalcification  occur;  (c)  the  cartilage  is  as  prominent  as  in  rickets, 
the  part  nearest  the  bone  being  soft.  The  immobility  of  the  leg  may 
suggest  paralysis  (Parrot). 


Fig.  14.— Notched  teeth.     Malformation  of  permanent  teeth  found  in  hereditary  syphilis. 

(Jonathan  Hutchinson.) 

Viscera.— BiSuse  infiltration  is  much  more  frequent  than  gummata. 
There  are  characteristic  changes  in  certain  organs  which  are  rarely 
involved  in  acquired  syphilis,  e.  g.,  in  the  thymus,  umbilical  cord, 
pancreas,  lungs,  intestines  and  adrenals.  The  liver  and  spleen  are  greatly 
enlarged;  the  Spirochete  pallida  is  found  in  these  viscera  in  vast  numbers, 
even  in  the  macerated  fetus.  To  conserve  the  classification,  these  changes 
have  been  described  under  Special  Symptomatology.  Fournier  de- 
scribes enlargement  of  the  peripheral  veins.  Vascular  changes  are 
especially  marked,  as  in  the  umbilical  vessels,  with  a  tendency  to  hemor- 
rhage— syphilis  hemorrhagica  neonatorum.  Hemorrhages  in  the  skin, 
mucous  membranes  and  viscera,  may  be  profuse,  especially  in  the  liver 
and  lungs,  where  the  circulation  is  precipitately  altered  after  birth. 
Levaditi  found  spirochetes  in  the  foci  of  hemorrhage.    Some  vessels  may 

be  thickened  or  infiltrated  (disease  of  the  vasa  vasorum). 

$ 

Acquired  Syphilis  in  Children vs. Hereditary. 

Less  mortality  and  less  malnutrition.  Marked. 

After  third  month  (are  exceptions) .  Before  third  month. 

A  primary  lesion  occurs.  Absent. 

Lymph  glands  enlarged.  Absent  (from  accidental  causcsonly). 

Usual  sequence  of  primary,  secondary  and  Snuffles,  anemia,  diffuse  pigmentation, 
tertiary    symptoms.      Secondary    lesions,  pemphigus,     involvement    of    soles     and 

then  tertiary.  palms,  epiphyseal  changes,  etc.     Second- 

ary and  tertiaiy  together. 


224  PROrOZOAX  IXFECriOXS 

Syphilis  hereditaria  tarda  develops  its  first  symptoms,  mostly  between 
the  tenth  and  eighteenth  years  (rarely  before  the  tenth  year).  The 
symptoms  are  those  of  infantilism,  in  regard  to  puberty,  bone  develop- 
ment, teeth,  hair  and  brain. 

Treatment  of  Syphilis. — Prophylaxis. — The  sexual  instinct  is  even 
stronger  than  that  of  self-preservation.  Irregular  intercourse  is  promoted 
by  class  differences,  lack  of  barriers  among  the  ignorant  and  destitute, 
and  the  struggle  for  existence  which  makes  early  marriage  impossible. 
Prostitution,  hidden  or  open,  is  the  basis  of  syphilis.  In  prostitutes, 
condylomata  last  years  and  repeatedly  recur  about  the  genitalia;  the 
\Yassermann  test  is  found  in  all  women  who  have  been  prostitutes  over 
three  years.  Continence  is  the  sole  prophylactic  measure.  Enforced 
medical  inspection  is  ineffectual.  American  sentiment  is  against  licensed 
prostitution,  which,  besides,  does  not  regulate  men  or  hidden  prostitution. 
Licensing  also  teaches  the  young  that  immorality  is  safe.  ]vlany 
infections  are  acquired  under  the  influence  of  liquor  (Sine  Baccho 
friget  Venus).  "Where  ethical  considerations  fail,  an  appeal  to  fear  may 
be  effectual.  [Metchnikoff  comments  upon  the  remarkable  fact  that 
diseases  conveyed  by  insects  are  rapidly  becoming  preventable,  whereas 
diseases  like  syphilis  and  tuberculosis  conveyed  by  rational  human 
beings,  are  not.  Efforts  to  educate  the  public  will  doubtless  avail  much; 
syphilis,  however,  must  be  presented  as  an  infection  and  dissociated 
from  ethics  and  retribution. 

The  curse  of  the  disease  lies  in  its  long  course,  the  involvement  of  vital 
viscera,  its  transmission  to  the  \^dfe  and  offspring  whose  mortality  and 
morbidity  are  enormous,  and  its  wide  dissemination  (13  per  cent,  of 
the  population  acquire  the  disease,  and  1,650,000  persons  are  infected 
annually; . 

Marriage  should  be  forbidden  for  at  least  three,  better  four,  years  or  best, 
till  the  sero-test  remains  negative.  In  cases  of  doubtful  infection  of  the 
wife  or  husband,  both  should  be  treated.  Inunctions  should  be  given 
the  pregnant  mother.  The  physician  should  never  countenance  employ- 
ing a  healthy  wet-nurse  for  the  syphilitic  child.  Circumcision  is  thought 
to  lessen  chances  of  infection.  Blue  ointment,  applied  before  intercourse, 
is  prophylactic. 

1.  Initial  Lesion. — Early  mercurial  treatment  is  indicated,  but  only 
when  the  diagnosis  is  certified  by  a  typical  chancre  and  spirochetes. 
Mercury  is  indicated  in  all  stages  of  syphilis,  for  abortive  treatment  as 
well  as  that  of  the  established  disease.  Local  treatment  includes  the 
use  of  antiseptics,  iodoform,  mercurial  plasters,  iodoform  in  suppository 
(rectum  or  vagina),  bichloride  washes  (mouth)  and  calomel  for  condy- 
lomata (calomel  6  parts,  boric  acid  3,  and  salicylic  acid  1  part). 

2.  Secondary  Stage, — In  the  secondary  stage  mercury  is  a  specific 
against  the  spirochetes.  The  teeth  should  be  cleaned  first,  and  bad 
teeth  filled.  Calomel  acts  especially  on  the  lesions  of  the  mouth  and  is 
prone  to  salivate.  Mercury  may  disagree  (v.  i.)  in  tuberculous,  cachectic, 
alcoholic  or  anemic  subjects,  in  bleeders  and  in  cases  of  galloping  syphilis, 
in  which  latter  iodides  mav  be  better  than  mercurv.    ]\Iercury  must  be 


SYPHILIS 


99=; 


used  with  great  care  in  nephritic  subjects.  During  and  after  a  course  of 
mercury,  tobacco  must  be  interdicted  because  it  perpetuates  syphihtic 
sores  in  the  mouth  for  years,  even  decades.  ]Moderation  in  all  matters 
of  life  is  enjoined  upon  the  patient. 

Methods  of  AdminiMration. — 1.  By  Mouth. — Ninety-five  per  cent,  of 
cases  are  thus  treated  in  this  country,  whence  some  account  of  this 
method  is  appropriate  despite  the  fact  that  it  is  uncertain  and  unwise, 
and  syphilides,  gummata,  tabes,  general  paresis  and  aortitis  often  develop 
after  oral  administration,  but  rarely  after  systematic  inunctions,  (a) 
Calomel  (hydrargyri  chloridum  mite)  is  especially  adapted  to  children 
under  three  years  of  age  with  hereditary  syphilis;  gr.  j  to  |  t.  i.  d.  It 
is  insoluble,  and  is  probably  converted  by  the  alkaline  carbonates  in  the 
intestines  into  the  gray  oxide  which  is  absorbed  with  the  fats.  (6)  Blue 
mass  (massa  hydrargyri),  gr.  k  to  1,  is  less  irritant  to  the  stomach  than 
calomel,  but  produces  salivation  oftener  than  any  other  mercurial. 
(c)  Hydrargyrum  tannicum  oxydulatum  (50  per  cent,  mercury)  is  non- 
irritant,  produces  less  diarrhea  and  is  easily  assimilated;  gr.  1  to  1| 
plus  pulv.  opii  gr.  yo!  (^0  The  hydrarg.  iodidum  flavum  or  protiodide  is 
mild,  insoluble  and  analogous  to  calomel. 

I^ — HydrargjTi  iodidi  Q.■^i^■i gr.  xv 

Extr.  opii gr.  v 

Extr.  gentianse q.  s. 

]M.  et  ft.  pilulse  no.  Ix. 
S. — One  after  meals. 

(c)  The  soluble  sublimate  or  bichloride  is  irritating  (hydrarg.  chloridum 
corrosivum) ;  it  is  not  prone  to  salivate,  is  absorbed  by  the  intestine 
and  stimulates  the  liver.  ^Mercury,  administered  internally,  produces 
more  irritation  and  is  less  likely  to  be  absorbed,  but  patients  are  more 
apt  to  persist  in  this  form  of  treatment.  ^Mercury  internally  was  first 
used  by  Benedictus  (1525). 

2.  Inunctions. — Rubbings  must  be  thorough  and  given  where  the  skin 
is  soft  (flexor  surfaces).  Mercury  is  absorbed  by  the  lymph  vessels. 
The  skin  must  be  bathed  daily.  A  simple  diet  should  be  given;  as  a 
rule,  mercury  somew^hat  loosens  the  bowels.  The  rubbing  requires 
twenty  to  thirty  minutes.  Hairy  regions,  the  axillae,  navel,  nipple  and 
areas  of  accidental  eczema,  psoriasis,  etc.,  are  to  be  avoided.  If  the  hair 
on  the  body  is  redundant,  the  skin  should  be  shaved.  The  occasional 
mercurial  dermatitis  is  often  due  to  decomposition  of  the  fat  in  the 
inunction.  On  the  first  day  the  inunction  should  be  given  on  the  abdomen, 
on  the  second  day  on  the  chest,  on  the  third  on  the  calf,  then  on  the  thigh, 
forearm,  arm,  etc.  After  inunction,  the  part  is  enveloped  m  cotton. 
If  an  attendant  gives  the  rubbing,  his  hand  is  protected  by  a  rubber 
glove.     Written  instructions  should  always  be  given  to  the  patient. 

Twenty  to  thirty  inunctions  should  be  given  for  the  macular  and 
pajjular  types;  more  than  thirty,  for  all  pustular  or  ulcerating  eruptions, 
but  not  more  than  forty  should  be  given  continuously.  Inunctions  must 
be  interrupted  for  diarrhea  or  stomatitis.  Salivation  is  not  desirable, 
nor  is  it  a  sign  that  enough  mercury  has  been  given.  The  unguentum, 
contains  50  per  cent,  of  mercury,  and  the  more  elegant  oleatum  but 
15 


226  PROTOZOAN  INFECTIONS 

25  per  cent.,  which  should  be  considered,  as  about  5ss  of  mercury  should 
be  incorporated  daily. 

I^ — Unguent,  hydrarg §iv 

Div.  in  dos.  equal,  no.  xxx. 

Dent,  ad  cartam  ceratam. 
S. — One  as  directed  daily. 

In  children,  mercurial  ointment  may  be  applied  on  a  binder  and 
allowed  to  remain  for  days.  Children  stand  relatively  large  doses  but 
women  may  endure  only  half  the  adult  dose.  The  advantages  of  inunc- 
tions are  as  follows:  They  cause  almost  no  digestive  disturbance;  they 
are  especially  good  in  children;  they  are  the  most  rapid  and  effective 
method,  and  are  attended  by  the  least  general  ill-effects  The  disad- 
vantages are  publicity,  troublesomeness  and  dirtiness,  but  these,  however, 
are  only  relative  objections.    Inunctions  were  first  used  by  the  Galenists. 

3.  Injections. — ^Their  advantages  are  prompt  action  and  exact  dosage. 
Intravenous  injections  may  be  imperative  in  cases  with  coma  and  other 
urgent  symptoms.  The  disadvantages  are  the  risk  of  embolism,  slough- 
ing and  pain;  once  given,  their  action  cannot  be  regulated  or  decreased. 
The  soluble  salts  are  best: 

I^ — Hydrarg.  chlorid.  corrosivi '    .      .  1 .  00 

Sodii  chloridi 10.00 

Aquae  dest 100.00 

One  c.c.  daily  equals  0.01  gm.  or  gr.  ^  of  HgCl2;  forty  injections  con- 
stitute a  course.  The  succinamide  is  less  irritating  (hydrargyri  succin- 
amidum,  grain  ^);  the  best  preparation  is  the  insoluble  basic  salicylate 
of  mercury — grain  j  to  TUx  of  albolene,  injected  two  or  three  times  a 
week.  Insoluble  preparations  are  painful;  ten  deaths  followed  injections 
of  gray  oil  (Grancher) ;  since  1906,  Riehl  collected  90  fatalities  from  in- 
jection of  insoluble  salts.  Mercury  may  first  make  the  eruption  clearer 
(Herxheimer's  reaction). 

4.  Baths. — 5ij-iij  of  IIgCl2  to  the  bath  are  useful  for  skin  lesions,  as 
syphilitic  psoriasis.     5.  Fumigations  are  impracticable. 

As  a  working  rule,  mercury  should  first  be  given  two  months  and 
stopped  one  month,  through  the  first  year,  i.  e.,  two-thirds  of  the  time; 
in  the  second  year,  about  half  the  time,  with  intervals;  in  the  third  year, 
one-third  of  the  time.  The  Wassermann  test  is  used  to  control  the 
therapy;  the  positive  sero-test  lessens  under  mercurialization  and  recurs 
when  therapy  is  intermitted.  To  convert  a  positive  into  a  negative 
reaction  requires  very  energetic,  repeated  treatment  (v.  i.  page  229). 

Mercury  is  incompatible  with  nearly  everything.  Coincident  anemia 
is  treated  by  iron,  strychnine  and  arsenic.  Syphilitics  tolerate  mercury 
well,  in  large  doses,  and  for  a  remarkable  period.  Considering  briefly 
the  action  of  the  drug;  in  the  smallest  doses  it  is  tonic,  and  increases 
the  number  of  red  cells.  Back  of  the  tongue  near  the  epiglottis  and  in  the 
folds  of  the  pillars,  a  white,  cloudy  film  may  develop  (perhaps  due  to  the 
organisms  of  Vincent's  angina).  In  larger  doses  there  develops  a  symp- 
tom-complex known  as  salivation,  of  which  peculiar  fetor  is  first  noted;  then 


SYPHILIS  227 

sore  teeth,  red,  swollen,  spongy  and  bleeding  gums,  and  increased  saliva, 
follow.  The  drug  is  never  given  beyond  this  point.  In  still  larger  doses 
the  tongue  becomes  swollen,  the  gums  inflamed  and  the  teeth  loose; 
the  greatly  increased  saliva  is  viscid  and  stringy;  the  salivary  glands 
intumesce;  eruptions  appear,  resembling  eczema,  scarlatina,  measles 
and  more  rarely,  purpura  and  pemphigus.  Fever,  albuminuria  and 
dysenteric  passages  may  be  noted  (the  kidneys  cannot  excrete  more  than 
10  mgm.  of  mercury  a  day  without  irritation).  Severe  salivation  results 
in  loss  of  teeth,  necrosis  of  jaw,  ulceration  of  the  mouth  and  contiguous 
parts,  marked  changes  in  the  blood  and  profound  exhaustion.  The 
treatment  consists  of  potassium  chlorate  as  an  antiseptic  mouth  wash 
and  astringents,  as  tr.  myrrh  and  tannic  acid. 

3.  Tertiary  Stage. — The  resolvent  action  of  iodides  is  little  short 
of  miraculous.  They  were  introduced  by  Welch,  of  Ireland,  and  popular- 
ized by  Ricord  in  France.  They  are  sometimes  used  in  the  secondary 
stage,  especially  in  febrile  cases,  secondary  osseous  and  nervous  mani- 
festations, and  weakly  persons  with  a  marked  macular  eruption.  They 
act  more  slowly  and  far  less  specifically  on  the  spirochetes  than  mercury, 
though  they  aid  in  absorbing  gummata  or  infiltrations,  and  rendering 
the  tissues  less  sensitive  to  the  spirochete  (v.  s.  Immunity).  Their  use 
should  be  intermittent  and  alternative  with  mercury.  Mercury  is  con- 
jointly employed  in  all  tertiaries,  particularly  when  organs  of  great 
importance  are  involved,  such  as  the  larynx,  brain  and  eye. 

The  therapeutic  tests  for  syphilis  are  cure  with  mercury  and  iodides 
and  tolerance  by  the  patient  of  very  large  doses.  Regarding  their  diag- 
nostic value  the  influence  of  the  drugs  must  be  unequivocal  and  a  positive 
Wassermann  be  converted  into  a  negative  reaction.  Before  negative 
conclusions  are  drawn,  it  must  be  remembered  that  loss  of  tissue,  e.  g.,  in 
arterial  occlusion  and  paralysis  from  brain  softening,  cannot  be  restored. 

Sodium  iodide  is  milder,  produces  less  iodism,  is  less  bitter,  and  has 
less  effect  on  metabolism  than  potassium  iodide,  which,  however,  is 
better  than  other  iodides,  though  it  irritates  the  stomach  and  bowel, 
and  depresses  the  muscles  and  motor  nerves. 

The  following  proportions  for  a  single  ordinary  dose  may  be  em- 
ployed; the   mercury   becomes   mercuric   iodide: 

I^ — Potassii  iodidi gr.  xv  (gm.  1) 

Hydrargyri  chloridi  corrosivi S^-  ^2  (gni-  0.002) 

Tincturse  opii lUij       (gm.  0.13) 

SsTOipi  aurantii  corticis 5ss       (gm.  2) 

M.  et  S. — After  meals  in  a  glass  of  water. 

Large  doses  of  iodide  are  given  in  urgent  cases,  5j~ii  t.  i.  d.,  to  break 
down  more  rapidly  the  new-formed  granulation  tissue.  Enormous 
doses  are  unnecessary  and  not  without  danger  (v.  i.).  Fournier  warns 
against  their  intemperate  use — "iodide  debauches."  Iodide  dissolves 
in  its  own  weight  of  water;  hence  one  minim  of  a  saturated  solution 
equals  one  grain  of  iodide.  Iodides  are  eliminated  as  the  sodium  salt; 
nine-tenths  is  eliminated  in  a  few  hours.  If  the  stomach  is  intolerant, 
iodides  may  be  given  in  nutrient  enemata.  It  is  best  disguised  by  syr. 
sarsaparillse  co. 


228  PROTOZOAN  INFECTIONS 

lodism  is  often  produced  by  small,  but  usually  ceases  with  larger,  doses. 
It  is  obviated  by  intermittent  administration,  by  daily  baths,  by  flushing 
out  the  kidneys,  the  inactivity  of  which  is  the  usual  cause,  by  giving 
aromatic  spirits  of  ammonia,  arsenic  or  belladonna.  lodism  is  likely 
to  occur  in  renal  disease.  Its  leading  characters  are:  Increased  secretion 
from  the  eyes,  nose,  mouth,  salivary  glands,  bronchi,  stomach,  bowels, 
skin  and  kidneys  (i.  e.,  from  all  organs  concerned  in  the  elimination  of  the 
drug).  The  eyes,  throat,  larynx  and  salivary  glands  swell.  The  writer 
once  nearly  suffocated  from  edema  of  the  pharynx  and  uvula  after  inges- 
tion of  10  grains  of  iodide  for  a  cold.  Pulmonary  edema  and  albuminuria, 
or  even  nephritis,  may  develop;  5ss  induced  edema  of  the  larynx. 
Gastric  irritation  and  nervous  depression,  mental  derangement  or 
excitement;  acne,  hemorrhages,  blebs  and  telangiectases  in  the  skin; 
cachexia,  anemia,  and  hyperthyroidism  especially  in  goitrous  subjects; 
emaciation,  wasting  of  mammse  and  testes;  fever,  increased  pulse  and 
neuralgias  are  also  symptoms  of  iodism. 

Iodides  are  continued  for  two  months  and  their  use  then  remitted  for 
one  month  aud  so  on.  After  years,  iodides  and  mercury  are  given  for 
one  month  twice  a  year,  e.  g.,  in  January  and  July. 

Salvarsan. — Ehrlich  (1909)  introduced  this  arsenical  preparation  as  a 
spirillicide,  with  the  hope  that  one  massive  dose  would  result  in  complete 
curative  sterilization.  It  was  welcomed  as  our  first,  scientific  discovery 
in  therapy,  destroying  all  spirochetes  in  all  stages  and  forms  of  the  disease, 
acting  most  rapidly  in  its  production  of  antibodies  and  operating  in  other 
spirilloses — as  relapsing  fever  and  Vincent's  angina,  as  well  as  in  other 
types  of  parasitic  disease.  Its  indications  were:  (i)  primary  lues,  in 
which  its  best  results  were  claimed;  (ii)  secondary  and  tertiary  lues, 
particularly  in  malignant  types  and  (iii)  types  refractory  to  mercury; 
(iv)  hereditary  syphilis;  and  (v)  parasyphilitic  lesions,  without  optic 
atrophy.  Its  contra-indications  included:  (i)  organic  diseases  of  the  heart 
(hypertension,  aneurysm,  etc.),  of  the  lungs  (tuberculosis)  and  of  the 
kidneys  (severe  nephritis);  (ii)  cachectic  states,  as  severe  diabetes; 
(iii)  when  arsenic  had  been  administered  previously,  or  there  was  idio- 
syncrasy to  it;  (iv)  optic  neuritis  or  atrophy;  (v)  severe  nervous  lesions, 
as  general  paralysis;  and  (vi)  profound  hereditary  syphilis  and  preg- 
nancy. The  early  results  were  striking  in  rapidity  of  action,  marked 
tonic  effects,  the  remarkable  healing  of  ulcerations  in  the  mouth,  genitalia 
and  skin,  coertion  of  malignant  and  pustular  forms,  relief  from  pain 
and  the  amenability  of  the  occasional  cases  resisting  mercury;  its  speci- 
ficity in  apes  (experimental  syphilis)  and  in  human  syphilis  on  the  clinical 
lesions  and  on  the  Wassermann  reaction.  The  initial  optimism  was 
soon  followed  by  complications;  deaths,  sudden  or  slower;  and  prejudice 
pro  and  contra.  Local  complications  were  necroses  at  the  point  of  intra- 
muscular injection  (20  per  cent.),  all  bloodvessels  obliterating  and  the 
arsenic  being  but  slowly  dissolved.  Given  intravenously,  thrombophle- 
bitis often  occurred.  General  reaction  was  common,  with  fever,  leuko- 
cytosis, chill,  head  and  backache,  nausea  and  vomiting,  local  pain  and 
tenderness,  rapid  pulse  and  respiration,  even  with  dyspnea,  collapse, 
bidder  irritation,  anxiety  and  other  developments,  suggesting  anaphyl- 


MALARIA  229 

axis.  The  fever  was  not  wholly  due  to  bacteria  in  the  distilled  water 
nor  to  the  saline  of  the  infusion.  Paralyses  (facial,  polyneuritis,  etc.) 
developed;  these  neurorecidives,  specially  of  the  cranial  nerves,  were 
attributed  to  the  disease  (Benario)  or  to  the  drug  (Finger).  Finger 
observed  44  neurorecidives  in  500  salvarsan  injections  as  against  5  in 
over  2000  mercurial  treatments. 

Deaths  from  hemorrhagic  encephalitis,  nephritis,  cardiac  failure,  etc., 
have  run  into  hundreds  published  and  probably  many  more  unpublished. 
Then  salvarsan  therapy  was  "modified";  first  given  intramuscularly 
and  then  intravenously,  it  was  next  given  both  ways;  then  it  was  pre- 
ceded and  followed  by  mercury ;  now  neosalvarsan  comes,  with  its  milder 
local  action  and  solubility,  but  with  its  quota  of  accidents  and  deaths; 
and  salvarsan  instead  of  sterilizing  the  body  with  one  dose,  is  given  many 
times,  once  a  week  for  6, 8  or  more  doses.  Adrenalin  recently  is  advocated, 
to  prevent  and  cure  untoward  effects. 

One  may  not  state  now  what  is  the  value  of  salvarsan.  It  is  certainly 
no  more  a  cure  than  mercury;  it  does  not  replace  mercury  and  even 
demands  its  cooperation;  it  entails  a  far  greater  mortality;  it  entails 
a  surgical  procedure  with  its  attendant  expense;  and  it  is  less  penetra- 
tive than  mercury  which  becomes  part  of  the  tissues  as  an  albuminate, 
whereas  "606"  remains  a  foreign  body.  When  are  we  justified  in  using  it? 
If  used,  the  writer's  personal  preference  is  for  the  intramuscular  injection, 
in  oil,  and  repeated;  it  rarely  kills  in  this  form.  It  is  most  valuable 
early  before-'  the  Wassermann  test  develops;  when  mercury  fails;  in 
malignant  types;  and  where  special  prophylaxis  is  imperative.  The 
intraspinal  injection  of  salvarsanized  serum  is  recommended  by  Swift 
and  Ellis  in  lues  of  the  nervous  system,  since  the  choroid  plexus  blocks 
the  blood  to  the  spinal  fluid  circulation. 

Control  hy  the  Wassermann  Reaction. — With  some  exceptions,  treatment 
by  mercury,  iodides  or  arsenic  is  measured  by  the  turning  of  a  positive 
into  a  negative  reaction.  Salvarsan  leads  in  the  early  effects;  in  later 
syphilis  mercury  and  salvarsan  are  alike.  After  one  course  of  mercury, 
the  reaction  becomes  negative  in  50  per  cent.;  after  8  or  more,  in  90  per 
cent.;  it  takes  several  or  many  intravenous  injections  to  effect  the  same 
result.  Jonathan  Hutchinson  held  that  even  mercury  pills  caused  a 
negative  reaction  in  70  per  cent.  Mercury,  though  slower  in  action, 
remains  the  remedy  for  the  practitioner. 

A  SYPHILITIC  SHOULD  NEVEE  BE  DISMISSED  or  be  givcu  any  guarantee 
of  the  extinction  of  the  disease  (Ricord). 

MALARIA. 

Definition. — An  acute  infection  caused  by  the  Plasmodium  malarise, 
inoculated  in  man  by  the  mosquito  and  characterized  clinically  by 
(1)  paroxysms  of  intermittent,  quartan,  tertian  or  quotidian  fever,  or 
))y  (2)  remittent  or  subcontinuous  fever,  and  sometimes  by  (3)  per- 
nicious, or  chronic  cachectic  forms. 

History. — Malaria,  known  to  Hippocrates  and  Celsus,  is  the  most 
com])letely  investigated  of  all  diseases,  in  that  (a)  its  cause  is  known; 


230  PROTOZOAN  INFECTIONS 

(h)  its  prophylaxis  is  exact,  since  the  discovery  of  infection  by  the  mos- 
quito; (c)  the  stages  of  the  disease  can  be  followed  in  the  blood;  and 
(d)  there  is  a  truly  specific  therapy. 

Etiology. — Men  are  more  exposed  to  infection;  such  occupations  as 
sewer  and  railroad  building,  ditching  and  night  work,  especially,  are  pre- 
disposing factors;  32  per  cent,  of  the  French  soldiers  in  Madagascar 
in  1895  acquired  malaria;  reduced  physiological  resistance,  exposure, 
excesses  and  alcoholism  predispose  to  infection.  Negroes  have  a  relative 
immunity.  Epidemics  may  occur,  as  during  the  building  of  the  Paris 
boulevards.  Indirect  causes,  as  climate,  the  warm  season,  moisture, 
rain,  swampy  localities,  bad  air  (mal-aria)  and  impure  drinking-water 
are  causes  only  in  so  far  as  they  relate  to  the  breeding  of  the  mosquito. 
In  Africa,  severe  forms  of  malaria  are  found  everywhere  except  in  its 
lower  part  and  in  the  Sahara.  In  the  far  East  its  chief  seats  are  India, 
Burma,  Assam,  Faral  and  the  East  Asiatic  coast;  Asia  Minor,  Japan 
and  the  East  Indies.  In  Europe,  lower  Russia,  Italy,  Hungary,  the 
Balkans  and  Greece  are  most  affected.  Malaria  was  probably  the  cause 
of  the  decadence  of  ancient  Greece.  Malaria  also  abounds  in  the  northern 
three-fourths  of  South  America.  In  the  West  Indies,  severe  types  prevail. 
In  the  United  States,  malaria  seldom  develops  on  the  Pacific  coast,  in 
the  Northwest,  the  dry  West  and  the  Lake  region.  Even  in  the  South 
it  is  becoming  less  frequent. 

Direct  Cause. — The  malarial  parasite,  described  by  Laveran,  in  1880, 
and  Marchiafava  and  Celli,  in  1885,  is  a  red-cell  parasite,  a  hemocyto- 
zoon.  The  biology  of  the  Plasmodium  malarice  concerns  (^4)  its  life  in 
the  human  blood,  and  {B)  its  life  in  the  mosquito.  Various  species 
are  recognized  because  (1)  their  morphology  varies;  (2)  their  geography, 
seasonal  prevalence  and  malignancy  vary;  and  (3)  on  inoculation,  the 
type  is  maintained. 

{A)  The  Plasmodium  in  Man. — Special  forms  of  the  parasite: 

1.  The  quartan  parasite  (Plasmodium  malariee)  has  a  life-cycle  of  three 
days.  In  the  first  twelve  hours  the  young  form  is  a  small,  amorphous, 
hyaline  spot  in  the  red  cell ;  there  is  some  ameboid  movement  upon  warm- 
ing the  slide.  Pigment  or  melanin  appears  as  coarse,  dark  rods  and 
granules  with  little  movement.  Melanin  is  hemoglobin  digested  by  the 
parasite;  it  is  dark  or  black  and  resembles  the  melanin  of  malignant 
growths.  Movement  of  the  parasite  ceases  as  pigment  increases.  The 
parasite  occupies  one-half  to  two-thirds  of  the  red  cell  after  forty-eight 
hours,  and  almost  the  entire  cell  after  sixty  hours.  Flagella  and  vacuoles 
{v.  i.)  are  not  frequent.  The  red  cell  on  which  the  plasmodium  feeds 
undergoes  no  change  in  size  or  becomes  smaller  and  darker  peripherally. 
As  sporulation  occurs,  the  pigment  gathers  centrally  and  the  spores, 
usually  numbering  not  more  than  ten,  develop  into  the  "daisy"  form. 
After  sixty-nine  hours,  segmentation  occurs  in  the  peripheral  blood  three 
hours  before  the  paroxysm,  which  corresponds  with  their  rupture  from 
the  red  corpuscle  into  the  plasma.  Sporulation  of  the  adult  parasite 
means  its  "death  in  childbed,"  as  Mannaberg  describes  it;  the  spores 
rupture  through  the  red  cell  and  escape  into  the  plasma,  whence  they 
enter  other  red  cells,  to  repeat  their  life-cycle.    The  pigment  and  frag- 


PLATE  VIII 


a 


<^^MS'S 


'e' 


# 


B 


Malarial  Parasites. 


A.  Tertian  parasite.  1,  young  fornn  ;  2-4,  stages  of  gi'owtlni  and  iDignrien- 
tation  ;  S-7,  segmentation  ;  8,  rxApture  of  spores  froni  corpuscle  ;  9,  extra- 
cellular forni  ;   lO,   flagellate  forni. 

B.  Quartan  parasite.  1-6,  development  and  pigmentation;  7,  8,  central 
grouping  of  pigment  and  spore  formation;  9,  rosette  of  spores  with  nuclei; 
lO,  extracellular  forni;   11,   flagellate  form. 

C.  .<^sti vo-autumnal  parasite.  1,  ring-like  body;  2,  S,  ameboid  forms; 
4,  parasite  in  brassy  degenerated  red  cell;  S,  pigmentation;  6,  segmentation; 
7,  8,   half-moon   bodies;  9,   flagellate  forms. 


MALARIA  231 

ments  of  red  cells  are  carried  by  the  leukocytes  to  the  liver  and  spleen. 
Some  forms  (gametocytes)  do  not  mature  nor  sporulate,  but  are  taken 
up  by  the  mosquito^  to  complete  in  it  another  cycle.     (Plate  VIII.) 

2.  The  tertian  organism  (Plasmodium  vivax)  has  a  forty-eight-hour 
cycle.  In  its  first  day  it  is  a  small  (l/x  or  2^),  bright,  unpigmented 
disk  in  the  red  cell,  thrusting  out  pseudopodia,  with  active  ameboid 
movement,  and  possessing  a  large  nucleus — partly  clear  chromatin,  and 
partly  deeply  stained  chromatin.  It  fills  one-third  of  the  cell.  In  its 
second  day,  pigment  accumulates  as  fine  granules  or  rods,  which  are 
peripherally  located,  and  have  a  swarming  movement,  like  that  of  boiling 
water,  due  to  currents  in  its  protoplasm.  The  ameboid  movement  de- 
creases in  thirty  hours,  as  the  parasite  grows  and  the  pigment  increases, 
but  some  movement  remains  for  a  long  time.  Vacuoles  are  frequent. 
The  parasite  occupies  two-thirds  to  three-fourths  of  the  red  cell,  which 
becomes  distended  and  chlorotic.  The  most  common  form  of  sporula- 
tion  is  the  concentric  accumulation  of  pigment  and  the  development 
of  fifteen  to  twenty  small,  round,  rough,  refractile  spores,  which  form 
in  two  concentric  circles  ("sunflower"  arrangement),  or  are  more  fre- 
quently irregular,  like  a  bunch  of  grapes.  Sporulation  occurs  three  hours 
before  the  chill  and  rise  of  temperature,  and  is  completed  in  forty-eight 
hours,  when  the  toxins  secreted  produce  the  rigor  and  fever.  Few  spores 
are  seen  at  the  time  of  the  chill,  because  sporulation  occurs  to  a  greater 
extent  in  the  internal  organs  than  in  the  peripheral  blood  stream.  When 
spores  are  seen  between  paroxysms  they  represent  the  sporulation  of 
another  generation  of  parasites,  too  few  to  induce  a  paroxysm.  The 
generations  are  never  absolute,  as  they  are  in  the  quartan  type,  and  the 
parasites  of  the  same  generation  vary  six  or  eight  hours  in  their  cycle. 
This  explains  the  clinical  variations  in  periodicity.  A  few  minutes  after 
withdrawal  of  the  blood,  nodulated  and  clubbed  flagella  lash  about  and 
indent  the  red  cells.  They  may  break  off  and  swim  about.  They  occur 
in  parasites  which  never  sporulate  in  human  blood,  but  remain  as  large 
bodies  with  vibrating  pigment,  representing  gametocytes  or  "sexual 
forms,"  which  develop  later  in  the  mosquito  (MacCallum). 

3.  The  estivo-autumnal  'parasite  has  a  life-cycle  of  from  twenty-four 
to  forty-eight  hours.  There  are  two  subtypes — the  tertian  (Plasmodium 
falciparum)  and  quotidian  (Plasmodium  falciparum  quotidianum) .  It 
has  a  very  small,  unpigmented  body,  and  possesses  most  active  ameboid 
movement,  thus  attracting  early  attention,  though  it  possesses  almost  the 
same  refraction  as  the  red  cell.  It  becomes  quiet  after  drawing  the  blood 
from  the  body,  when  it  appears  characteristically  ring-like,  often  with  a 
central  vacuole.  The  shape  may  be  successively  ameboid,  diskoid, 
annular,  cruciform,  or  with  a  slight  knob — the  seal-ring  form.  Mature 
forms  contain  particles  of  hemoglobin.  The  pigment  is  extremely  fine, 
powder-like,  dark,  peripherally  located,  and  somewhat  motile.  When 
the  parasite  reaches  one-third  the  size  of  the  corpuscle,  it  is  usually 
motionless,  the  pigment  concentrating  centrally.  Motion  in  the  parasite 
has  been  seen  in  the  cadaver.  The  spores  number  six  to  sixteen,  are  very 
small,  round,  and  without  movement  or  vacuoles.  Fever,  pigment 
concentration  and  sporulation  coincide  (Golgi).    Large  parasites  in  the 


232  PROTOZOAN  INFECTIONS 

peripheral  blood  with  much  pigment  denote  the  onset  of  a  paroxysm, 
and  after  the  paroxysm,  ring-forms  without  pigment  may  be  observed. 
Young  forms  circulate  in  the  blood  stream,  though  sporulation  occurs 
in  the  viscera.  The  half -moon  bodies  or  crescents  are  delicate,  highly 
refractile  bodies,  measuring  eight  to  ten  by  two  or  three  microns,  develop 
in  the  bone-marrow  or  spleen,  and  possess  pigment,  which  is  usually 
mesially  located  and  has  little  motion.  They  have  no  ameboid  movement 
but  may  slowly  change  shape;  they  are  spindle,  oval  or  spherical.  They 
occur  singly  in  the  red  cell  and  do  not  multiply  in  the  human  blood.  The 
adult  forms  are  seen  in  the  peripheral  blood,  which  offers  the  best  op- 
portunity for  leaving  the  body — through  the  bites  of  mosquitoes.  The 
male  form  of  the  crescent  has  flagella  (microgametes)  which  penetrate 
the  sexual  elements  of  the  female  crescents  (macrogametes),  outside  of 
the  body,  either  on  the  slide  or  in  the  body  of  the  mosquito  (Ross). 
Fever  rarely  occurs  when  crescents  alone  are  found  in  the  blood ;  in  fever, 
ameboid  bodies,  also,  are  nearly  always  found.  The  red  blood  cell 
becomes  copper-colored  or  brassy. 

The  parasite  may  be  stained  with  the  Nocht-Romanowsky  jfluid, 
methylene  blue  or  hematoxylin,  and  counter-stained  with  eosin.  For  the 
beginner,  study  of  the  fresh  blood  under  an  oil-immersion  is  the  best 
method. 

(B)  The  Life  of  the  Organism  without  the  Human  Body. — 
King  (1883)  first  suggested  that  the  mosquito  was  the  intermediate 
host  and  sole  source  of  infection.  It  takes  the  plasmodium  from  man 
and  reino'culates  him  with  it  after  the  life-cycle  within  its  body.  Other 
analogous  infections  are  known,  such  as  the  hemosporidia  of  birds, 
frogs,  bats,  dogs,  sheep,  monkeys,  Texas  cattle-fever  inoculated  b}^  the 
tick,  and  the  African  trypanosoma  in  animals  and  man,  inoculated 
by  the  tsetse  fly.  Manson  (1894),  especially,  then  Ross,  Grassi,  Bas- 
tianelli,  Bignami  and  others,  have  developed  this  interesting  subject. 
The  Plasmodium  malarise  is  found  only  in  man  and  the  mosquito.  The 
mosquito  is  the  primary  and  higher  host,  since  the  sexual  reproduction 
in  its  stomach  is  biologically  higher  than  the  simple  sporulation  in  man. 
Of  its  two  chief  genera,  the  culex  does  not  contain  or  convey  the  parasite. 
Its  palpi  are  very  short  and  its  wings  have  no  mottling.  When  sitting, 
its  hindlegs  are  carried  above  the  body  and  its  body  lies  parallel  with  the 
wall,  or  may  sag  from  the  blood  it  has  sucked.  Its  eggs  are  laid  in  tanks 
or  puddles.  It  is  the  ordinary  house  mosquito  and  is  found  chiefly  in 
cities.  The  anoyheles  conveys  malaria.  Its  palpi  are  almost  as  long  as  the 
proboscis;  the  wings  are  mottled;  the  hindlegs  usually  depend,  or 
touch  the  wall.  Its  body  makes  an  angle  of  45°  with  the  wall.  The 
eggs  are  laid  in  pools  or  sluggish  streams  with  algse  growth,  and  the 
open  country  is  its  preferred  habitat.  Species:  (1)  The  most  important, 
the  Anopheles  maculipennis;  (2)  A.  crucians;  (3)  A.  punctipennis;  (4) 
A.  argyritarsis.  After  the  female  anopheles  bites  persons  whose  blood 
contains  sexually  mature  forms  of  the  plasmodium  (gametocytes), 
and  the  blood  reaches  the  insect's  stomach,  flagellation  in  the  male 
form  occurs  and  the  flagella  enter  the  female  cells.  After  fecundation 
the  impregnated  cell  enters  the  muscular  walls  of  the  intestine,  and. 


MALARIA  233 

after  two  days,  small,  round,  refractile,  pigmented  bodies  appear,  which, 
after  a  week,  grow  to  60  to  TO^i  in  diameter.  They  develop  into  myriads 
of  sporoblasts  which  reach  the  salivary  glands  of  the  insect,  whence  they 
are  again  inoculated  into  man  by  biting.  The  sporozoids  thus  resulting 
from  sexual  conjugation  in  the  mosquito,  are  equivalent  to  spores  formed 
by  asexual  sporulation  in  the  human  blood.  Entering  the  red  cells  in  man, 
they  follow  the  cycle  of  their  type  as  above  described,  and  produce 
either  sporulating  forms  or  sterile  forms.  The  sterile  forms  in  the  human 
blood — i.  e.,  the  forms  which  do  not  sporulate — linger  in  the  peripheral 
blood  with  the  teleological  purpose  of  preserving  and  continuing  their  life 
in  the  mosquito,  and,  on  reaching  its  body,  develop  again  the  agents  of 
reinfection.  This  knowledge  concerning  the  mosquito  explains  many 
interesting  and  formerly  incomprehensible  details.  We  now  know  why 
those  living  in  the  first  story  of  houses  are  more  likely  to  be  infected 
than  those  living  in  the  upper  floors  and  why  those  who  slept  in  houses 
facing  inland  were  infected  while  those  in  houses  exposed  to  the  sea  air 
escaped,  etc.  In  Rome,  the  fever  prevailed  just  outside  the  Porta  del 
Populo,  while  the  Corso,  three  hundred  feet  distant  in  the  city,  escaped. 
During  the  winter,  man,  not  the  mosquito  perpetuates  the  disease. 
Bass  and  Johns  successfully  cultivated  all  types  of  malarial  parasites. 

Symptomatology. — 1.  Fever. — Fever  is,  next  to  the  melanin  and  Plas- 
modium, the  most  constant  symptom.  It  develops  after  an  incubation  of 
one  and  a  half  to  fifteen  days.  Fever  bears  a  close  relation  to  sporulation 
(Golgi,  1885).  The  fever-curve  is  irregular  in  some  types  or  almost 
mathematically  regular  in  others.  It  is  usually  irregular  at  first  even 
in  regular  types.  It  may  be  remittent  (subcontinuous),  intermittent 
(tertian,  quartan,  quotidian),  or  continuous  for  a  few  days,  when  it  ends 
by  crisis  or  becomes  remittent  or  intermittent  before  recovery.  The 
paroxysm  may  be  delayed  beyond  the  time  when  it  is  due  -(postponens) , 
or  may  anticipate  this  time  {anteponens) .  In  the  algid  variety  there  may 
be  hyperpyrexia,  or  normal  or  subnormal  temperature.  Wade  Brown's 
experiments  suggest  that  the  paroxysm  is  caused  by  the  pigment. 

The  classical  components  of  the  paroxysm  are  chill,  fever  and  sweating, 
whose  respective  duration  is  in  the  proportion  of  3-2-7,  but  any  compo- 
nent may  be  absent,  especially  in  virulent  varieties  and  in  persons  partly 
immunized.  The  paroxysm  lasts  ten  (four  to  forty-eight)  hours,  and  in 
91  per  cent,  occurs  between  10  a.m.  and  3  p.m.  (a)  The  chill  is  sudden  in 
onset,  often  severe,  with  headache,  emesis,  coldness  and  lividity  of  the 
skin  {cutis  anserina) ;  the  temperature  by  rectum  is  elevated,  the  pulse 
rapid,  small  and  hard;  the  respiration  is  rapid  or  even  dyspneic,  and  the 
urine  is  increased.  The  parasites  pervade  the  peripheral  blood  in  the 
tertian  and  quartan  types  but  largely  the  internal  organs  in  the  estivo- 
autumnal  type.  (6)  The  fever  is  high,  perhaps  not  higher  by  rectum 
than  during  the  chill,  but  is  more  evidenced  by  the  red  skin,  thirst, 
delirium,  headache,  soft,  full  or  dicrotic  pulse,  and  other  fever  symptoms. 
In  this  stage  the  young  parasites  are  free  in  the  blood  and  begin  to  attack 
new  red  cells.  After  their  entrance  into  these  cells  the  fever  ceases, 
(c)  In  the  siveating  stage  the  young  parasites  are  found  in  the  red  cells 
and  phagocytes  take  up  the  detritus  and  pigment.    The  sweat  is  usually 


234 


PROTOZOAN  INFECTIONS 


profuse,  giving  off  an  odor  like  that  of  semen.    Postfebrile  euphoria  is 
usual. 

Special  Febrile  Types  of  Malaria. — The  quartan  and  tertian  forms 
are  regular  and  intermittent,  and  the  estivo-autumnal  forms  are  more 
irregular  and  remittent. 


Day 

1 

.     2 

3 

4 

TEMP. 

104 

\ 

\ 

, 

h 

103 

y 

\ 

100 

/ 

\ 

\ 

> 

^AA 

r" 

J 

\ 

\/ 

/ 

V 

Fig.  15. — Quartan  malaria.     (Silvestrini.) 

1.  The  quartan  fever  is  the  rarest  of  all  types  (0.8  per  cent.),  is 
found  in  the  temperate  zones,  and  occupies  a  position  geographically 
intermediate  between  the  tertian  and  estivo-autumnal  varieties.  It  is 
caused  by  the  quartan  parasite,  is  the  most  regular  of  all  types,  and  is 
called  quartan  because  the  simple  form  causes  paroxysms  every  fourth 


Fig.  16. — Tertian  malaria. 


day.  The  parasitic  cycle  is  readily  followed  in  the  circulating  blood,  and 
the  organisms  do  not  accumulate  in  the  internal  organs.  The  fever  is 
obstinate  and  recurrence  is  frequent,  but  quinine  quickly  exerts  its 
specific  action.  The  type  may  be  single,  from  one  generation  of  parasites ; 
double,  from  two  generations ;  or  triple,  from  three  generations  producing. 


MALARIA 


235 


respectively,  temperature,  every  fourth,  every  first  and  second,  or  every 
day  of  the  cycle. 

2.  Tertian  fever,  most  frequent  in  the  temperate  zone,  is  found  in  all 
malarial  countries  and  constitutes  50  to  65  per  cent,  of  all  malaria. 
The  organisms  accumulate  in  the  internal  organs.  It  is  rarely  per- 
nicious. The  type  may  be  single,  or  more  frequently,  double  from  two 
generations  of  parasites,  causing  almost  continuous  fever.  It  responds 
readily  to  quinine  and  may  recover  spontaneously. 

3.  Estivo-autumnal  fever,  caused  by  the  estivo-autumnal  parasite,  is 
often  irregular,  remittent,  intermittent  or  continuous  (subcontinuous) . 
It  is  characterized  clinically  by  severe  recurrent  fever,  marked  anemia, 
frequently  by  absence  of  paroxysms  (chills  occurring  in  71  per  cent,  only) 
and  sometimes  by  pernicious  symptoms.  It  was  called  estivo-autumnal 
by  Marchiafava  and  Bignami,  in  contradistinction  to  the  milder  or 
vernal  forms.  Subtypes:  (a)  Regular  intermittent  estivo-autumnal 
fever:   (i)  The  estivo-autumnal  tertian,  in  which  the  fever  is  apt  to  be 


Day 

1 

2 

a 

4 

.5 

6 

7 

8 

TEMP. 

106 

105 

104 

A 

103 

A 

/ 

\ 

A 

102 

/ 

A/ 

V\ 

A 

101 

/ 

V 

\   , 

V 

\a 

h 

V 

100 

^ 

•v 

\ 

99 

v^ 

s 

\ 

9S 

Fig.  17. — Estivo-autumnal  malaria. 


high,  and  the  paroxysm  doubly  long.  The  typical  curve  may  be  modified 
by  an  exaggerated  pseudocrisis,  a  briefer  or  longer  duration  of  the 
attack,  by  anticipation  or  procrastination,  and  by  double  attacks,  (ii) 
The  estivo-autumnal  quotidian,  with  a  short  attack,  but  an  abrupt 
elevation  of  fever.  This  often  irregular  form  has  fewer  symptoms  than 
the  other  variety,  and  may  recover  spontaneously.  It  is  readily  confused 
with  typhoid.  (6)  The  irregular  form  presents  marked  irregular  inter- 
mittency  or  remittency,  or  subcontinuous  fever,  because  the  attacks  are 
duplicated,  anticipated  or  prolonged.  The  paroxysm  may  last  twenty 
hours.    The  symptoms  may  be  mild  or  very  severe. 

2.  Blood  Findings. — ^The  blood  findings  are  yathognomonic,  viz.,  para- 
sites, melanemia,  anemia,  and  absence  of  leukocytosis. 

(a)  Red  Cells. — Anemia  results  from  deglobulization  by  the  parasite. 
Acute  anemia  is  more  marked  and  rapid  than  in  any  other  infection. 
The  loss  is  greatest  in  the  first  attack,  sometimes  reaching  half  a  million 
cells.  Reduction  to  500,000  red  cells  may  give  the  picture  of  pernicious 
anemia. 


236  PROTOZOAN  INFECTIONS 

(h)  White  Cells. — The  absolute  and  relative  leukopenia  is  due  to  the 
collection  of  the  white  cells  in  the  liver  and  spleen,  to  destruction 
of  the  phagocytes,  and  to  lesions  of  the  blood-making  organs.  As  in 
other  anemias  caused  by  disease  of  the  bone-marrow  and  spleen,  an 
increase  of  lymphocytes  or  large,  mononuclear  cells  (20  per  cent.),  with 
decrease  of  the  polymorphonuclear  cells,  may  be  observed.  An  absolute 
increase  is  sometimes  observed  in  the  "black-water  fever,"  but  the 
increase  is  in  the  lymphocytes.  (Thomson  describes  a  leukopenia  (when 
many  parasites  sporulate)  and  a  leukocytosis,  even  up  to  50,000  or 
125,000,  when  few  parasites  sporulate.) 

(c)  Melanemia. — ^Nlelanemia  (Virchow  and  Heschl,  1847-50)  is,  next 
to  the  presence  of  ike  Plasmodium,  the  most  constant  change  in  malaria. 
It  is  present  during  fresh  infection  and  may  occur  shortly  after  the  fever 
has  disappeared,  as  in  the  half-moon  forms.  After  infection  it  usually 
disappears  within  forty-eight  hours.  It  is  practically  pathognomonic  of 
malaria,  though  said  to  occur  in  recurrent  fever,  melanotic  new  growths 
and  Addison's  disease.  It  is  found  chiefly  in  the  polymorphonuclears. 
It  is  seen  in  the  smaller  capillary  walls  where  their  diameter  suddenly 
decreases  (lung  alveoli,  intestinal  villi,  renal  glomeruli,  cerebral  con- 
volutions, spleen,  liver  and  bone-marrow) ;  the  capillaries  may  be  occluded 
by  pigment.  Besides  this  pigment  copper-colored  hemosiderin  may  be 
found  in  the  vessels  and  hepatic  parenchyma. 

3.  Spleen. — Enlargement  of  the  spleen  (Andouard,  1803)  is  the 
third  important  finding.  It  is  palpable  in  88  per  cent,  of  cases  and  ana- 
tomically is  rarely  absent.  Its  size,  hardness  and  plumpness  are  pro- 
portionate to  the  duration  of  the  fever,  increase  with  its  rise,  remit 
between  attacks  and  disappear  with  recovery.  In  acute  infections  the 
spleen  is  increased  three-  to  fivefold;  it  is  soft  and  friable:  the  paren- 
chyma is  flooded  with  infected  red  and  macrophagic  cells;  and  there 
are  areas  of  focal  necrosis.  The  jNIalpighian  bodies  contrast  strongly 
with  the  congested  pulp.  A  sticking  pain  over  the  organ  is  due  to 
perisplenitis,  and  is  often  associated  with  pain  and  tenderness  in  the 
bones.  In  chronic  infections  the  spleen  is  permanently  enlarged  (fever- 
cake),  reaching  even  into  the  pelvis.  It  may  weigh  ten  pounds,  the  cap- 
sule is  thickened,  even  calcified,  perisplenic  adliesions  occur  and  friction 
is  frequent.  Sometimes  a  systolic  murmur  is  heard.  The  redundant 
pigment  gradually  decreases.  The  acute  hyperemia  and  focal  necrosis 
lead  to  increase  of  the  connective  tissue;  ultimately  little  remains  of 
the  pulp,  follicles  and  splenic  function.  Rare  complications  are  pressure 
on  the  intestines,  nerves  and  ureters,  torsion  of  the  pedicle  of  a  wander- 
ing spleen,  abscess  or  rupture  (of  which  Choux  collated  147  cases). 

4.  Skin. — The  vasomotor  constriction  during  the  chill  gives  way, 
during  the  febrile  rise,  to  hyperalgesia  and  vasodilatation.  Miliaria 
appear  in  the  sweating  stage.  Herpes  is  very  frequent,  mostly  nasal 
or  labial.  Edema  and  a  cachectic  hue  occur  in  chronic  cases.  Slight 
urobilin  icterus  is  not  infrequent;  icterus  is  sometimes  intense.  In- 
frequent complications  are  urticaria,  erythema,  roseolee,  petechise,  etc. 

5.  Circulatory  Symptoms. — ^The  heart  is  little  involved.  The  pulse 
rises  parallel  with  the  fever,  small  at  first  from  vasoconstriction,  later 


MALARIA  237 

full  from  vasodilatation.     Endocarditis,  myocardial  degeneration  with 
dilatation,  and  phlebitis  are  rare  developments. 

6.  Respiratory  Symptoms. — The  rare  dyspnea  and  pulmonary 
congestion  during  a  paroxysm  are  due  to  parasites  and  phagocytes 
accumulating  in  or  even  occluding  the  capillaries  of  the  lung.  Plasmodia 
have  been  seen  in  the  sputum.  Chronic  bronchitis,  emphysema  and 
"proliferating"  interstitial  pneumonia  occur  as  complications.  Broncho- 
pneumonia is  frequent  in  malarial  cachexia.  Lobar  pneumonia  occurs 
only  as  a  mixed  infection.  It  is  atypical  and,  in  malarial  cachexia,  is 
especially  fatal. 

7.  Digestive  Symptoms. — The  oral  mucous  membrane  is  dry,  the 
tongue  heavily  coated  and  the  breath  foul.  The  stomach  may  be  the 
seat  of  hyperemia  or  infarction  with  plasmodia.  Anorexia,  vomiting 
and  gastralgia  are  common  symptoms.  Ulceration  from  amyloid  de- 
generation is  observed  only  in  a  few  chronic  cases.  Hematemesis  from 
chronic  splenic  tumor  has  proved  fatal. 

The  Intestines. — Swelling  of  the  lymphatic  structures,  hyperemia, 
thrombosis  from  parasite  aggregation,  meteorism  and  rarely  diarrhea 
are  observed.  Acute  abdominal  pain  is  not  uncommon;  it  may  simulate 
peritonitis.  Rarely  the  disease  may  resemble  dysentery,  with  ulcers  in 
the  large  and  small  gut. 

The  Liver. — In  acute  infections  the  liver  is  enlarged,  hyperemic,  and 
its  macrophagic  endothelial  cells  are  swollen,  though  few  parasites  are 
present.  Icterus  may  develop  from  red-cell  destruction;  it  is  usually 
polycholic.  Pigmentation  from  degenerated  red  cells  is  more  common 
than  actual  melanosis.  In  chronic  infections  the  liver  may  weigh  eight 
or  ten  pounds,  is  hard  and  smooth,  and  has  a  thick  capsule.  The  changes, 
seriatim,  are  focal  necrosis,  atrophy  or  partial  regeneration,  and  pig- 
mentation with  hyperemia;  angioma,  lymph  cysts  or  abnormal  lobules; 
and  hyperplasia  of  the  perilobular  connective  tissue,  with  ultimate 
cirrhosis.  Cirrhosis  may  follow  chronic  malaria  without  necessarily 
being  of  malarial  origin.  Amyloid  degeneration  and  simple  atrophy 
from  pylethrombosis  are  uncommon  sequels.  Acute  ascites  may  result 
from  pylethrombosis,  by  plugging  of  the  capillaries  by  melaniferous  cells. 

8.  Genito-urinary  Symptoms. — Polyuria  is  often  observed  during 
the  paroxysm.  The  urine  is  decreased  in  the  estivo-autumnal  type. 
The  postmalarial  polyuria  of  convalescence  is  frequent.  In  one  instance 
the  author  observed  a  veritable  diabetes  insipidus. 

The  urea,  chlorides  and  specific  gravity  of  the  urine  are  increased. 
AUmminuria  is  present  in  30  per  cent,  of  cases,  and  usually  disappears 
with  the  paroxysm.  Ehrlich's  diazo  reaction  is  obtained  in  5  per  cent, 
of  the  cases.  Nephritis  occurs  in  4.5  per  cent,  but  is  seldom  fatal.  Plas- 
modia frequently  abound  in  the  intertubular  capillaries  but  rarely  in  the 
glomeruli.  Glomerular  desquamation  and  epithelial  exfoliation,  endo- 
capsular  exudation,  necrosis  and  cast  formation  in  the  convoluted  tubules 
occur.  Chronic  parenchymatous  and  interstitial  nephritis  may  result 
from  malaria.  Hemoglobinuria,  anuria  and  uremia  occur  in  black-water 
fever.  Gangrene  of  the  genitalia  is  an  uncommon  sequel.  Metrorrhagia 
and  abortions  occur  frequently. 


238  PROTOZOAN  INFECTIONS 

9.  Nervous  Symptoms. — The  parasite  especially  affects  the  nervous 
system,  whence  Van  Swieten  called  malaria  a  neurosis.  There  is  scarcely 
a  nervous  symptom  which  is  not  observed  occasionally  in  malaria. 
The  sensorium,  involved  slightly  in  mild  cases,  is  seriously  affected  in 
pernicious  types  (q.  v.).  Headache  is  usual,  and  neuralgias  are  frequent, 
especially  of  the  fifth  nerve.  In  pernicious  types  it  is  not  easy  to  determine 
whether  nervous  symptoms  are  due  to  toxemia  or  cerebral  thrombosis. 
The  endothelial  cells  of  the  vessels  are  fatty,  swollen  and  pigmented. 
Thrombosis  in  grave  cases  may  result  from  swelling  of  the  endothelium, 
though  it  is  usually  caused  by  the  rough  infected  red  cells.  The  infected 
erythrocytes  never  leave  the  vessels. 

Paralysis  (hemiplegia,  paraplegia  and  monoplegia),  or  motor  irritation 
(tremor,  chorea,  contractures,  epileptic  attacks  or  reflex  spasms),  may 
occur  in  urgent  types.  Neuritis,  psychoses,  ascending  spinal  paralysis, 
bulbar  symptoms,  symptoms  resembling  multiple  sclerosis,  tabes  or  acute 
ataxia  are  rare  sequences. 

10.  Muscles  and  Bones. — ^The  muscles  and  bones  are  often  painful. 
The  bone-marrow  at  first  shows  fat  and  pigment  which  then  disappear 
with  marked  vascularization,  and  ultimately,  proliferation  of  the  marrow 
cells  and  connective-tissue  thickening. 

Latency. — Craig  analyzed  the  latent  malarial  infections  in  which  the 
Plasmodia  may  be  demonstrated  in  the  blood,  without  conspicuous 
symptoms.  The  latent  type  amounted  to  24  per  cent,  of  the  cases 
examined,  which  were  discovered  only  in  the  routine  examination;  they 
might  have  been  sources  of  infection  to  others  for  weeks  or  months. 

Relapses. — Relapses  are  almost  invariable  in  all  forms,  but  are  most 
obstmate  in  the  estivo-autumnal  type.  Craig  believes  that  the  chief 
cause  of  maintenance  of  malarial  infection  is  intracorpuscular  conjuga- 
tion, thus  producing  within  the  body  a  resting  or  zygote  stage  of  the 
Plasmodium  w^hich  resists  quinine. 

Chronic  Malaria. — Untreated  infection,  or  reinfection,  persists  for 
months,  notably  in  the  estivo-autumnal  variety.  It  is  accompanied 
by  irregular  fever,  marked  anemia,  the  parasite  in  the  blood,  and  splenic 
and  hepatic  swelling.  In  severe  chronic  cases,  the  malarial  cachexia 
develops,  usually  after  years  of  infection.  It  is  most  marked  in  intensely 
malarial  regions,  in  estivo-autumnal  infection,  and  in  reduced  subjects. 
The  fever  is  slight,  irregular  or  absent.  The  features  of  malarial  cachexia 
are  (1)  anemia  from  defective  blood  regeneration,  with  its  general  symp- 
toms, such  as  edema,  rapid  pulse,  venous  thrombosis  and  hemorrhages 
in  the  skin,  retinae,  etc. ;  (2)  vascular  changes,  possibly  due  to  pigment 
occlusion;  (3)  enlarged  spleen  and  liver;  and  (4)  gangrene,  nervous 
symptoms,  alimentary  and  respiratory  catarrh,  amyloid  disease,  liver 
hypertrophy,  and  extreme  malnutrition. 

Relation  to  the  Other  Diseases. — Malaria  and  typhoid  rarely  coexist; 
Craig  saw  but  8  instances  in  5000  personal  cases.  (The  plasmodia, 
and  typhoid  bacillemia  or  the  Widal  test  are  necessary  for  diagnosis.) 
Surgical  operations  may  arouse  a  latent  malaria.  Erysipelas,  septicemia, 
dysentery,  cholera,  smallpox,  tuberculosis,  etc.,  very  infrequently  coexist 
with  malaria, 


MALARIA  239 

Pernicious  Malaria. — Pernicious  malaria  constitutes  but  a  small  propor- 
tion of  cases  of  estivo-autumnal  malaria,  and  very  seldom  follows  infection 
with  the  ordinary  tertian  parasite.  It  is  characterized  by  severe  obsti- 
nately recurring  fever,  intractable  anemia,  pernicious  visceral  symptoms, 
abortive  paroxysms  without  chills  and  by  depression.  The  pathogenesis 
of  perniciousness  lies  in  the  inelastic,  irregular,  infected  red  cells  which 
cannot  pass  the  visceral  capillaries,  and  therefore  slow  the  blood  current. 
Melanosis,  phagocyte  aggregations  and  endothelial  swelling  are  of  second- 
ary importance.  In  cases  of  capillary  hemorrhages,  only  the  normal, 
not  the  parasite-laden  red  corpuscles,  escape  from  the  vessels.  Regressive 
organic  changes  may  occur  in  the  cerebrum,  gastro-intestinal  mucosa, 
spleen,  liver  and  kidney.  Accessory  factors  are  (a)  arteriosclerosis, 
renal  disease,  cardiac  dilatation,  alcoholism,  sunstroke,  overwork,  mal- 
nutrition and  lack  of  acclimatization;  (6)  the  number  of  parasites  and 
their  abundance  in  internal  organs.  Estivo-autumnal  parasites,  with 
large  blocks  of  central  pigment,  indicate  many  plasmodia  in  the  viscera. 
The  parasites  are  often  few  in  the  peripheral  blood  though  abundant 
in  the  brain  at  autopsy;  (c)  great  activity  in  multiplication  may  be 
observed  in  the  peripheral  blood  even  during  the  sporulating  stage; 
and  (d)  necroses  in  the  viscera  and  the  great  morphological  alteration 
of  the  "brassy"  red  cells  suggest  an  increased  toxicity. 

1.  The  pernicious  typhoid  form  (perniciosa  typhosa)  is  inappropriately 
called  typhomalaria.  Its  clinical  picture  is  variable;  chills  are  often 
absent.  Years  ago  the  differential  diagnosis  was  made  ex  juvantibus 
by  quinine.  Without  blood  examination  malaria  and  typhoid  may  be 
confused;  benign  or  malign  malaria  may  resemble  typhoid  closely, 
with  slow  dicrotic  pulse,  splenic  tumor,  headache,  fever-curve,  cerebral 
and  abdominal  symptoms,  and  even  roseolse  and  intestinal  hemorrhage; 
on  the  other  hand,  erratic  typhoid  with  remittent  temperature,  chills 
and  sweats,  or  typhoid  in  the  latter  part  of  its  normal  course,  may 
simulate  malaria. 

The  following  differentiation  is  modified  from  Baccelli: 

Malaria : vs. Typhoid. 

Begins  intermittently.  Progressively  remittent. 

Remissions  very  irregular.  Regular  in  the  morning;  step-like. 

Temperature  may  be  high  at  first.  High  fever  only  after  several  days. 

Headache  in  beginning  is  rare,  variable  in  Early,  permanent,  frontal,  oppressive,  char- 
site  and  intensity,  pulsating  and  neuralgic.  acteristic. 

Eyes  dull,  subicteric  from  beginning.  Glistening  eyes;    no  icterus. 

Stupor,  dry  tongue  and  sordes,  less.  Marked. 

Breath  nauseating.  Mouse-like. 

Delirium  from  beginning;   recurrent.  In  advanced  stage;    constant. 

Lung     congestion     begins     suddenly;      foci  Slow    development,     hypostatic;      dyspnea 
change    recurrently;     dyspnea    from    de-  rare  (from  tympany), 

ranged  circulation. 

Nervous  restlessness,  jactitation.  Stupor,  prostration. 

Meteorism  not  characteristic;  stools  darker.  Metcorism   and    diarrhea   begin    gradually; 

pronounced;    ochre  stools. 

Liver  congestion  frequent;    subicterus.  Less  congestion;    rarely  icterus. 

Herpes  frequent.  Rare.     Roseolas. 

Cycle,  none.  Typical. 

Blood:  Plasmodia  and  melanemia.  Widal  reaction  and  typhoid  bacillemia. 

Recurrence.  Relapses  less  frequent. 

Convalescence  more  rapid  and  easier.  Tardy. 

In  adynamic  type,  icterus,  hemoglobinuria.  Does  not  respond   to   quinine,   which  is  a 
leukocytosis,  great  anemia,  25  per  cent,  specific  in  malaria, 

mortality, 


24(J  PROTOZOAN  INFECTIONS 

2.  Of  cerebral  forms,  the  comatose  {perniciosa  comatosa)  is  the  most 
frequent.  Mental  depression  is  followed  by  contracted  pupils,  involuntary 
evacuations  or  paralysis.  The  pulse  at  first  is  slow;  death  is  usually 
cardiac.  The  respiration  may  be  noisy,  hurried  or  Cheyne-Stokes's.  If 
fever  is  present  it  is  irregular.  The  author  has  seen  four  such  cases  in 
Chicago.  Apoplexy,  uremia  and  sunstroke  must  be  considered.  The 
splenic  tumor  yer  se  suggests  a  blood  examination.  The  "meningeal 
type"  occurs  especially  in  children;  the  slow  pulse,  headache,  rigid, 
tender  neck,  stupor,  convulsions,  hyperesthesia  and  ultimate  coma  can 
be  correctly  interpreted  only  after  a  blood  examination.  Delirium  may 
be  the  main  symptom,  and  may  appear  as  a  mania,  as  fixed  ideas,  hallu- 
cinations or  as  melancholia.  The  rare  convulsive  type  may  be  generalized, 
simulating  hysteria,  uremia  or  epilepsy,  or  localized,  with  contractures, 
trismus  or  opisthotonos.  The  paralytic  is  the  least  frequent  type;  hemi- 
plegia with  aphasia  is  more  common  than  monoplegia,  the  bulbar  form,  etc. 

3.  The  algid  pernicious  type  occurs  with  cyanosis,  collapse,  Hippo- 
cratic  expression,  alimentary  symptoms,  and  usually,  early  death. 

4.  After  the  cerebral  type  the  pernicious  g astro-intestinal  variety  is 
most  frequent,  with  vomiting,  epigastric  distress,  icterus  and  dysentery. 
In  soldiers  from  Cuba,  the  author  observed  profuse  hemorrhages  from 
the  bowel,  promptly  responding  to  quinine. 

5.  The  pernicious  biliary  fever  ("jungle  fever")  occurs  with  vomiting, 
polycholia,  icterus,  nervous  symptoms,  hemorrhages,  adynamia,  edema 
and  dark  albuminous  urine;  even  after  the  administration  of  quinine 
this  type  may  be  lethal. 

6.  The  hemorrhagic  types  resemble  Werlhoff's  disease,  and  scurvy. 

7.  The  febris  biliaris  hemoglobinurica  ("black-water  fever")  occurs  in 
South  America,  in  Africa  and  in  our  Southern  States.  The  suspected 
causal  factors  are  repeated  malarial  attacks,  undue  exertion,  cold,  and 
the  use  of  quinine.  Some  maintain  that  it  is  a  separate  disease.  The 
cardinal  symptoms  are  (a)  hemoglobinuria ;  the  urine  is  always  albumin- 
ous, neutral  or  alkaline  in  reaction;  hemoglobin  is  detected  only  after 
the  destruction  of  at  least  one-sixth  of  the  red  corpuscles;  (b)  icterus, 
invariable  except  in  the  mildest  cases;  (c)  irregular  fever;  (cl)  the  Plas- 
modia, found  in  96  per  cent,  before  the  attack  and  in  62  per  cent,  at  the 
onset.    The  mortality  of  50  per  cent,  is  due  to  syncope,  anuria  and  coma. 

Diagnosis. — 1.  From  Sy:\iptoms. — A  probable  diagnosis  can  often  be 
made,  for  instance,  by  typically  intermittent  fever  which  occurs  early 
in  the  day  and  is  distinct  from  the  vesperal  hectic  or  septic  fever.  The 
three  elements  of  the  paroxysm  are  most  marked  in  the  benign  malaria. 
In  estivo-autumnal  forms  the  chills  may  be  absent.  Splenic  enlargement 
and  herpes  are  suggestive,  but  also  occur  in  ephemeral  fevers,  pneumonia, 
etc.  ]Much  emphasis  was  once  placed  on  intermittent  neuralgia,  vertigo, 
herpes  zoster,  etc.,  but  intermittence  is  not  synonymous  with  malaria. 

2.  The  Diagnosis  ex  Juvaxtibus. — Laveran  excluded  malaria, 
when  the  fever  resisted  30  grains  of  quinine  for  more  tlian  four  days;  in 
tropical  forms  more  quinine  may  be  necessary. 

3.  The  Plasmodium  may  be  mistaken  for  vacuoles  resulting  from 
mechanical  injury  to  the  red  cells;  retraction  of  the  hemoglobin;  swarm- 


MALARIA  241 

ing  particles  from  the  red  blood  cells;  blood  plates,  sometimes  mistaken 
for  spores,  in  unstained  specimens;  and  poikilocytosis.  Fewest  mistakes 
are  made  when  the  inexperienced  observer  examines  the  fresh  blood. 
Leukocytes  containing  pigment  are  distinguished  by  their  large  nucleus, 
and  by  their  ameboid  movement  which  is  lacking  in  plasmodia  sufficiently 
large  to  cause  confusion. 

Positive  findings  are  obtained  in  98  per  cent.  The  malarial  parasite 
is  found  in  the  blood  of  malarial  patients  only.  It  is  usually  stated 
that  they  occur  in  largest  numbers  before  or  at  the  time  of  the  paroxysm, 
though  it  must  be  admitted  that  the  early  examinations  are  often  negative. 
Quinine  may  obscure  the  findings.  Melanemia  is  practically  pathog- 
nomonic.    (Pigment  lying  free  in  the  plasma  is  most  often  contamination.) 

Negative  findings  are  of  relative  value  only,  and  depend  upon  the 
skill  of  the  observer  and  the  time  of  examination.     The  findings  were 
negative  in  only  2  per  cent,  of  Baccelli's  series. 
Differential  Diagnosis. — 1.  From  typhoid  {v.  pages  46  and  239). 

2.  Sepsis,  pyemia  (page  46),  ulcerative  endocarditis,  liver  abscess 
or  pulmonary  phthisis  may  be  confounded  with  malaria.  We  find  in 
malaria  the  plasmodium,  melanemia,  response  to  quinine  and  absence 
of  leukocytosis;  whereas  in  sepsis,  leukocytosis,  positive  blood  cultures 
and  septic  localizations  are  distinctive. 

3.  Irregular  grippe,  recurrent  fever,  miliary  tuberculosis,  fever  in 
malignancy,  especially  sarcomatosis,  pernicious  anemia,  pseudoleukemia, 
Weil's  disease  and  yellow  fever  may  be  confused  with  malaria,  without 
careful  blood  examinations.  Pernicious  malaria  may  superficially  simu- 
late apoplexy,  sunstroke,  meningitis,  cholera  or  purpura.  Among  1267 
malaria  patients,  25  per  cent,  were  "masked,"  simulating  tuberculosis, 
pneumonia,  dysentery,  appendicitis,  etc.  (Craig). 

Prognosis. — The  type  of  parasite,  reinfection,  habits  of  the  individual, 
and  antecedent  renal  or  cardiac  disease,  are  most  important  considera- 
tions. The  prognosis  must  be  conservative  in  pernicious  and  cachectic 
forms.  In  Italy  the  yearly  death-rate  was  16,000,  and  the  French  lost 
6000  soldiers  in  Madagascar  in  three  months.  On  the  other  hand,  fully 
20  per  cent,  recover  with  rest  in  bed  and  a  full  diet,  as  is  shown  in  cases 
treated  with  placebos  and  saved  for  clinical  demonstrations;  in  spon- 
taneous recovery  the  factors  are  the  phagocytes  in  the  spleen,  bone- 
marrow  and  to  a  less  degree,  the  endothelium  of  the  hepatic  and  cerebral 
vessels,  Kupft'er's  cells  in  the  liver,  and  possibly  the  leukocytes. 

Treatment. — 1.  Prophylaxis  embraces  more  than  personal  prevention. 
In  Italy  and  elsewhere  it  is  a  national  economical  problem.  Drainage, 
the  filling-in  of  stagnant  pools  and  swamps  and  the  planting  of  pines, 
eucalyptus  trees  and  sugar-cane,  have  proved  successful;  the  drainage 
of  the  great  Bordeaux  swamp  in  1805  cost  3000  lives.  In  digging  canals 
or  building  roads,  immunes  should  be  employed,  but  whites  may  work 
successfully  if  they  avoid  alcohol  and  nocturnal  infection  by  mosquitos, 
minimized  by  nettings  on  all  doors  and  windows.  The  pools  where  the 
insects  breed  should  be  filled  in,  or  covered  with  crude  petroleum  to 
kill  the  larvae.  The  stocking  of  semistagnant  streams  with  fish  is  of 
value.  The  prophylactic  use  of  quinine  in  daily  doses  of  10  to  40  grains 
16 


242  PROTOZOAN  IXFECTIOXS 

is  eftecti\'e.  Sick  malarial  patients  and  those  with  malaria  but  without 
symptoms,  should  be  protected  from  the  bites  of  mosquitos,  which 
carry  infection  to  others.  In  the  Isthmian  Canal  Zone,  Gorgas  reduced 
the  mortality  to  one-seventeenth  of  the  French  death-rate.  The  Italian 
death-rate  has  been  reduced  from  16,000  to  3500  annually. 

2.  Specific  Treatmext. — Quinine  is  one  of  our  few  specifics.  Cin- 
chona has  been  used  for  ages  in  Peru  and  was  kno\Mi  as  the  "tree  of 
health"  to  Pizzarro  in  the  conquest  of  Peru.  Introduced  over  one  hundred 
years  later  into  Europe  by  del  Yego  (1640),  its  alkaloid  was  discovered 
by  Pelletier  and  Caventou  in  1820.  It  acts  on  the  malarial  organism 
while  it  is  developing  (Marchiafava  and  Bignami);  when  the  parasite 
has  transformed  all  the  hemoglobin  into  melanin,  and  segmentation 
begms,  quinme  is  ineffectual.  All  malarial  manifestations  as  fever, 
splenic  tumor  and  anemia  are  cured  by  quinine  except  in  pernicious  forms. 
It  acts  as  a  direct  protozoan  poison.  Malarial  subjects  escape  many  or 
all  of  the  symptoms  of  cinchonism,  such  as  tinnitus  aurium,  cephalic 
distention  and  slight  deafness  resulting  from  therapeutic  doses  (gr.  x). 
(Deafness,  disordered  vision,  flushed  face,  cerebral  congestion,  vomiting, 
staggering,  tremor  and  twitchings  result  from  larger  doses;  and  delirium, 
complete  deafness  and  amaurosis,  dilated  pupils,  convulsions,  paralysis, 
hemoglobmuria,  dyspnea,  coma,  weak  heart,  or  hemorrhages  result  from 
toxic  doses.) 

Administration. — Its  antiperiodic  action  is  enhanced  by  combining 
it  with  opium  gr.  ss.  Laxatives  are  unnecessary.  Pills  are  insoluble, 
and  the  drug  is  best  given  in  powders  involved  in  starch  wafers,  or  with 
one  drop  of  sulphuric  acid  to  each  gram  of  the  sulphate.  Coffee,  cognac 
and  extract  of  glycyrrhiza  but  poorly  disguise  its  bitterness.  If  the 
stomach  rebels,  a  warm-water  enema  with  equal  parts  of  quinine  and 
tinct.  opii  deodorat.  may  be  used.  In  severe  cases  the  hydrochloride 
(gr.  vij)  in  15  minims  of  water  may  be  used  h^'podermically,  but, 
though  every  care  be  taken,  abscesses  develop  often.  In  pernicious 
types,  Baccelli  injects  quinine  intravenously  (sterilized  solution  of 
sodium  chloride,  quinine  muriate  and  water,  in  the  proportion  of  1,  10, 
and  100  parts,  respectively). 

Time  of  Exhibition. — If  the  fever  recurs  regularly,  gr.  xx-xxx 
should  be  given  as  the  fever  falls,  to  act  on  the  young  growing  forms 
in  the  red  cells,  to  be  repeated  before  the  next  paroxysm,  in  order  to 
have  the  drug  m  the  circulation  when  the  spores  are  scattered  (Torti 
and  Golgi) .  If  the  fever  is  continuous  or  subcontinuous,  or  if  the  type 
is  severe,  gr.  v  should  be  given  every  four  hours.  Large  doses  are  more 
effectual;  small  doses  only  aggravate  malaria  and  develop  quiescent 
forms.  In  the  treatment  of  black-water  fever,  one  view  maintains  that 
quinine  is  its  cause;  it  should  be  given  only  when  plasmodia  are  found, 
and  given,  as  in  Italy,  a  daily  dose  of  six  grains,  for  three  months. 

3.  Treatment  of  the  Paroxysm. — During  the  vasoconstriction 
of  the  chill,  morphine  gr.  j  and  nitroglycerin  gr.  -g^,  hypodermically, 
and  spirits  of  chloroform  5j)  hi  hot  whisky  and  water  afford  great  relief. 
The  fever  is  short-lived  and  requires  little  beyond  cool  sponging.  The 
sweating  requires  no  treatment. 


RECURRENT  FEVER  243 

In  chronic  malaria,  iron  and  full,  increasing  doses  of  arsenic  should 
be  combined  with  quinine.  Arsenic  is  said  to  act  on  the  gametocytes. 
Salvarsan  is  recommended  for  obstinate  types. 


RECURRENT  FEVER. 

Synonyms. — Relapsing  fever;  febrisrecurrens;  typhus  recurrens ;  seven- 
day  fever;  famine  or  prison  fever;  bilious  typhoid. 

Definition. — A  specific  infectious  disease  caused  by  Obermeier's  spiril- 
lum; endemic  in  Ireland,  Russian  Poland  and  India;  characterized 
clinically  by  cyclic  febrile  attacks  lasting  six  or  seven  days,  followed  by 
an  equally  long  apyretic  interval  and  recurrence  of  the  fever. 

Etiology. — Recurrent  fever  was  first  described  by  Rutty,  of  Dublin, 
in  1739.  It  appeared  in  America  in  1844,  and  was  last  seen  in  1869. 
Obermeier  in  1873  described  a  specific  spirillum  or  spirochete  (Sjnrillum 
Ohcrmeieri).  S.  T.  Darling  concludes  that  the  Panama  spirochete  is  of  a 
strain  differing  from  the  European;  the  African  tick  fever  is  caused  by 
the  S.  duttoni,  the  relapsing  fever  of  India  by  the  S.  carteri  and  the 
American  form  by  the  S.  novyi.  The  secretions  are  apparently  not  in- 
fectious. The  disease  has  been  inoculated  in  monkeys  and  in  man,  from 
postmortem  cuts.  Bed-bugs  and  lice  also  convey  it.  Infection  is  carried 
chiefly  by  vagabonds  and  emigrants.  Males  are  especially  affected 
(90  per  cent.).  Most  cases  occur  between  the  twentieth  and  the  fortieth 
years. 

Symptoms.— After  an  incubation  of  five  to  seven  days,  usually  without 
I)rodromes,  the  invasion  begins  with  a  chill,  high  temperature  (reaching 
possibly  104°  on  the  first  day),  throbbing  headache,  and,  in  the  young, 
convulsions  and  vomiting.  The  vertigo  and  cerebral  confusion  may 
resemble  acute  alcoholism.  Because  of  the  severe  neuralgic  pain  in  the 
back  and  legs,  the  patient  lies  motionless.  There  are  great  depres- 
sion, conjunctival  suffusion,  subicteric  sclerse,  facial  pallor,  epigastric 
oppression,  with  or  without  vomiting,  and  tenderness  over  the  liver 
and  spleen. 

Specific  Findings. — 1.  The  hlood  is  dark  and  reveals  the  pathog- 
nomonic, motile,  cork-screw-shaped  spirillum.  It  appears  with  the 
fever,  disappears  before  it  falls,  and  reappears  with  the  next  attack. 
The  spirilla  are  found  in  the  blood  only.  Without  the  immersion  lens 
they  may  be  located  by  the  lashing  about  of  the  red  cells.  They  always 
lie  between  and  never  in  them,  appear  as  fine  threads,  sixteen  to  forty 
microns  in  length,  with  five  to  ten  waves  in  each,  and  move  by  undulation 
along  their  long  axes.  They  stain  best  with  fuchsin,  after  extraction  of  the 
hemoglobin.  Their  life  in  the  blood  is  usually  thirty-seven  days.  The 
white  blood  cells  are  increased. 

2,  The  spleen  is  enlarged,  painful  and  palpable.  In  no  other  infection 
is  the  spleen  so  large,  being  increased  five-  or  sixfold  and  weighing  even 
twenty  pounds.  The  capsule  is  tense,  the  pulp  is  a  fluid  red,  the  Mal- 
pighian  bodies  are  increased,  and  necrotic  areas  and  infarcts  are  common. 
Microscopically  there  are  hyperemia,  hyperplasia,   spirilla  and  fatty, 


244 


PRO  TOZOA  X  IXFEC TIONS 


desquamated  endothelium  from  the  veins,  thus  explaining  the  spindle  eeUs 
found  in  the  blood  stream.    Suppuration  and  rupture  may  occur. 

3.  The  hone-marrow  resembles  the  splenic  follicles  and  contains  granular 
cells,  and  aggregations  of  white  blood  cells. 

Other  Symptoms. — 1.  Nervous  System. — Headache  is  frequent.  The 
sensorium  is  usually  free,  delirium  and  insomnia  being  rare. 

2.  Temperature .^The  temperature  rises  abruptly  to  103°  or  104°, 
and  remains  continuously  high  (105°  to  107°)  from  five  to  seven  days, 
when  the  crisis  occurs.  In  no  other  disease  is  the  defervescence  so  pre- 
cipitate (5°  to  even  16°j .  In  five  to  seven  days  the  patient  is  well,  when 
in  99  per  cent,  of  cases  the  cycle  is  repeated,  ^-ith  usually  two  or  three 
relapses    (as   many   as   seven   are   recorded).     The   temperature-curve 


Uay   ,  I 

5 

c 

7   ,   S  i   9 

10 

11 

12 

13 

» 

15 

10 

i< 

IS 

19 

20 

21 

22 

23 

24 

25 

26 

27 

TEMP. 

105 

k 

104 

VI 

103 

/ 

nr] 

^' 

\ 

I 

i 

1 

102 

1 

1 

A 

V 

i 

I 

« 

101 

R    r[] 

A// 

100 

/ 

/W 

\a 

99 

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14 

! 

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/          :             1             1             t        II 

98 

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f 

■ 

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97 

\ 

N. 

H 

1 
96  1 

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95 

i 

v 

91 

V 

Fig.  18. — Fever  chart  in  recturent  fever. 


is  diagnostic.  Lysis  occurs  in  1  per  cent.  The  crisis  is  followed  by 
sweats,  shrinkage  of  the  spleen,  disappearance  of  the  spirillum  and 
rapid  convalescence. 

3.  Circulatory  System. — ^The  pulse  is  rapid  (120  to  140j,  hard, 
sometimes  irregular  and  slow  after  the  crisis. 

4.  Respiratory  Tract. — Bronchitis  and  increased  respirations  and 
in  fatal  cases  hypostasis,  pneumonia,  glottis  edema  and  pleurisy  have 
been  observed. 

5.  Gastro-intestinal  Tract. — The  tongue  is  white  and  later, 
yellowish-broTMi.  Hematemesis,  a  tender,  swollen  liver,  icterus,  gall- 
bladder distention,  bloody  effusions  in  the  alimentary  mucosa,  and 
hyperplasia  of  the  lymphatics  may  be  observed. 


KALA-AZAR  ^4o 

6.  Genito-urinary  Tract. — The  urinary  findings  resemble  those  of 
typhoid.    Nephritis  is  infrequent  and  abortion  occurs  in  66  per  cent. 

7.  Skin. — The  skin  is  usually  subicteric,  yet  the  stools  remain  colored. 
Herpes,  erythema,  petechise,  desquamation  and  even  roseola  have  been 
noted.    The  skin  becomes  drenched  at  the  crisis. 

Diagnosis. — The  specific  points  are:  A  prevailing  epidemic;  onset 
with  chill  and  fever;  swelling  and  tenderness  of  the  liver  and  spleen; 
muscular  pains;  abrupt  crisis;  apyretic  interval  with  recurrence  of  the 
cycle,  and  spirilla  found  by  blood  examination. 

In  bilious  typhoid  or  septic  recurrent  fever,  there  is  severe  icterus, 
hemolysis,  and  liver  findings  suggestive  of  acute  yellow  atrophy.  Hemor- 
rhages and  death  from  collapse  in  the  first  attack  are  common.  The 
colored  stools  and  enlarged  spleen  are  significant.  ]\Ialaria,  typhoid, 
typhus,  yellow  fever,  acute  yellow  atrophy  and  Weil's  disease,  are 
excluded  by  examination  of  the  blood. 

Convalescence. — Convalescence  is  rapid,  after  four  or  five  weeks. 
Death  results  from  toxemia,  heart  collapse  or  complications.  The 
prognosis  is  good,  the  mortality  averaging  4  per  cent,  or  60  per  cent, 
in  the  bilious  type.    One  attack  is  not  certain  to  confer  immunity. 

Treatment. — The  treatment  is  that  of  typhoid.  Pain  often  necessitates 
the  use  of  opiates.    Salvarsan  has  been  used  successfully. 

KALA-AZAR. 

The  Leischmaniases,  diseases  caused  by  Leischman's  organism,  include 
two  visceral  and  one  cutaneous  disease.  Indian  kala-azar  (Assam  or 
Dumdum  fever)  and  infantile  kala-azar  (splenomegaly)  are  caused  by 
the  Leischmania  donovani  (Leischman  and  Donovan,  1903),  and  the 
oriental  sore  by  the  L.  tropica. 

Indian  kala-azar  is  characterized  by  splenomegaly,  progressive 
anemia  and  remittent  fever.  The  protozoon  is  found  in  the  spleen, 
liver,  bone-marrow  and  sometimes  in  the  blood.  It  can  be  cultivated 
and  may  be  transmitted  by  the  bed-bug.  The  disease  begins  with  fever, 
which  is  oftenest  remittent,  rising  two  or  three  times  daily;  it  recurs. 
]Marked  emaciation  develops  with  abdominal  tenderness,  nervous  toxemia, 
neuritic  or  arthralgic  pains  and  various  hemorrhages.  The  sJan  is  dark, 
even  icteric  and  pigmented.  The  spleen  is  greatly  enlarged,  tender  and 
is  crowded  with  parasites.  The  liver  becomes  swollen  and  tender  from 
periliepatitis,  is  packed  with  parasites  and  frequently  becomes  cirrhotic. 
There  is  secondary  anemia;  there  is  relative  lymphocytosis,  usually  with 
leukopenia.  The  course  averages  6  to  9  months  and  the  mortality  is 
96  per  cent.  The  parasites  are  found  constantly  and  in  all  stages  by 
splenic  puncture  (which,  however,  may  entail  hemorrhage  or  rupture). 
Quinine  hypodermically  is  of  some  benefit. 

Infantile  kala-azar  or  splenomegaly  is  identical  with  the  Indian  type 
and  is  found  on  the  jNIediterranean  littoral  and  islands.  It  is  probably 
transmitted  by  dog  fleas. 

Oriental  sore  is  also  known  as  Delhi  boil,  Bagdad  sore,  etc.  It  occurs 
on  the  face  and  exposed  parts  of  the  body  as  a  small  node,  which  becomes 


246  PROTOZOAN  INFECTIONS 

covered  with  a  crust.  Beneath  it  is  granulating  tissue,  which  often  ulcer- 
ates, invades  the  lymphatics,  or  perhaps  the  nasal  mucosa — simulating 
lues,  tuberculosis  or  leprosy. 

TRYPANOSOMIASIS. 

The  trypanosoma  is  a  protozoon  found  by  Gruby  (1843)  in  frogs, 
Doflein  (1845)  in  rats,  and  later  in  many  other  animals  and  in  man 
(Xeprue,  1890-98).  There  are  many  species.  The  T.  gambiense  is 
leech-shaped;  its  body  is  granular,  measures  13  to  25,  by  2  to  4//  and 
contains  a  nucleus  and  micronucleus  (centrosome) ;  on  one  side  and. 
attached  to  an  "undulatmg  membrane"  is  a  solitary  flagellum  by  which 
the  parasite  moves.  In  cool  and  moist  hanging-drop  preparations  they 
may  live  for  a  month  and  a  half.  Xovy  and  ]McXeal  cultivated  the  T. 
Lewis  and  Brucei.  Infection  is  carried  by  the  tsetse  fly,  flea,  louse, 
mosquito  and  ticks.  In  man  trypanosomiasis  is  conveyed  by  the  tsetse 
fly  (Glossina  palpalis)  or  possibly  by  bites  from  infected  rats;  apparently 
the  fly  is  the  true  host.  Animals  may  be  infected  during  coitus,  by 
subcutaneous  inoculation  or  by  the  stomach. 

Trypanosoma  fever  was  first  described  by  Xepreu.  It  prevails  in 
central  and  western  Africa.  The  atrium  may  be  present  as  an  inflamed 
bite  or  the  history  of  a  bite  may  be  obtained.  Parasites  in  the  blood 
may  cause  no  symptoms,  even  for  a  year  (''carriers");  parasites  occur 
in  the  plasma,  not  in  the  corpuscles;  some  anemia  is  present  and  the 
large  lymphocytes  are  increased  up  to  20  per  cent.,  but  the  eosinophiles 
show  no  increase.  Most  parasites  are  found  in  the  lyviph  glands  which 
are  constantly  enlarged,  especially  the  posterior  cervical.  Fever  is  irregular, 
subcontinuous  or  remittent,  and  lasts  from  three  days  to  three  weeks. 
An  erythematous  eruption  is  almost  constant.  Edema,  particularly 
of  the  lower  lids,  weak  and  rapid  pulse,  prostration  and  splenic  tumor 
usually  occur.  In  treatment,  arsenic  (atoxyl  and  salvarsan),  antimony 
(gr.  1.5,  intravenously)  and  trypan  red  are  apparently  helpful,  while 
quinine  is  without  effect.  Careful  feeding  and  cardiac  stimulation  are 
indicated.  The  patient,  as  in  yellow  fever,  should  be  so  screened  that 
flies  can  neither  convey  fresh  infection  to  him  nor  bite  him  and  thus 
infect  others. 

Sleeping  sickness  or  African  lethargy,  endemic  in  Central  Africa,  is 
due  to  localization  of  the  trypanosomes  in  the  nervous  system,  causing 
a  diffuse  meningo-encephalomyelitis  (jMott) .  X'egroes  are  chiefly  affected 
and  slaves  imported  to  America  developed  the  disease;  Caucasians  may 
contract  the  disease. 

The  incubation  is  long,  possibly  years.  Incipient  symptoms  are  those 
of  the  trypanosoma  fever  or  less  often  there  are  preliminary  psychical 
phenomena,  as  epileptiform  convulsions,  melancholia  or  mania.  There 
is  a  fine  tremor  and  shuffling  gait.  Somnolence  develops,  from  which  at 
first  the  patient  can  be  aroused,  but  which  later  develops  into  profound 
lethargy.  The  parasite  is  found  in  the  blood  in  92  per  cent.  (Bruce) 
and  in  100  per  cent,  of  eases  in  the  cerebrospinal  fluid,  withdrawn  by 
lumbar  puncture  (Castellani).     Malnutrition,  decubitus  and  sometimes 


SMALLPOX— VACCINATION  247 

secondary  infections  develop,  and  after  the  convulsions  deepen  into 
coma  the  patient  dies.  The  course  lasts  from  months  to  several  years. 
Treatment  is  usually  unavailing;  some  10  cures  are  reported.  More 
than  a  quarter  of  a  million  people  died  in  Uganda  in  the  last  few  years 
from  this  affection. 

OTHER  PROTOZOA. 

Amebiasis  has  been  described  with  bacillary  dysentery. 

Yaics,  or  frambesia  is  a  highly  contagious  disease,  found  in  Africa, 
Asia,  Central  and  South  America  and  various  islands.  In  the  days  of 
slavery  it  was  common  in  the  South,  where  cases  are  still  found.  It  is 
due  to  the  Treponema  pertenue  (Castellani,  1905) ;  the  parasite  resembles 
the  T.  pallidum  and  the  clinical  course  resembles  syphilis.  At  the  site 
of  inoculation,  usually  on  the  legs  or  face,  a  papule  forms,  which  in  one 
week  becomes  an  ulcer;  this  heals  in  another  week;  the  fungoid  tubercle 
resembles  a  raspberry  (frambesia)  and  is  called  the  initial  lesion.  In 
six  weeks  to  three  months,  fever,  malaise,  headache  and  joint  pains 
reappear — the  secondary  stage — in  which  the  lesions  resemble  the  primary 
or  condylomata.  In  some  instances  destructive  tertiary  lesions  develop. 
In  differentiation  from  lues,  the  primary  and  secondary  lesions  are  identi- 
cal, extragenital  and  lack  the  endothelial  proliferation  and  perivascular 
exudation  of  syphilis ;  the  lesions  are  not  pleomorphic,  involve  the  mucosa 
only  at  its  junction  with  the  skin  and  never  the  viscera,  brain,  etc.  The 
death-rate  ranges  under  1  per  cent,  and  salvarsan  is  absolutely  specific. 

The  trichomonas  (cercomonas)  is  found  in  acid  vaginal  mucus  and  the 
intestines.  It  may  initiate  enteritis  or  cystitis.  The  Lamhlia  intestinalis, 
a  pear-shaped  flagellated  monad,  may  occasion  diarrhea;  it  has  been 
found  in  pleuris}',  pulmonary  gangrene  and  bronchiectasis.  The  Balan- 
tidium  coli,  common  in  hogs,  may  cause  dysentery  (g.  v.)  in  apes  and  man; 
it  is  found  in  the  stool  and  submucosa  and  sometimes  in  the  bloodvessels 
and  lymph  glands. 

Coccidia  may  rarely  be  found  in  the  liver,  kidneys,  bladder,  spleen, 
intestine,  peritoneum,  etc.  Tumors,  like  tubercles  or  mucous  cysts 
may  develop.     A  typhoid-like  course  is  described. 


INFECTIONS  OF  DOUBTFUL  ETIOLOGY. 

SMALLPOX  (VARIOLA).     VACCINATION. 

Definition. — Smallpox  is  an  acute,  highly  infectious  disease.  It  begins 
suddenly  with  a  chill,  headache,  vomiting  and  intense  epigastric  and 
lumbar  pain,  and  is  characterized  by  a  typical  fever-curve  and  by  an 
eruption  on  the  skin  and  mucosae  of  papules,  vesicles,  pustules  and  crusts 
successively. 

History. — Smallpox  prevailed  in  China  and  India  1000  years  before 
the   Christian   era.      Galen's  -pesta   magna  of  the  second  century  was 


24S 


INFECTIONS  OF  DOUBTFUL  ETIOLOGY 


probably  variola.  Epidemics  occurred  in  the  sixth  century  and  during 
the  crusades.  Rhazes  (Arabia,  ninth  century)  gave  us  the  first  clinical 
description  of  the  disease.  Smallpox  was  introduced  into  Mexico  in  1520 
by  the  Spaniards,  and  three  and  a  half  million  persons  contracted  the 
disease.  Sydenham's  classic  of  the  seventeenth  century  is  most  accurate 
and  reliable.  In  1718,  Lady  Montague  introduced  into  England  preven- 
tive inoculation,  which  had  been  practised  for  centuries  in  Asia,  and 
though  the  mortality  fell  to  1  per  cent,  the  disease  was  disseminated 
in  a  mitigated  form.  Jenner's  discovery  of  vaccination,  in  1796,  greatly 
lessened  the  terrors  of  variola,  which  in  Europe  alone  carried  off  nearly 
half  a  million  persons  yearly. 

Etiology. — The  virus  is  unknown.  Weigert  and  others  found  pyogenic 
organisms  in  the  skin  and  elsewhere,  but  suppuration  is  due  to  a  later 
mixed  infection.  The  cytorrhydes  varioloB  of  Guarnieri  (1892)  is  an 
ameba  found  in  the  blood  in  the  incipient  stage;  and  in  the  lower  epithelial 
layers,  in  vacuoles  in  the  cells;  these  small  structureless  bodies  measure 
one  to  four  microns  and  become  granular  and  segmented. 


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INCUBATION        PRODROMAL  STAGE        ERUPTION  OF  MACULES      ERUPTION  OF    SUPPURATION  EXSICCATION  A 
12  DAYS  3.DAYS  AND  PAPULES  3  DAYS  VESICLES  3  DAYS  DECRUSTATION 

2  DAYS  7  DAYS 

Fig.  19. — Temperature  chart  and  stages  of  smallpox.     (Pfeiffer.) 


That  the  blood  is  infectious  at  an  early  stage  was  demonstrated  by 
the  infection  of  an  individual  on  whom  skin  had  been  transplanted  from 
a  person  in  the  early  stages  of  smallpox.  As  variola  without  eruption 
is  contagious,  it  seems  that  the  secretions  and  excretions  convey  the  virus. 
The  greatest  infectiousness  is  noted  in  dried  pustules  in  which  the  virus 
localizes.  Infection  is  direct  from  person  to  person,  or  indirect  by  a 
third  party  or  by  fomites.  Cadavers  of  variola  victims  are  dangerous. 
The  virus  is  very  penetrative,  even  beyond  the  room,  building  or  area  of 
the  isolated  case.  The  disease  persists  in  infected  communities  for 
years. 

Susceptibility  to  smallpox  is  almost  universal;  only  1  per  cent,  of 
people  are  immune.  Temporary  immunity  is  more  frequent  than  con- 
genital. Practically,  immunity  is  only  acquired  by  vaccination  or  a 
previous  attack.  Either  sex  and  all  ages  may  be  affected.  Mothers 
with  the  disease  may  deliver  babes  with  the  florid  eruption  or  with  scars. 
The  virulence  of  the  virus  is  great  in  aboriginal  and  colored  races  (Indians 
and  Mexicans).  Severe  cases  may  follow  mild  infection,  as  shown  in 
Osier's  description  of  the  Montreal  epidemic,  in  which  3164  persons, 


SMALLPOX— VACCINATION  249 

Infected  by  a  mild  case  in  a  Pullman-car  conductor,  died  among  the 
French  Canadians,  who  oppose  vaccination.  Variola  occurs  sporadically, 
epidemically,  or  pandemically. 

Atrium. — Infection  occurs  through  the  respiratory,  and  perhaps  also 
the  digestive  tract. 

Symptoms. — Forms: 

I.  Variola  vera  — 1.  Discreta,  discrete. 

— 2.  Confluens,  confluent. 
II.  Variola  — 3.  Purpura  variolosa  (black  smallpox). 

hemorrhagica      — 4.  Variola  hemorrhagica  pustulosa. 
III.   Varioloid  — 5.  Smallpox  modified  by  vaccination. 

1.  Variola  Vera  Discreta. — (^4)  The  incubation  is  symptomless  and 
averages  twelve  days  (five  to  twenty). 

(jB)  The  yrodroinal  stage,  dating  from  the  first  symptom  to  the 
eruption,  is  the  same  in  all  types,  and  averages  three  days.  It  is  shorter 
in  children  and  in  confluent  smallpox;  the  longer  it  is,  the  more  severe 
is  the  infection.  Its  intensity  bears  no  invariable  relation  to  prognosis, 
for  mild  smallpox  may  begin  severely;  however,  if  the  onset  is  mild, 
the  disease  will  not  be  confluent  or  hemorrhagic. 

The  invasion  begins  acutely  with  chill,  fever,  rapid  pulse  and  respiration, 
nervous  toxemia,  intense  headache,  backache  and  vomiting,  (a)  The 
chill  is  severe,  and  frequently  is  repeated.  In  children  it  is  often  absent. 
(fe)  The  initial  fever  rises  suddenly  to  103°  or  104°,  and  reaches  its  maxi- 
mum on  the  second  or  third  day.  The  j^u^se  is  rapid  (120)  and  full. 
The  more  frequent  respirations  (30  to  36)  constitute  the  so-called  toxemic, 
"cerebral  respiration."  The  skin  is  red,  hot  (calor  mordax)  and  dry; 
there  may  be  sweating  in  the  discrete  variety  and  in  favorable  cases. 
(c)  Nervous  toxemia  is  evidenced  by  the  benumbed  sensorium,  depression, 
restlessness,  insomnia,  delirium  especially  in  alcoholics,  or  convulsions 
and  meningeal  symptoms  in  children.  Headache  appears  with  the  chill 
and  is  frequently  frontal  or  temporal.  When  severe,  it  may  suggest 
meningitis,  especially  when  accompanied  by  vomiting  and  neckache. 
{d)  Backache  appears  with  the  chill,  and  lasts  one  or  two  days.  It  occurs 
in  nearly  all  cases,  though  less  frequent  than  headache  and  vomiting.  It 
is  severe,  like  lumbago,  or  actually  agonizing.  The  "  veritable  paraplegia" 
described  by  Trousseau  is  only  immobility  due  to  toxemic  pain.  It  is 
rare  in  other  fevers  likely  to  be  confused  with  variola.  Pain  is  sometimes 
observed  in  the  intercostal  nerves,  sciatics,  muscles,  joints,  pharynx, 
larynx  or  heart,  (e)  Vomiting  and  early  epigastric  pain  are  constant  in 
children.  The  spleen  is  not  often  enlarged  in  the  initial  period.  It  is 
often  tender,  as  are  the  liver  and  epigastrium.  (/)  The  initicd  or  yrodromal 
eruptions,  present  in  10  per  cent.,  have  considerable  diagnostic  value. 
They  are  commonly  limited  to  the  lower  abdomen,  inside  of  the  thighs, 
axillse  and  sometimes  to  the  extensor  surfaces  of  the  knees  and  elbows. 
There  are  two  varieties: 

1.  The  morbilliform  variety  (roseola  variolosa)  appears  during  the 
second  day  on  the  face  and  body  as  small,  sometimes  crescentic  maculae 
and  usually  lasts  one  day;  it  is  hyperemic  but  may  be  purpuric.  ]Most 
often  seen  in  varioloid,  it  is  a  favorable  prognostic. 


250  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

2.  The  more  rare  scarlatinal  form  (erythema  variolosum)  occurs  on 
the  first  day.  It  is  less  punctate,  extensive  and  bright  than  the  scarlet 
fever  rash.  If  it  is  purple  and  purpuric,  it  is  almost  always  variolous. 
It  occurs  on  the  lower  abdomen,  thighs  and  knees,  forming  a  triangle 
with  base  upward  when  the  legs  are  together.  Sometimes  it  is  found 
over  the  axilla  or  shoulders,  and  is  seen  in  women  more  frequently  than 
in  men.  These  areas  are  rarely  invaded  by  the  pustular  eruption.  Some 
writers  speak  of  an  erysipelas-like  and  urticarial,  prodromal  rash. 

(C)    The  eruptive  stage  comprises  several  serial  substages. 

1.  Macules  and  papules  {stadium  maculosum  et  papulosum)  occur  on 
the  fourth  day,  and  advance  for  three  days,  beginning  on  the  forehead 
near  the  hair  and  on  the  cheeks,  with  itching  and  burning  macules,  re- 
sembling flea-bites,  which  soon  become  papules.  The  papules  are  reddish, 
discrete,  circular,  elevated,  and  hard  or  "shotty."  A  day  later  they 
appear  on  the  body,  and  on  the  next  day,  on  the  extensor  aspects  of  the 
extremities;  i.  e.,  the  papular  eruption  advances  for  three  days,  and  is 
descending.  The  papules  are  thickest  on  the  face  and  trunk.  The  eyelids 
show  collateral  edema.  If  the  eruption  appears  on  the  second  day,  the 
confluent  type  may  be  expected;  if  on  the  third  day  of  the  disease,  the 
discrete  type. 

Weigert  holds  that  the  first  changes  are  necrobiotic  or  diphtheroid 
in  the  rete  Malpighii  followed  by  inflammation  in  the  necrotic  areas. 
Other  authorities  consider  inflammation  the  primary,  and  necrosis  the 
secondary  process. 

Unlike  measles  and  scarlatina,  the  fever  remits  when  the  eruption  appears, 
and  the  backache  and  headache  improve.  In  three  days  the  fever  reaches 
normal  by  irregular  steps.  The  lower  the  fever  falls  in  this  remission,  the 
lighter  is  the  type  of  smallpox. 

2.  In  the  stage  of  vesiculation  {stadium  vesiculosum) ,  lymph  gathers 
in  many  but  not  in  all  of  the  papules.  This  occurs  on  the  seventh  day 
of  the  disease  and  lasts  about  two  days.  The  vesicles  are  multilocular, 
since  they  occur  in  the  cells  of  the  rete  Malpighii.  Umbilication  occurs 
in  the  centres  of  many  vesicles,  caused  by  elevation  of  their  edges  by 
infiltration  and  by  the  follicles  in  their  centres;  it  corresponds  to  the 
area  of  primary  necrosis  and  is  suggestive  but  not  pathognomonic 
of  smallpox.  On  the  soles  and  palms  the  fluid  is  situated  deep  in  the 
resistant  tissues. 

3.  The  stage  of  suppuration  {stadium  pustulosum)  or  maturation 
begins  on  the  ninth  day  with  clouding  of  the  vesicles  and  inflammatory 
congestion  about  them  (areola) ;  it  advances  for  three  days.  The  pustules 
become  opaque,  then  yellow,  and  the  thick  pus  obliterates  the  umbilica- 
tion and  renders  the  eruption  globular.  The  areola  or  halo  becomes  more 
vivid  and  inflammatory  edema  may  result  from  fusion  of  the  areolae. 
This  causes  increased  tension,  deformity  especially  in  the  face  and  parts 
where  the  skin  is  most  loose,  closure  of  the  eyes,  occlusion  of  the  nose, 
and  great  tenderness  and  pain.  Pustulation  follows  the  descending 
direction  of  the  initial  eruption  and  the  pustules  are  thickest  on  the 
extremities  and  head.  On  the  volar  and  plantar  surfaces  they  are  less 
prominent  and  there  is  less  edema.    The  pustules  evacuate  spontaneously, 


SMALLPOX— VACCINATION  251 

especially  on  the  face,  but  may  dry  without  rupture.  Various  stages  of 
the  eruption  may  be  observed  in  different  parts  of  the  body  at  the  same 
time;  not  all  vesicles  become  pustules.  The  skin  exhales  a  peculiar, 
penetrating,  offensive  odor,  and  bed-sores  may  develop. 

Anomalies  are  variola  siliquosa — air  in  the  pustules,  and  very  large 
eruptions  three-quarters  of  an  inch  in  diameter.  The  pus  originates  from 
the  vessels  of  the  papillae  which  undergo  pressure-atrophy,  or  even  necrosis. 

Mucous  membranes:  The  pock  eruption  occurs  mostly  in  the  mouth 
and  nasopharynx;  the  successive  stages  of  papulation,  vesiculation, 
pustulation,  etc.,  may  develop,  but  less  typically  than  in  the  skin; 
erosions,  stomatitis,  glossitis,  phlegmonous  angina,  etc.,  may  result. 
The  eruption  is  found  in  very  rare  instances  in  the  Eustachian  tube, 
eye,  respiratory,  alimentary  and  genito-urinary  tracts. 

With  pustulation  there  is  a  gradually  rising  secondary  fever,  due  to  the 
smallpox  virus  and  mixed  pyogenic  infection,  and  proportionate  to  the 
degree  of  pustulation.  In  variola  discreta  the  temperature  does  not 
remain  high  more  than  twenty-four  to  thirty-six  hours,  with  morning 
remissions.  A  marked  leukocytosis,  of  10,000  to  34,000  attends  the 
secondary  fever  and  parallels  the  degree  of  infection.  The  lymphocytes 
are  increased  (to  66  or  50  per  cent.),  the  polymorphonuclears  decreased 
(to  50  or  33  per  cent.),  and  the  myelocytes  may  reach  12  per  cent. 

Delirium  with  suicidal  tendencies,  albuminuria,  acute  exhaustion  and 
heart  paralysis  may  develop. 

( D)  The  Stage  of  Involution. — Exsiccation,  decrustation  begins  on  the 
twelfth  day.  It  occurs  in  the  same  descending  order  as  the  florition 
and  suppuration,  with  decrease  in  the  edema,  redness  and  pain,  but 
with  an  intolerable  itching.  Crusts  form,  and  remain  longest  on  the 
soles  and  palms  where  they  may  form  complete  casts  of  the  parts.  Mucous 
erosions  heal  more  readily.  The  hair  falls  out,  and  by  the  end  of  the 
second  week  the  fever  reaches  normal.  Fever  at  this  stage  indicates 
some  complication.  The  higher  the  granulating  surface,  the  deeper  is 
the  cicatrix.  Scars  occur  when  the  true  skin  has  been  involved,  and  are 
seen  chiefly  on  the  face,  scalp,  palms  and  soles.  Sydenham  held  that 
discrete  smallpox  rarely  leaves  its  mark  but  others  maintain  that  sup- 
puration and  cicatrices  are  necessary  stigmata  of  variola  vera.  Scar 
formation  lasts  three  or  four  weeks.  Complete  convalescence  follows  the 
disappearance  of  the  last  crust. 

2.  Variola  Vera  Confluens. — ^This  malignant  type  was  more 
frequent  in  prevaccination  days,  and  is  now  seen  largely  in  persons 
unvaccinated  or  vaccinated  but  once.  The  initial  stage  is  violent.  The 
headache  and  backache  are  agonizing.  The  status  typhosus  and  gastric 
symptoms  are  marked,  the  fever  remission  is  slight  or  absent,  or  if  the 
fever  remits  there  is  little  or  no  improvement  in  the  symptoms.  The 
exanthem  is  precipitate  both  in  its  development  (on  the  second  or  third 
day),  and  in  its  extension.  The  earlier  the  exanthem  in  variola,  the 
greater  is  the  probability  of  confluent  smallpox.  The  eruption  becomes 
confluent  especially  on  the  face  and  head,  and  sometimes  on  the  hands 
and  feet;  on  the  body  and  limbs  it  is  largely  discrete.  With  fusion  of  the 
eruption,  great  inflammatory  edema  appears,  swelling  and  erosion  of  the 


252  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

mucous  membranes,  closure  of  the  eyes,  keratitis  and  obstruction  of  the 
nose  develop.  The  general  aspect  is  desperate.  High  fever,  high  pulse, 
rapid,  even  irregular  or  stertorous  breathing,  delirium,  albuminuria, 
persistent  nausea  and  vomiting,  great  thirst,  salivation  in  adults  and 
diarrhea  in  children,  husky  voice,  enlarged  cervical  glands  and  often 
parotitis,  are  present.  As  to  prognosis,  Sydenham  says  that  "  if  upon  the 
face  the  pustules  are  as  thick  as  sand,  it  is  no  advantage  to  have  them 
few  and  far  between  upon  the  body."  Death  occurs  from  acute  toxemia 
{variola  typhosa),  with  hyperpyrexia  and  cardiac  asthenia  usually  within 
a  week;  or,  if  the  patient  lives  longer,  from  septicopyemia,  phlegmon, 
gangrene,  pneumonia  and  nephritis.  The  patient  usually  dies  if  the 
eruption  does  not  appear.    Recovery  from  variola  confluens  is  infrequent. 

3.  Purpura  Variolosa. — ^This  is  the  black  smallpox — smallpox 
with  primary  hemorrhage  in  the  initial  stages.  It  is  the  worst  type, 
results  almost  uniformly  in  early  death  and  is  important  because  of  the 
difficulty  in  its  diagnosis.  It  is  seen  most  frequently  in  the  unvaccinated. 
The  incubation  is  short  (six  to  eight  days),  the  invasion  is  stormy,  with 
agonizing  lumbar  pain,  great  prostration,  a  rapid,  small  and  soft  pulse, 
and  disproportionately  increased  respiration.  The  initial  epigastric 
pain  and  vomiting  may  last  until  death. 

On  the  second  day  (or  even  on  the  first),  there  appears  a  plum-colored 
eruption,  with  brick-red,  purple  or  inky  ecchymoses,  especially  about 
the  eyes.  The  aspect  of  the  discolored  and  swollen  face,  and  ecchymotic, 
sunken  and  alert  eyes,  is  desperate.  Hematuria  is  the  most  common 
of  visceral  hemorrhages.  Other  forms  are  hematemesis,  enterorrhagia, 
epistaxis,  metrorrhagia  and  hemorrhage  from  the  gums,  ears  and  bronchi, 
sometimes  accompanied  by  gangrene  of  the  pharynx.  Tympanites  and 
albuminuria  may  be  noted.  Miscarriage  is  frequent.  The  disease  does 
not  usually  reach  the  real  eruption  of  variola,  or,  at  the  most,  only  the 
papules  are  observed,  because  it  is  fatal  in  four  or  five  days.  The  mind 
often  remains  lucid  to  the  end.  In  most  cases  the  fever  is  not  high,  but 
in  the  most  fulminant  type  it  reaches  105°  or  106°,  with  collapse,  coma  and 
death  in  a  few  hours,  even  before  cutaneous  hemorrhage  is  seen,  although 
internal  hemorrhages  are  found  at  autopsy.  The  "blood  dissolution" 
of  the  older  writers  is  a  mycotic  coagulation  thrombosis. 

4.  Variola  Pustulosa  Hemorrhagica. — Hemorrhage  after  the 
eruption  appears  {secondary  hemorrhage)  is  more  common  than  primary 
hemorrhage.  This  form  occurs  in  weakly  or  alcoholic  Subjects.  The 
initial  stage  is  severe,  and  secondary  hemorrhages  occur  into  the  vesicles 
or  pustules,  or  into  the  lower  parts  of  the  body  or  there  may  be  "  blood 
dissolution,"  epistaxis,  hematuria  and  metrorrhagia.  Adynamic  mani- 
festations are  usual,  and  the  outcome  is  almost  always  fatal,  though 
hemorrhage  at  the  vesicular  stage  may  be  followed  by  rapid  abortion 
of  the  rash  and  recovery. 

5.  Varioloid. — ^Varioloid  {variola  modificata  s.  mitigata,  variolois)  is 
variola  mitigated  hy  vaccination.  The  more  marked  the  initial  eruption, 
which  is  often  morbilliform,  the  less  the  number  of  pustules.  Varioloid 
begins  suddenly.  The  fever  is  atypical;  it  may  reach  103°  and  usually 
falls  with  the  specific  eruption,  reaching  normal  on  the  fourth  day; 


SMALLPOX— VACCIX  A  TION  253 

secondary  suppuration  is  rare  or  absent.  The  eruption  varies  in  amount, 
being  present  on  the  trunk  only,  or  being  typical  chiefly  on  the  hands  and 
feet.  It  may  be  absent  entirely.  It  may  not  be  umbilicated  and  may 
desiccate  rapidly  without  rupture;  scars  are  rare.  The  mucous  surfaces 
are  little  involved.  The  entire  course  is  shorter,  more  irregular  and 
rudimentary,  and  more  benign  than  in  variola  vera. 

Complications  and  Sequelae. — The  many  complications  and  sequelae  of 
variola  embrace  severe  early  toxemia  and  later,  secondary  infections. 

1.  The  Nervous  System. —  Delirium  is  caused  by  cerebral  toxemia, 
alcoholism  or  hyperpyrexia.  Convulsions  are  frequent  in  children. 
The  unusual  psychoses  are  generally  asthenic.  Meningitis,  encephalitis, 
embolism,  cerebral  softening,  and  abscess  are  occasional  complications. 
Myelitis  and  neuritis  are  exceptional  sequels. 

2.  The  VAScrLAH  System. — Circulatory  changes  are  more  rare.  The 
heart  muscle  may  soften  and  dilate,  microscopically  revealing  segmenta- 
tion, cloudy  and  fatty  conditions,  coronary  endarteritis  and  myocarditis; 
a  systolic  bruit  may  be  heard  at  the  apex,  with  weak  first  tone  and  tachy- 
cardia, as  in  typhoid.  Aortitis,  pericarditis,  ulcerative  endocarditis  and 
phlebitis  are  infrequent. 

3.  The  Respiratory  Tract. — Edema  of  the  larynx  and  perichondritis 
are  usually  fatal,  for  larjmgeal  anesthesia  promotes  inhalation  pneumonia. 
Bronchitis  is  invariable  in  severe  cases.  Pneumonia,  usually  lobular, 
occurs  in  60  per  cent,  of  fatal  cases;  lobar  pneumonia,  lung  abscess, 
embolism  and  gangrene  are  uncommon. 

4.  The  Digestwe  System. — Glossitis,  retropharyngeal  abscess,  paro- 
titis, noma,  phlegmonous  esophagitis,  and  hemorrhage  in  the  throat 
are  ominous  though  uncommon  complications.  The  early  vomiting 
rarely  persists.  Diarrhea  is  not  common,  but  a  simple  form  is  seen  in 
children  and  a  dysenteric  form  occasionally  in  adults.  Peritonitis,  retro- 
peritoneal cellulitis,  mediastinitis  and  perineal  abscess  are  infrequent. 
The  alimentary  tract,  with  the  exception  of  the  rectum,  is  commonly 
exempt  from  the  eruption.  The  liver  may  suffer  cloudy  or  fatty  change, 
focal  necrosis  or  diffuse  hepatitis.  The  spleen  is  usually  swollen  and 
soft. 

5.  The  Gexito-urixary'  Tract. — Albuminuria  occurs  early  in  25 
per  cent,  of  cases,  during  the  eruption,  suppuration  or  convalescence. 
Nephritis  now  and  then  develops  during  the  fever  or  in  convalescence; 
it  is  often  glomerular.  Pyelitis,  ovaritis  and  vulvar  gangrene  have  been 
observed.  ^Menorrhagia  is  common  in  the  early,  stages  of  onset  or  in 
hemorrhagic  forms,  and  abortion  from  hemorrhagic  endometritis  is  the 
rule  in  pregnant  women.  Orchitis  variolosa  is  very  frequent;  the 
multiple  inflammatory  foci  lie  mostly  in  the  connective  tissue,  but  are 
rarely  suppurative. 

6.  The  Special  Senses. — ^The  eye  is  involved  in  1  per  cent.  Pox 
in  the  conjunctivee  are  rare,  as  are  conjunctivitis,,  keratitis,  irido- 
choroiditis,  metastatic  panophthalmitis,  etc.  Otitis  and  suppurative 
thrombophlebitis  may  occur. 

7.  Locomotor  Syste:m. — ^IMuscular  abscess  and  arthritis  may  occur 
during  desiccation.     Arthritis  is  more  often  suppurative  than  serous. 


254  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

and  is  but  one  feature  of  the  secondary  sepsis.  In  the  bones  there 
are  almost  invariably  hemorrhage  into  the  marrow,  hyperplasia  of  the 
marrow  cells,  and  multiple  foci  of  necrosis  or  non-suppurative  osteo- 
myelitis (in  72  per  cent.,  Chiari). 

8.  Skin. — Decubitus,  erysipelas,  local  or  pyemic  abscesses,  desqua- 
mation, acute  gangrene,  hemorrhages  into  existing  exudates,  and  less 
often  into  the  viscera,  also  occur. 

Diagnosis. — The  diagnosis  of  smallpox  is  usually  easy  when  chill, 
fever,  headache  and  vomiting  occur  after  exposure  to  infection.  Vac- 
cination and  revaccination  scars  must  be  searched  for.  ^Mistakes  in 
the  diagnosis  of  the  first  cases  of  an  epidemic  or  in  abortive  or  purpuric 
cases,  are  often  inevitable.  Hemorrhagic  scarlatina  or  measles  sometimes 
causes  confusion;  in  the  former  the  mucous  membrane  hemorrhages  are 
less  frequent  than  in  smallpox.  The  initial  suggestive  scarlatiniform  erup- 
tion has  been  unduly  emphasized;  the  prodromal  eruptions  plus  purpura 
are  highly  suggestive.  An  acute  onset  and  high  temperature  are  signi- 
ficant, although  acute  onset  and  high  fever  may  occur  in  typhus,  pneu- 
monia, scarlatina  and  influenza;  lumbar  and  sacral  pain  is  more  common 
in  smallpox.  Intense  frontal  headache,  severe  backache,  vomiting, 
chill  and  fever  are  sufficient  grounds  for  a  tentative  diagnosis  and  isolation 
but  the  diagnosis  is  uncertain  until  the  eruption  is  seen.  In  the  variola 
sine  exanthemate  (febris  variolosa,  variola  sine  variolois,  varioles  frustes) 
the  diagnosis  must  be  made  from  the  history  of  exposure,  the  presence 
of  an  epidemic,  fever,  pain,  delirium,  possibly  the  initial  rash,  and  the 
absence  of  secondary  fever  because  there  is  no  suppuration.  An  erup- 
tion which  appears  on  the  third  day  of  the  affection,  accompanied  by  a 
fall  of  the  fever  and  euphoria,  is  most  important.  Jenner  described  an 
early  cutaneous  inflammation  in  the  vaccination  site,  in  those  who  are 
immune  to  smallpox;  this  diagnostic  phenomenon  was  later  described 
by  V.  Pirquet  as  allergistic  (see  diphtheria  therapy,  allergy). 

Varicell.\ vs. Variola. 

Vaccination  and  smallpox  do  not  protect.  Smallpox  may  closely  resemble  chicken-pox; 

mild  cases  especially  misleading. 

Age:  usually  before  puberty;    it  may  occur  Usually    after    puberty    (numerous    excep- 

in  adults.  tions). 

An  initial  stage  is  practically  absent.  It  is  severe,  even  in  mild  cases. 

Temperature:    no   remission   -ndth    onset   of  Typical   remission    and    a   secondary   fever 

rash.    White  cells  normal  or  decreased.  (except  in  varioloid) .  Leukocytosis  (mono- 
nucleosis) . 

Prodromal  rash:  very  exceptional.  Frequent  (10  to  16  per  cent.). 

Vesicles  and  roseolse  simultaneously  and  in  Never  in  crops;    first  macules,   then  hard, 

crops;  very  rarelj' shotty.  shotty  papules,  vesicles,  etc. 

Rash  evolution:  much  more  rapid;    vesicles  Much  slower;    vesiculation  on  the  seventh 

on  the  first  or  second  day.  day  (see  Pfeiffer's  table). 

Eruption    is    universal;     successive    crops;  Development    progresses    downward — face 

most    abundant    and    characteristic    on  first,  then  hands  and  feet;   less  on  trunk. 

back;     begins    on    body;     less    on    face, 

scalp,  mucosse,  hands  and  feet. 

The  vesicle  is  superficial,  and  the  fluid  trans-  The  fluid  is  pearl-colored,  not  transparent, 

parent.     (Wyss  observed  confluent  erup-  and  has  a  thicker  covering. 

tion  and  umbilication) . 

Areola  (halo)  is  usually  absent.  Marked. 

Involution  is  rapid.  Tardy. 


SMALLPOX— VACCINATION  255 

IMistakes  may  be  made  even  by  smallpox  experts,  but  attention  to 
the  history,  somatic  findings  and  course,  rather  than  to  the  eruption, 
prevents  many  disastrous  results. 

Measles vs. Variola. 

Both  present  the  same  prodromal  duration;  in  each  the  eruption  begins  on  the  face; 
according  to  some  observers,  simultaneously  on  face  and  trunk. 

Age:  eminently  a  childhood  affection.  Chiefly  in  adults. 

Catarrhal  stage  characteristic.  Catarrh,  if  any,  rudimentary. 

Fever:  present  in  catarrhal  stage,   but  low       High    before    eruption    and    falls    with    the 

before  exanthem,  and  rises  with  its  ap-  exanthem  even  in  severe  cases. 

pearance. 
Kophk's  spots  on  buccal  mucosa;     bluish-       Absent.     Early  papular  eruption  on  palate, 

white  surrounded  by  red.  etc. 

Eruption  later  with  rise  of  fever.  Possibly    an    initial    morbilliform    eruption 

with  the  primary  fever. 
Papules  "grouped,"  crescentic.  Never  so. 

Papules    remain     relatively    flat,     smooth,        Change  into  vesicles,  pustules,  crusts,  scars; 

velvety.  hard  and  shotty. 

Grisolle's  sign  absent  and  the  eruption  dis-       Grisolle's  sign  present;    i.  e.,  persistence  of 

appears  under  pressure.  the   smallpox   papule   on   stretching   the 

skin,    distinguishing    it    from    scarlatina, 
varicella,  etc. 
Areola  (halo)  absent.  "Halo"  present. 

Scarlatina — vs.' Variola. 

Rash   on    the    second    day,    angina,    straw-  Rash    later;      slow    evolution    of    different 

berry     tongue,      desquamation,      glands,  phases.       No     angina;       no     strawberry 

nephritis,   etc.      (See   cardinal   symptoms  tongue;     the   initial   scarlatinal    eruption 

of  scarlet  fever.)  is  not  punctate  and  less  bright. 

No  double  elevation  of  fever  curve.  Double  summit  to  curve. 

In  drug  rashes  (copaiba,  etc.),  the  pustules  occur  largely  on  the  face, 
head,  arms  and  forearms.  In  syphilis  the  chancre,  glands,  polymorphic 
rash,  and  the  moderate  fever,  are  easily  distinctive. 

The  lumbago  form  of  acute  nephritis,  acute  myelitis  or  erythema, 
septicemic  rashes  and  acne  only  superficially  resemble  variola. 

Glanders  may  cause  more  hesitation  in  diagnosis.  Its  features  are 
pyrexia,  pains,  papules,  pustules,  nasal  discharge,  the  bacteriological 
findings,  and  general  symptoms  severer  than  the  skin  eruption. 

Prognosis. — The  prognosis  depends  on  (a)  previous  vaccination,  the 
disease  being  fatal  in  50  per  cent,  of  those  unprotected  by  vaccination. 
Smallpox  is  rarely  fatal  in  persons  vaccinated  within  five  or  six  years; 
only  8  per  cent,  of  those  vaccinated  once  die,  and  only  4  per  cent,  of  those 
vaccinated  twice,  (b)  On  the  genus  epidemicus:  In  the  last  American 
epidemic  the  death-rate  was  but  1.6  per  cent,  (c)  On  the  type,  being 
practically  100  per  cent,  in  purpura  variolosa;  nearly  100  per  cent, 
in  variola  pustulosa  hemorrhagica;  60  per  cent,  in  variola  confluens — 
especially  fatal  in  the  first  decade  of  life;  25  per  cent,  in  variola 
discreta  —  particularly  dangerous  in  those  over  fifty  or  under  ten 
years,  in  pregnancy,  the  puerperium,  in  weakly  and  alcoholic  subjects; 
1  per  cent,  in  varioloid;  recovery  usual  in  variola  sine  exanthemate. 
(d)  On  individual  symptoms:  (i)  Incubation  is  short  in  unfavorable 
forms,  especially  in  purpura  variolosa,  (ii)  Initial  symptoms  are  mild, 
chiefly  in  varioloid,  but  may  be  severe  in  both  the  benignant  and  malignant 


256  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

forms,  (iii)  The  initial  rash  is  usually  a  partial  erythema  in  mild  forms 
of  smallpox;  in  general,  morbilliform  eruptions  occur  in  varioloid. 
Scarlatiniform  eruptions  occur  in  rather  severe  forms  and  a  universal 
scarlatinal  hemorrhagic  eruption,  especially  in  the  groins,  occurs  par- 
ticularly in  purpuric  types,  (iv)  The  danger  is  proportionate  to  the 
amount  of  the  eruption  on  the  face  and  hands.  A  slow,  typical  exanthem 
indicates  variola  discreta,  and  a  precipitate  atypical  eruption  presages 
variola  confluens.  (v)  A  prompt  fall  in  temperature  after  the  eruption 
is  favorable.  A  slow,  colnplete  fall  occurs  chiefly  in  the  severe  forms. 
Accession  of  fever  after  pustulation  is  ominous.  Hyperpyrexia  or  tem- 
perature collapse  during  suppuration  is  a  sign  of  imminent  death,  (vi)  In 
the  stage  of  suppuration  the  danger  parallels  the  height  of  the  fever  and 
the  amount  of  efflorescence.    Enlargement  of  the  spleen  is  ominous. 

Treatment. — 1.  Prophylactic  Vaccination. — Vaccinia. — Protection 
by  cow-pox  vaccination  was  discovered  by  Jenner,  who  published  his 
results  in  1796,  although  certain  of  his  evidence  twenty  years  earlier;  the 
idea  had  been  long  prevalent  among  farmers  that  cow-pox  afforded 
immunity  to  smallpox.  Professor  Waterhouse,  of  Harvard,  in  1800, 
introduced  vaccination  into  this  country. 

The  nature  of  cow-pox  or  vaccinia  is  still  disputed.  It  is  probable  that 
cow-pox  and  horse-pox  are  human  smallpox  modified  by  transmission 
through  animals.  Variola  inoculated  in  the  cow  produces  typical  vaccinia. 
The  other  view  is  based  upon  Chauveau's  experiments,  which  conclude 
that  the  two  affections  are  distinct.  The  bacteriology  of  vaccinia  is 
also  uncertain;  micrococci,  bacilli  and  amebse  (Guarnieri's  cytorrhyctes 
vaccinicB)  have  been  found. 

Usual  Symjptovis. — During  the  incubation  period  of  three  days,  there 
may  be  slight  local  traumatic  reaction.  On  the  third  day  a  hard  papule 
develops,  surrounded  by  a  delicate  halo.  The  papule  enlarges,  and  on  the 
fifth  (or  sixth)  day  shows  Jenner' s  vesicle  filled  with  clear  serum  and  umbili- 
cated  in  its  centre.  In  the  indurated  and  painful  skin  around  it  the  magni- 
fying lens  shows  many  minute  vesicles  by  the  eighth  day.  By  the  tenth  day 
the  vesicle  becomes  purulent  and  the  surrounding  tissues  hard  and  painful. 
By  the  eleventh  day  a  small  central  crust  appears,  which,  by  the  end  of 
the  second  week,  covers  the  entire  vesicle,  when  the  adjacent  cellulitis 
regresses.  In  one  or  two  weeks  the  ulceration,  decrustation  and  granula- 
tion are  usually  complete,  and  a  scar  or  pit  remains,  which  pales  with 
time.  Constitutional  reaction  is  greatest  in  children.  The  fever  in  most 
cases  appears  on  the  fifth  day,  and  lasts  a  few  days,  with  leukocytosis, 
restlessness,  headache  or  backache.  Swelling,  depending  on  the  site  of 
inoculation,  occurs  in  the  axillary  or  inguinal  glands.  School  physicians 
should  not  accept  certificates  of  recent  vaccination  but  should  watch 
the  evolution  of  the  vaccination. 

Unusual  Symptoms. — The  vesicles  may  run  a  course  shorter  by  half 
than  the  usual  one,  or  the  eruption  may  be  tardy  and  atypical.  In  both 
instances  revaccination  is  indicated. 

Complications. — (1)  Erythema,  urticaria,  roseolse  or  erysipelas  (third 
to  eighth  day);  in  Germany,  in  1895,  two  deaths  (from  erysipelas) 
occurred  in  two  and  a  half  million  vaccinations.    To  offset  this  theo- 


SMALLPOX— VACCINATION  257 

retical  risk  there  is  the  almost  universal  susceptibility  to  smallpox  in 
all  unvaccinated  individuals.  (2)  Accessory  vaccinia  near  the  original 
inoculation;  or  generalized  vaccinia,  on  the  trunk  and  extremities;  vesicles 
sometimes  continue  to  develop  for  over  a  month,  and  in  weakly  subjects 
are  very  exceptionally  fatal.  (3)  Secondary  infection  in  the  first  week 
or  two,  either  local  (deep  ulceration,  gangrene,  lymphangitis  or  lym- 
phadenitis), or  systemic  (sepsis,  pericarditis,  meningitis  and  parotitis). 
In  95  reports,  McFarland  (1903)  collected  68  certain  cases  of  tetanus. 
Albuminuria  is  infrequent.  (4)  Later  infections:  Tuberculosis  is  prob- 
ably never  inoculated;  it  can  be  prevented  by  the  Belgian  method  of  not 
using  the  lymph  until  the  animal  has  been  killed  and  found  healthy. 
In  some  cases  a  latent  tuberculosis  in  the  patient  may  be  awakened  by 
vaccination,  which  seems  to  act  like  tuberculin.  There  was  danger 
of  inoculating  syphilis  when  human  virus  was  used;  in  fifteen  days  a 
chancre,  and  in  eight  weeks  more  the  secondaries  appeared.  Syphilis  may 
be  inoculated  accidentally  and  also  intentionally,  as  in  the  oft-cited 
case  of  Dr.  Cory.  In  exceptional  cases,  latent  syphilis  may  be  aroused 
by  vaccination.  There  are  no  clear  cases  of  inoculation  of  leprosy. 
Howard  found  the  ray  fungus  24  times. 

Age. — Children  should  be  vaccinated  in  the  third  or  fourth  month, 
but  never  later  than  the  first  year. 

Technique. — ^The  arm  or  leg  should  be  washed,  but  no  antiseptics 
should  be  employed,  lest  they  neutralize  the  virus.  A  fold  of  skin  is 
raised  and  rubbed  with  sterile  gauze  or  scraped  with  a  knife  held  almost 
parallel  to  the  skin,  until  the  epidermis  is  removed  and  slight  oozing 
of  lymph  appears.  The  virus  must  reach  the  lymph  stream,  and  therefore 
blood  should  not  be  drawn,  as  coagulation  somewhat  inhibits  "taking." 
The  vaccine  should  be  slowly  rubbed  over  and  into  the  abraded  skin. 
Only  after  the  virus  has  thoroughly  dried  should  the  spot  be  covered  with 
a  sterile  dressing  or  cloth  held  in  place  by  adhesive  plaster.  Boric, 
carbolic  or  bichloride  gauze  must  not  be  used. 

Lymph. — Vaccinia  virus  is  harmless  if  it  is  collected  in  the  vesicular 
and  not  in  the  pustular  stage,  and  preserved  in  sealed  sterile  tubes  with 
three  parts  of  glycerin.  This  obviates  pyogenic  infection,  preserves  the 
virus  four  months,  and  is  more  economical.  Human  virus  must  be 
taken  from  a  perfectly  sound  child,  carefully  examined  for  tuberculosis 
and  syphilis,  and  taken  on  the  seventh  day  from  the  clear,  unbroken 
vaccinia  vesicle,  which  must  be  free  from  pus ;  no  blood  should  be  with- 
drawn. 

Results. — The  successful  vaccination,  accompanied  by  typical  papula- 
tion, vesiculation,  pustulation,  crustation,  cicatrization,  and  by  local 
and  often  general  reaction,  confers  immunity  in  almost  all  cases.  Vac- 
cination is  the  greatest  triumph  of  prophylaxis.  The  nature  of  the 
immunity  conferred  is  still  disputed,  but,  unlike  the  immunity  of  diph- 
theria, it  is  probably  due  to  actual  tissue  change.  Vaccination  imme- 
diately after  exposure  is  thought  to  prevent  or  modify  an  impending 
attack.  Partial  immunity  is  evidenced  by  varioloid  (smallpox  mitigated 
by  vaccination).  Immunity  is  not  life-long,  as  Jenner  thought,  nor  is  it 
absolute.  In  some  few  cases,  the  individual  is  permanently  protected  by 
17 


258  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

one  vaccination,  but  protection  lasts  on  an  average  ten  years,  after  which 
60  (to  90)  per  cent,  can  be  successfully  revaccinated  once  or  twice.  Con- 
versely, the  child  should  be  revaccinated  in  his  tenth  to  twelfth  year,  and  if 
the  vaccination  does  not  "take,"  it  should  be  repeated.  The  reaction,  fever, 
induration,  and  size  of  the  vesicle  and  scar,  are  less  in  revaccination.  As 
immunity  is  more  enduring  when  more  than  one  inoculation  has  been 
made,  the  Germans  vaccinate  two  areas  or  even  four  or  six.  The  general 
beneficence  of  vaccination  needs  no  multiplied  statistics.  There  has  been 
no  epidemic  of  smallpox  in  Germany  since  1875.  Epidemics  prevail  in 
communities  which  are  least  protected,  and  conversely,  they  disappear 
with  systematic  compulsory  vaccination. 

2.  Other  Methods  of  Prophylaxis. — Isolation  hospitals  and 
stations  are  indispensable.  Isolation  is  necessary  from  the  invasion 
until  disappearance  of  the  last  crust.  The  dead  body  is  dangerous  and 
the  funeral  must  not  be  public.  The  clothes  used  by  the  patient  must 
be  steamed,  and  other  articles  must  be  washed  with  bichloride  of  mercury 
and  fumigated  with  formaldehyde  vapor;  Schoch's  method  has  the 
advantages  of  requiring  no  special  form  of  apparatus,  of  cheapness,  and 
freedom  from  danger  of  fire.^  Disinfection  of  the  face,  hands,  beard  and 
hair  of  attendants  by  bichloride  solution  is  imperative.  The  family 
should  be  isolated  for  sixteen  to  twenty  days. 

3.  Actual  Treatment. — ^There  is  no  specific  treatment.  The  hygiene 
and  dietary  are  the  same  as  in  typhoid.  For  headache,  the  ice-bag, 
opium  and  hydrotherapy  are  employed.  Pain  is  relieved  by  opiates. 
The  initial  vomiting  is  difficult  to  overcome,  but  its  duration  is  fortunately 
short.  Ice-pills,  lime-water,  iodine,  chloroform,  morphine,  carbolic  acid 
and  bismuth  may  be  used  as  in  typhoid  (g.  v.);  mustard  plasters  may 
necrose  the  skin. 

Early  hydrotherapy  is  important  in  fever.  It  lessens  the  derma- 
titis; when  the  rash  develops,  baths  are  contra-indicated. 

Delirium  may  be  relieved  by  hydrotherapy,  by  chloral,  bromides 
and  hyoscine.  Morphine,  in  half-grain  doses,  is  invaluable  to  lessen 
itching  and  pain  and  conserve  metabolism.  The  patient,  if  delirious, 
may  escape  or  injure  himself.  A  classmate  of  the  author  killed  himself 
by  jumping  through  a  window.  Patients  should  never  be  confined  by 
straps,  lest  serious  skin  necrosis  ensue. 

The  eruytion  may  be  pricked  and  cauterized  with  silver  nitrate,  treated 
with  bichloride  or  boric  compresses  or  covered  with  mercurial  plaster; 
1  per  cent,  carbolic  vaseline  is  the  best,  because  it  counteracts  the 
particularly  offensive  odor,  but  should  be  used  on  the  face  only,  since 
general  use  may  cause  carbolic  poisoning.  These  measures  do  not  prevent 
cicatrix  formation,  but  relieve  dermatitis  and  itching.     Protecting  the 

1  The  following  are  required:  Good  quicklime  in  lumps,  commercial  sulphuric  acid  and 
ordinary  40  per  cent,  formaldehyde  solution.  For  every  1000  cubic  feet  of  space,  the  size 
of  the  average  room,  one  pound  of  commercial  formaldehyde  (40  per  cent.),  one-half  pound 
of  sulphuric  acid  and  three  pounds  of  quicklime  are  required.  The  acid  and  the  formalde- 
hyde are  first  mixed  in  an  earthenware  vessel  by  pouring  the  acid  into  the  formaldehyde. 
Then  the  lime  is  placed  in  a  shallow  vessel  in  the  centre  of  the  room.  All  openings  to  the 
room  are  carefully  closed,  the  mixture  is  poured  on  the  quicklime,  and  the  operator  leaves 
the  room.     The  rooms  should  remain  closed  for  from  five  to  eight  hours. 


CHICKEN-POX  259 

face  from  the  light  with  wet  compresses  seems  to  lessen  the  pitting. 
The  crusts  should  be  kept  soft  with  olive  oil.  The  hair  should  be  cut 
short  and  the  eyes  douched  frequently  with  boric  acid  solution.  The 
mouth,  lanaix,  circulation,  skin  and  diarrhea  should  be  treated  as  in 
typhoid  fever. 

For  sepsis,  quinine  (v.  sepsis)  and  alcohol  (v.  typhoid)  are  given  by 
the  rectum,  since  dysphagia  is  always  present.  Egg-nog  properly  prepared 
will  not  irritate  the  throat.  During  convalescence  the  crusts  should  be 
carefully  washed,  and  the  patient  may  be  considered  safe  only  when  the 
skin  is  clear  of  the  last  scab. 

CHICKEN-POX    (VARICELLA). 

Definition.— An  acute  specific  febrile  contagious  disease,  chiefly  of 
childhood,  characterized  by  an  exanthem  of  vesicles. 

History. — Varicella  was  recognized  by  Ingrassias  in  1553,  Heberden 
in  1767,  and  by  Trousseau,  as  a  disease  distinct  from  smallpox. 

Etiology. — It  is  transferable  by  direct  inoculation,  personal  contact, 
by  the  air  or  by  a  third  person.  It  is  infective  while  crusts  remain. 
Epidemics  of  varicella  may  coincide  with,  precede,  or  follow,  smallpox. 
Smallpox  does  not  prevent  an  attack  of  varicella  nor  is  the  converse 
true.  The  disease  occurs  chiefly  in  epidemics.  It  occurs  chiefly  in  the 
first  year  of  life,  or,  according  to  others,  66  per  cent,  of  cases  occur  under 
the  sixth  year.  The  actual  cause  is  not  determined.  Guttmann  described 
a  staphylococcus;  and  Pfeiffer  and  Guinon,  a  protozoon. 

Symptomatology. — 1.  Incubation. — This  stage,  like  that  of  measles, 
lasts  thirteen  or  fourteen  days. 

2.  Stage  of  Prodromes. — Prodromal  symptoms  are  rare,  or  they 
last  but  twenty-four  hours.  Severe  intoxication  is  rare,  but  the  follow- 
ing have  been  observed:  delirium,  convulsions,  vomiting,  hj^Derthermia, 
angina,  conjunctivitis,  dysphagia,  muscle  pains,  bloody  vomiting  and 
stools,  and  an  initial  erythema  (usually  scarlatiniform,  rarely  morbilli- 
form, in  the  fifteen  cases  recorded). 

3.  Stage  of  Eruption. — The  exanthem  appears  usually  in  one  day, 
as  red  macules  or  papules,  comparable  to  the  typhoid  roseolse,  slightly 
elevated,  disappearing  on  pressure,  lenticular  and  becoming  vesicular. 
The  vesicles  mature  within  a  day,  are  very  superficial,  and  do  not  occupy 
the  Avhole  roseola,  but  leave  a  slight  areola  about  them,  which  is  not 
inflammatory  as  in  smallpox.  In  some  cases  the  areola  may  be  absent, 
the  eruption  appearing  like  drops  of  water  sprinkled  on  the  skin.  Though 
usually  discrete,  confluent  eruptions  are  described.  The  vesicles  may 
be  few  or  numerous;  Thomas  counted  800  in  one  case.  The  eruption 
is  mostly  elliptical  or  circular.  The  vesicles  may  be  very  large,  and, 
in  exceptional  cases,  resemble  pemphigus. 

There  is  no  point  of  predilection  for  the  eruption,  and  no  part  is  exempt, 
though  most  vesicles  appear  on  the  trunk,  fewer  on  the  face,  arms  and 
legs,  and  the  least  number  upon  the  hands  and  feet. 

The  vesicle,  clear  at  first,  becomes  turbid  within  two  days.  Pustula- 
tion  and  hemorrhage  into  the  vesicle  rarely  occur.    The  vesicle  may  con- 


260  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

tain  air.  Umbilication  is  rare;  crusts  may  simulate  umbilication.  The 
vesicles  of  varicella  are  not  always  unilocular. 

Occurrence  in  crops  is  frequent,  when  the  skin  shows  simultaneously 
macules,  vesicles  and  crusts.  Yellowish-brown  crusts  form  on  the 
third  and  fourth  days  and  gradually  disappear.  Distinct  scars  may 
result  from  scratching  or  infection,  and  a  few  cicatrices  are  usual  in 
every  case  of  varicella,  but  they  are  smooth,  white  and  some  disappear 
with  time. 

Enanthems  are  not  frequent;  vesicles  may  easily  be  overlooked  on 
the  palate;  breaking  down,  they  resemble  aphthse.  On  rare  occasions 
they  are  seen  on  the  tongue,  larynx,  prepuce  or  labia. 

Fever. — The  fever  is  slight,  atypical  and  not  parallel  to  the  eruption. 
Fever  as  high  as  106.8°  is  recorded.  It  is  very  rare  in  the  prodromal 
stage,  but  may  occur  with  profuse  eruptions,  or  with  successive  crops; 
its  persistence  suggests  complications. 

General  Symptoms, — These  sometimes  include  dysphagia,  cervical  and 
submaxillary  swellings,  tracheitis,  bronchitis  or  albuminuria. 

The  entire  course  of  an  uncomplicated  case  lasts  one  or  two  weeks. 

Complications  and  Sequels. — These  are  usually  dismissed  with  a  few 
words.  Nephritis  is  generally  tubular,  and  occurs  within  two  weeks 
after  the  rash  declines.  Though  usually  mild,  fatal  cases  have  been 
reported,  as  well  as  some  eventuating  in  chronic  nephritis,  cardiac  hyper- 
trophy and  uremia.  Gangrene  of  the  extremities,  scrotum  or  eyelids 
has  been  noted  in  delicate  or  tuberculous  children.  Infrequent  complica- 
tions are  pleurisy,  pneumonia,  miliary  tuberculosis,  erysipelas,  glandular 
swelling,  pemphigus,  hemiplegia,  polyarthritis,  otitis,  neuritis,  etc. 

Diagnosis. — The  diagnosis  is  very  easy  if  the  case  is  seen  early.  Dif- 
ferentiation from  smallpox  (page  254).  In  pemphigus  the  vesicles  are 
larger  and  run  a  slower  course  of  weeks  or  months.  Miliaria  rubra  are 
preceded  by  sweats,  occur  chiefly  on  the  covered  parts,  have  acid  con- 
tents, are  smaller  than  the  varicellous  eruption  and  disappear  more 
rapidly.  Sometimes  consideration  must  be  given  to  molluscum  con- 
tagiosum  (soft,  umbilicated  tumors  with  white,  granular  contents); 
prurigo  varicelliformis  (with  crop-like  eruptions  at  longer  intervals); 
eczema  vesiculosum,  which  always  occurs  with  great  itching;  herpes, 
always  appearing  in  groups  and  often  along  nerve  trunks;  varicellse 
syphiliticse,  and  medicinal  rashes  from  cantharides,  bromide,  arsenic 
and  iodide. 

Treatment, — Active  treatment  is  rarely  indicated,  Kling  reports  success 
from  vaccination, 

SCARLET  FEVER  (SCARLATINA). 

Definition, — A  specific  infective  disease  of  unknown  bacteriology, 
characterized  by  sudden  onset,  fever,  diffuse  exanthem  and  angina. 

History, — It  was  recognized  by  Ingrassias  and  Coyttar  in  the  sixteenth 
century,  but  first  fully  described  and  differentiated  from  measles  by 
Sydenham  (1660).    It  was  introduced  into  America  in  1735, 

Etiology, — The  etiology  is  unknown.  The  virus  of  scarlet  fever  pro- 
duces severe  necrosis,  but  no  suppuration.     Mallory  describes  a  proto- 


SCARLET  FEVER  261 

zoon,  the  Sydaster  scarlatinalis.  The  streptococcus  is  the  most  important 
factor  in  the  production  of  compHcations  and  in  their  mortaHty.  Schleiss- 
ner  found  it  in  the  blood  in  55  per  cent.  It  is  found  in  about  70  per 
cent,  of  the  fatahties,  i.  e.,  it  is  the  cause  of  the  maHgnanc^'  of  the 
disease,  but  not  of  the  disease  itself. 

Susceptihility  is  not  universal — and  only  38  per  cent,  of  children  and 
5  per  cent,  of  adults  exposed  to  infection  acquire  the  disease;  90  per 
cent,  of  cases  occur  under  ten  vears  of  age.  It  is  rare  in  the  first  year 
of  life. 

So-called  ''surgical  and  puerperal  scarlatina,"  noted  in  1864  by  Paget, 
is  in  the  vast  majority  of  cases,  sepsis,  erythema  or  a  drug  rash.  Alice 
Hamilton  (1905)  collected  174  cases  from  the  literature,  and  concluded 
that  these  forms  are  mostly  septic,  or  that  the  scarlatina  is  merely 
accidental. 

The  rnrus  circulates  in  the  blood,  whence  the  possibility  of  fetal 
infection.  It  was  once  held  that  the  virus  was  disseminated  during 
desquamation,  but  oral,  nasal  or  otitic  discharges  probably  perpetuate 
infection,  perhaps  months  after  scaling  is  complete.  In  no  other  disease 
is  the  virus  so  tenacious;  it  may  persist  ten  years  on  clothes,  furniture, 
etc.  Light  are  as  contagious  as  severe  forms.  Inoculations  from  the 
living  subject  have  occurred  and  Leube  acquired  the  disease  by  an 
autopsy  cut.  The  atrium  is  probably  the  throat.  IMonkeys  have  been 
inoculated. 

As  to  the  degree  of  infectiousness,  smallpox  ranks  first,  measles  second 
and  scarlatina  third.  Infection  may  be  spread  by  servants,  physicians, 
any  third  person,  and  by  means  of  toys,  books,  clothes,  milk  and  schools ; 
the  mode  of  infection  is  often  obscure.  One  attack  usually  confers 
immunity,  but  second,  and  even  third,  attacks  are  known.  Some  indivi- 
duals temporarily  or  permanently  resist  infection.  Scarlet  fever  occurs 
more  often  in  the  autumn  and  winter.  Scarlatina  is  observed  more  in 
the  cities,  and  measles  prevails  more  diffusely  through  the  country. 
Scarlatina  is  more  permanent  than  measles.  When  it  becomes  epidemic 
it  spreads  widely  and  with  increased  mortality. 

Scarlatina  sometimes  occurs  with  other  infections,  such  as  diphtheria 
or  measles,  and  less  often  with  varicella,  pertussis,  etc. 

General  Symptomatology. — 1.  Incubation. — The  incubation,  with  no 
noticeable  symptoms,  lasts  from  two  to  four  davs  (ten  to  fourteen  davs, 
McCollom). 

2.  Invasion. — The  invasion  lasts  one  day.  Symptoms  heghi  suddenly, 
perhaps  with  a  chill,  followed  by  (a)  vomiting,  early  and  characteristic, 
which  occurs  in  scarlatina  more  often  (75  per  cent.)  than  in  other  diseases 
of  childhood  except  pneumonia;  (6)  headache,  convulsions  and  delirium; 
(c)  sudden  elevation  of  temperature,  with  disproportionate  pulse-rate, 
120  to  150,  dry,  burning  skin  and  febrile  urine;  {d)  burning  and  pain 
in  the  throat,  dysphagia  and  intumescence  of  the  cervical  glands. 

3.  ExANTHEM. — ^The  eruption  appears  on  the  second  day,  first  over 
the  clavicles,  upper  trunk  and  neck  and  then  on  the  extremities.  The 
skin  about  the  mouth  is  pale.  The  exanthem  pales  on  pressure.  It  first 
consists  of  small  red  spots  which  fuse  as  the  skin  swells,  and  result  in 


262  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

an  intense  diffuse  lobster-colored  erythema;  it  lasts  four  to  six  days. 
The  tongue  shows  swollen  red  papillae — "strawberry  tongue.''  On  the 
tonsils  and  palate  a  grayish-yellow  coating  and  confluent  spots  appear. 
The  nostrils  slightly  swell,  and  the  conjunctivse  redden.  Some  rales 
over  the  larger  bronchi,  a  slight  cough,  swelling  of  the  cervical  and  other 
glands,  and  sometimes  albuminuria,  may  be  noted. 

4.  Desqu.oiation. — Scaling  begins  first  on  the  face,  from  the  sixth 
to  ninth  daj^  and  lasts  several  weeks.  The  glandular  swelling  disappears, 
the  fever  falls  by  lysis,  and  convalescence  is  established  unless  com- 
plications intervene. 

Special  Symptoms,  Complications  and  Sequels. — 1.  Fevee. — The  fever 
is  less  t}"pical  than  in  smallpox  and  measles.  There  is  an  initial  rapid 
rise  to  104°  or  105°,  with  slight  remissions  and  gradual  subsidence  when 
the  rash  is  mature. 

In  the  most  severe  types  there  may  be  low  fever  or  no  fever  at  all,  or 
it  may  rise  to  107°.  A  close  parallelism  is  generally  noted  between 
the  abundance  of  the  exanthem  and  the  height  of  the  fever.  .  The  tem- 
perature should  be  taken  for  one  month  after  the  rash  disappears,  lest 
such  complications  as  sloughing  of  the  throat,  pleuritis,  endocarditis, 
pericarditis,  synovitis  or  adenitis  be  overlooked. 

2.  Eruption. — Tj^Dically,  it  begins  as  light  red,  pin-head-like  points, 
especially  in  the  axilla  and  groin;  second,  there  are  red  spots  in  a 
diffuse  erythema;  and  lastly,  there  are  red  spots  alone.  This  minute 
ixipidation  is  a  very  important  aid  to  diagnosis  in  the  second  week.  There 
may  be  minimal  white  lines  in  the  eruption,  but  rarely  spaces,  as  there 
are  in  measles.  The  eruption  appears  first  on  the  neck,  below  the  mastoid 
and  clavicles,  then  upon  the  trunk,  arms  and  hands,  and  lastly  legs  and 
feet.  It  is  most  intense  over  the  extensor  surface  of  the  joints  and  on 
the  trunk,  and  is  least  developed  on  the  face  and  scalp.  The  palms  and 
soles  are  usually  free.  The  pallor  around  the  mouth  is  triangular,  bounded 
by  the  nasolabial  folds  above  and  the  chin  below,  and  contrasts  vividly 
with  the  scarlet  cheeks  and  minutely  papulated  forehead.  Though  not 
pathognomonic,  it  is  valuable  in  differentiation,  and  is  due  to  vascular 
spasm.  Herpes  near  the  angles  of  the  mouth  is  very  common.  The 
eruption  is  occasionally  roseolous  about  the  ankles  and  wrists.  The 
skin  is  always  swollen.  The  hyperemic  eruption  pales  on  pressure  and 
disappears  after  death,  unless  there  are  punctate  hemorrhages,^  which 
are  not  uncommon  in  severe  types  of  the  disease.  After  twenty-four 
hours  the  tension  disappears,  and  the  bright  red  color  becomes  a  yellow- 
ish-red. After  complete  florition  desquamation  begins  from  a  slight 
exudation  of  serum  between  the  layers  of  the  skin;  it  is  usually  bran- 
like, as  in  measles,  on  the  head,  face,  neck  and  trunk,  but  is  more  scale- 
like and  lamellar  on  the  hands  and  feet,  complete  casts  of  which  are 
sometimes  shed.  In  severe  cases  even  the  hair  and  nails  are  shed,  or 
the  nails  become  furrowed.     It  begins  on  the  cheek  with  the  "rouge- 

^  The  Rumpel-Leede  phenomenon,  consisting  of  the  production  of  hemorrhages  above 
the  elbow  after  constriction  as  by  a  blood-pressure  arm  band,  is  not  specific;  nor  is  Pastia's 
sign,  the  occurrence  of  two  to  four  small,  dark  red  o  reven  hemorrhagic  lines  on  the  anterior 
surface  of  the  elbows. 


SCARLET  FEVER  203 

and-powder"  appearance,  and  the  skin  may  present  a  "pin-hole"  or 
"worm-eaten"  aspect  before  desquamation  begins.  Its  duration  is 
usually  from  one-half  to  three  weeks.  Scarlatina  levigata  is  the  typical 
rash  described  above.  Anomalies  of  eruption  are  scarlatina  levis  (rudi- 
mentary eruption);  scarlatina  sine  exanthemate  (the  rash  being  absent); 
scarlatina  papulosa  (marked  papulation);  scarlatina  miliaris  (from  sweat- 
ing, and  exudation  between  the  rete  Malpighii  and  epidermis);  scarla- 
tina variegata  (like  measles,  though  not  equally  elevated);  scarlatina 
hemorrhagica  (usually  ominous,  and  at  times  part  of  a  general  hemor- 
rhagic diathesis).    In  general,  irregular  forms  are  dangerous. 

3.  Throat. — The  throat  changes  are  the  iiiost  constant  lesions  in  scarlet 
fever,  and  constitute  the  internal  eruption  (enanthem).  The  disease 
begins  in  the  throat  with  uniform  redness  and  early  swelling.  The 
throat  becomes  speckled  with  fine  red  points  like  the  skin  papulation, 
(a)  In  mild  cases,  a  simple  catarrh  with  little  swelling,  a  thick  mucous 
coating,  and  reddening  of  the  palate  and  tonsils,  develop,  ih)  In  mod- 
erate cases  there  is  more  swelling  of  the  palate,  and  tonsillitis,  (c)  In 
severe  cases,  membrane,  small  abscesses,  gangrene,  minute  hemorrhages, 
sloughing,  edema,  adenitis  or  cellulitis  develop.  Severe  inflammation 
in  the  throat  occurs  in  65  per  cent,  of  cases. 

Clinical  and  anatomical  diphtheria  are  often  confused.  "Necrotic 
inflammation"  in  scarlatina  is  that  caused  by  the  virus  of  scarlatina 
alone.    Genuine  diphtheria  may  accompany  or  follow  scarlatina. 

Diphtheritic  Membrane vs. Scarlatinal  Membrane. 

Firm,  adherent.  Softer,  loosened  in  fragments. 

Yellowish-gray.  Brownish  tint. 

Deep  ulceration  rarer,  in  more  severe  eases  More  frequent  and  earlier  (even  in  twenty- 
only,  and  later.  four  hours). 

Phlegmon  rare.  Not  infrequent. 

Laryngeal  membrane  (croup)  frequent  and  Rare,   membrane  thinner;     lung  complica- 

deeper.  tions  rare. 

Bacteriologically,   the  Klebs-Loeffler  bacil-  Streptococcus  (Klebs-LoefHer  bacillus  only 

lus.  as  a  complication) . 

Paralysis  frequent.  Rare,    except  local  paralysis   due   to  local 

swelling  of  pharynx. 

Recurrence  frequent.  Infrequent. 

4.  Respiratory  Tract. — ^Though  often  unaffected,  the  respiratory 
tract  may  become  involved  secondarily  by  a  descending  process.  The 
nose  is  involved  in  direct  ratio  to  the  severity  of  the  throat  developments, 
such  as  necrosis  or  diphtheria.  Acute  edema  of  the  glottis  is  infreciiient. 
Bronchopneumonia,  acute  lobar  pneumonia  (usually  in  the  upper  lobe 
and  coexisting  with  nephritis),  gangrene,  infarcts  and  hypostasis  are 
not  uncommon.  Pleurisy  occurs  in  5  per  cent,  of  cases.  It  is  likely 
to  be  severe  and  is  frequently  purulent. 

5.  Circulation. — The  heart  is  greatly  damaged  by  the  scarlatinal 
virus  in  35  per  cent,  of  cases,  not  including  the  cases  of  sepsis  and  neph- 
ritis. Endocarditis  is  frequently  mural,  whence  its  frequent  latency", 
but  it  may  result  in  chronic  disease,  especially  of  the  mitral  valves. 
After  rheumatism,  scarlatina  is  the  most  frequent  cause  of  endocarditis. 
Pericarditis  is  usually  septic.     Disquieting  cardiac  dilatation  may  be 


264  •        IXFECTIOXS  OF  DOUBTFUL  ETIOLOGY 

seen  in  severe  cases,  accompanied  by  the  usual  evidences  of  acute  cardiac 
insufficiency;  the  causal  myocarditis  may  occur  during  the  fever  or  in 
convalescence.  The  blood-pressure  is  reduced  25  per  cent.  Tachy- 
cardia may  result  from  toxemia  or  acute  infective  myocarditis.  The 
pulse  is  irregular  in  90  per  cent,  of  cases  and  is  both  weak  and  fast. 
Dilatation  and  hypertrophy  are  much  more  frequent  in  children  than  in 
adults,  and  often  complicate  renal  lesions.  Blood:  Leukocytosis  develops 
early  and  may  become  extreme  in  fatal  cases.  The  average  count  in 
adults  is  10,000  and  in  children  23,000.  The  polymorphonuclears  are 
increased  two  or  three  days  after  the  eruption.  The  eosinophiles  are 
increased.  In  the  polynuclears,  Dohle's  so-called  "inclusion  bodies" 
are  found,  oval,  rod-like  or  sickle-shaped  inclusions,  and  present  up  to  the 
fourth  day;  they  also  occur  in  other  infections.  The  hemoglobin  suffers 
an  early  and  increasing  reduction.  A  hemorrhagic  diathesis  is  generally 
septic. 

6.  Digestive  System. — The  tongue  is  swollen,  indented,  broad  and 
thick.  Its  coating  is  first  grayish,  but  on  the  third  to  fifth  day  disappears, 
leaving  the  tongue  red,  dry  and  glistening,  on  which  the  enlarged  papillae 
appear  granular  and  warty — the  "strawberry"  or  "cat's  tongue."  It 
is  quite  pathognomonic  and  ]\IcCollom  found  it  the  only  constant  sign 
in  1000  cases  of  scarlatina.  Diphtheritic  ulcers  and  secondary  necrosis 
in  the  stomach,  esophagus  and  intestines;  vomiting  from  nephritis  or 
toxemia;  moderate  swelling  of  the  liver  and  spleen  or  abdominal  pain 
may  be  noted.  Constipation  is  usual.  Diarrhea  may  result  from  (a) 
catarrhal  enteritis;  (h)  dysentery,  with  tenesmus  and  blood;  or  (c)  the 
so-called  "scarlet  tj^hoid,"  accompanied  by  tympany,  hemorrhage,  rapid 
pulse,  lethal  outcome,  and  autopsy  findings  of  splenic  intumescence,  and 
hyperplasia  and  ulceration  of  Peyer's  patches. 

7.  Kidneys. — The  urine  is  febrile.  It  often  responds  to  Gerhardt's 
reaction  and  the  diazo  test;  urobilinuria  is  ascribable  to  hepatitis.  Albu- 
minuria occurs  in  75  per  cent,  of  cases.  The  initial  "catarrhal  nephritis" 
is  marked  by  hyperemia,  parenchymatous  changes,  little  interstitial 
involvement,  some  fluid  in  the  glomeruli  and  a  few  cylinders  in  the 
tubules. 

Xephritis  usually  develops  in  the  third  week.  Its  frequency  varies 
with  the  epidemic,  between  5  or  even  90  per  cent.  Xo  relation  exists 
between  its  frequency  and  the  severity  of  the  infection.  Glomerulo- 
nephritis is  the  most  frequent  anatomical  form,  characterized  anatomi- 
cally by  hyperemia,  increased  consistence,  and  such  glomerular  changes 
as  gray  color,  diffuse  fatty  granular  degeneration,  increase  of  nuclei, 
and  increase  in  the  size  of  the  tufts,  which  become  sausage-like,  solid 
masses.  We  also  note  exudation  of  leukocytes  about  the  afferent  vessels, 
multiplication  of  capsular  epithelium  with  occlusion  of  the  lumen,  hyaline 
alteration  of  the  vessels,  and  early  interstitial  changes,  and  later,  con- 
nective-tissue gro\\i:h. 

Clinically  (a)  the  urine  is  decreased  or  suppressed,  heavy  with  sediment 
and  albumin  (averaging  0.5  per  cent.),  poor  in  urea,  turbid  (specific 
gravity  1.030),  and  full  of  casts  of  all  types — especially,  long,  flat,  band- 
like, twisted  and  frayed  casts.    Much  oxalic  and  uric  acid  is  found  and, 


SCARLET  FEVER  265 

in  many  cases,  blood.  Pollakiuria  occurs  in  10  per  cent,  (b)  Hydrops 
shows  the  characters  of  renal  dropsy;  it  appears  first  under  the  skin, 
the  bloodvessels  of  which  are  altered  by  the  virus.  It  shifts  its  location 
without  cause,  and  may  also  produce  hydrothorax,  ascites,  edema  of  the 
larynx,  lungs  or  genitalia.  Rarely  hydrops  occurs  without  nephritis,  and 
kidney  inflammation  without  urinary  alterations.  There  may  be  lumbar 
pain,  vesical  tenesmus  and  (c)  uremic  symptoms,  such  as  headache, 
twitchings,  convulsions,  wide  pupils,  amaurosis,  coma,  vomiting,  diarrhea, 
cardialgia,  rapid  pulse  and  breathing,  and  pale  skin  tinged  with  cyanosis. 
Many  convulsions  usually  imply  a  lethal  termination  in  coma.  The 
prognosis  is  more  favorable  if  the  pupils  are  not  immobile.  Uremia, 
hydrops  and  intercurrent  inflammation  are  always  dangerous.  Recovery 
is  possible  after  one  or  even  three  weeks  of  anuria.  Convalescence  is 
the  rule  after  four  to  six  weeks  and  the  nephritis  rarely  becomes  chronic. 

8.  Special  Senses. — Middle-ear  inflammation  (22  per  cent.)  usually 
begins  before  desquamation,  and  is  accompanied  by  fever  alone  or  with 
pain,  glandular  swelling,  difficult  hearing,  tinnitus,  a  reddened,  glisten- 
ing, sunken  membrane,  and,  in  children,  by  some  brain  manifestations. 
It  is  quite  frequent  in  early  life  and  rare  after  the  fifteenth  year;  at 
least  10  per  cent,  of  cases  of  acquired  deafness  result  from  scarlatina. 
Catarrhal  conjunctivitis,  diphtheritic  inflammation,  herpes  or  necrosis 
of  the  cornea;  panophthalmitis,  muscular  paralysis  and  disturbance  in 
accommodation,  are  possible  complications.  Uremic  amaurosis,  septic 
or  nephritic  neuroretinitis  and  retinal  hemorrhage,  are  rare. 

9.  LyjMPHATIC  System. — The  glands,  spleen,  follicles  and  in  severe 
cases,  all  lymphatic  structures,  are  affected  by  the  sepsis.  McCollom 
found  enlargement  of  the  cervical  glands  in  50  per  cent.,  and  suppuration 
in  8  per  cent.  The  "collar  of  brawn"  results  from  cervical  adenitis  and 
periadenitis.  Gangrene,  retrosternal  abscess  and  jugular  phlebitis  with 
sepsis,  occur  in  desperate  cases. 

10.  Bones  and  Joints. — Scarlatinal  arthritis  (in  6  per  cent.)  usually 
occurs  in  the  second  or  third  week,  wdth  desquamation  and  subsidence 
of  the  fever,  and  lasts  three  or  four  days.  It  attacks  the  smaller  rather 
than  the  larger  joints,  the  wrists  and  ankles  rather  than  the  elbows, 
shoulders  and  knees.  It  is  not  so  migratory  as  ordinary  rheumatism. 
Swelling  of  the  joints  does  not  always  occur.  It  occurs  in  old  rather 
than  in  young  subjects.    The  prognosis  is  usually  good. 

Scarlatinal  sequels  are  anemia,  retarded  development,  decreased  phy- 
siological resistance  and  rarely  tuberculosis.  Latent  sepsis  with  brain 
foci,  valvular  disease,  chronic  nephritis,  chronic  adenitis,  otitis,  mastoid- 
itis, arthritis,  meningitis,  hemiplegia,  facial  paralysis,  etc.,  are  fortu- 
nately rare  complications  and  sequels. 

Diagnosis. — Typical  cases  are  determined  easily  when  an  epidemic 
prevails,  and  when  the  eruption  is  subordinated  to  other  criteria: 

1.  Sudden  onset  and  rapid  development,  with  fever  and  vomiting. 

2.  Angina,  punctate  spots  in  the  throat,  swelling  and  dysphagia  are 
practically  always  present.  Severe  throat  symptoms  are  always  sus- 
picious. 

3.  Strawberry  tongue,  which  is  constant. 


266  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

4.  Exanthem,  first  about  the  clavicles,  with  the  face  less  involved; 
the  mouth  free  and  intense  on  the  body;  papules,  then  erythema  develop; 
there  are  no  free  spaces;  it  results  in  desquamation. 

5.  Lymphadenitis.  In  this  the  cervical  are  less  important  than  the 
inguinal  or  other  glands. 

6.  Fever,  hydrops,  albuminuria  and  nephritis  in  atypical  cases. 

7.  Scaling,  tender  joints  and  albuminuria  help  in  making  a  retrospec- 
tive diagnosis  if  the  initial  symptoms  were  not  clear. 

Diagnosis  of  Atypical  Scarlatina. — 1.  Severe  scarlatina,  (a) 
The  anginose  form  resembles  septic  diphtheria,  with  marked  toxemia, 
necrosis  and  adenitis.  (b)  Atactic  form;  violent  intoxication,  high 
fever  and  death  before  the  eruption  appears;  blood  dissolution,  vomit- 
ing, diarrhea,  convulsions,  coma  and  a  rapid,  weak  heart,  are  the  chief 
symptoms,  (c)  Hemorrhagic  scarlatina,  characterized  by  severe  fever 
and  brain  symptoms  at  the  onset;  incomplete  exanthem,  necrosing 
angina,  marked  glandular  and  splenic  swelling;  subcutaneous,  serous 
and  mucous  membrane  hemorrhages  with  exulceration.  It  is  usually 
lethal  after  ten  to  twenty  hours  from  hyperpyrexia,  vomiting,  diarrhea, 
delirium,  convulsions  and  dyspnea,  especially  in  reduced  subjects  under 
two  years  of  age. 

2.  Very  light  cases  may  present  (a)  all  the  usual  signs,  though  but 
mildly  developed;  or  (6)  some  symptoms  may  be  absent  (scarlatina 
fragmentaria) ,  as  in  cases  with  no  temperature  (scarlatina  sine  febre),  no 
rash  (s.  sine  exanthemate) ,  or  no  angina  (s.  sine  enanthemate) .  In  some 
atypical  cases  a  definite  diagnosis  is  impossible,  as  in  acute  nephritis 
with  uremia,  fever,  sore  throat  and  gastro-enteritis,  without  the  character- 
istic rash.  Recurrence  is  noted  in  0.2  per  cent.;  many  of  these  cases 
are  septic  complications. 

Differentiation. — The  differentiation  is  as  follows: 

Scarlet  Fever ■ — vs. Sepsis. 

Bright    red     erythema,     with     small     red       A    very    deep    purple-red    rash,    sometimes 
papules.  spreading  over  entire  body. 

The  eruption  is  much  the  same  in  both  diseases,  the  same  places  being  exempt. 

Miliaria  are  rare.  Frequent. 

Rather  typical  desquamation.  Desquamation  observed  less  frequently. 

Criteria:  angina,  tongue,  onset,  glands,  etc.       Etiology,   chills,  sweats,  fever  irregularity, 

polymorphous  exanthems,  etc. 

Diphtheria  is  often  differentiated  with  difficulty.  A  simple  erythema 
is  sometimes  observed  in  diphtheria,  which  is  darker,  more  on  the  trunk, 
and  more  transitory  than  in  scarlatina  (v.  s.). 

Drug  rashes,  from  belladonna,  iodoform,  quinine,  iodide,  chloral  or 
copaiba  may  be  easily  difi^erentiated,  if  the  cardinal  signs  of  scarlatina, 
rather  than  its  rash  alone,  are  considered. 

Measles  and  German  measles  (page  273).  Acute  exfoliating  dermatitis 
also  begins  with  fever,  with  a  spreading  erythema,  and  early  desquama- 
tion, but  the  cardinal  criteria  of  scarlatina  are  lacking.  Erythema  is 
more  transitory;  the  points  are  absent;  it  occurs  with  less  fever  and 


SCARLET  FEVER  267 

without  angina  or  adenitis.  Erysipelas  presents  edematous  swellings  a 
sharp  border,  marked  pain  and  a  slow  advance. 

Prognosis. — The  death-rate  depends  on  the  genius  epidemicus  (between 
2  and  40  per  cent.),  but  averages  10  per  cent.  The  prognosis  is  least 
favorable  in  hospital  cases  and  most  deaths  occur  under  six  years;  in 
children  under  five  3'ears  the  mortality  is  25  per  cent.,  and  still  higher 
in  the  first  year  of  life. 

Uremia  accounts  for  50  per  cent.,  and  respiratory  coviplications  for 
20  per  cent,  of  scarlatinal  fatalities;  15  per  cent,  of  nephritic  cases  die. 
The  severity  of  the  infection,  hemorrhagic  forms,  severe  toxemia,  com- 
plicating sepsis,  necrosis  in  the  throat,  otitis  and  heart  complications 
are  the  other  factors  in  prognosis. 

Treatment. — The  disease  runs  its  self-limited  course. 

1.  Prophylaxis. — Isolation  is  imperative  in  all  cases;  indeed,  light  or 
ambulatory  forms  more  often  convey  infection.  Susceptibility  is  not  uni- 
versal and  the  virus  is  less  penetrative  than  in  measles,  wdience  it  is 
possible  to  circumscribe  its  diftusion.  Care  should  be  taken  to  prevent 
transmission  through  schools,  fomites  or  third  persons.  The  infected  room 
should  be  kept  empty  and  exposed  to  the  wind  and  sun  for  one  month 
afterward.  The  physician  should  wear  an  operating  gown  and  carefully 
wash  his  face,  beard  and  hands  after  leaving  the  sick-room.  Quarantine 
should  be  maintained  from  eight  to  ten  weeks,  or  longer  if  discharges 
from  the  nose,  nasopharynx,  or  ears  continue.  All  discharges  should  be 
disinfected.  Formaldehyde  fumigation  has  been  discussed  (page  258). 
Care  in  surgical  and  puerperal  cases  is  important,  but  the  danger  has 
been  overestimated.  Bichloride  wrappings  should  be  placed  about  the 
dead  body,  and  the  funeral  should  be  private. 

Schools  must  be  closed  during  epidemics.  In  hospitals  the  cases  of 
scarlatina  with  streptococcus  infection  are  well  separated  from  cases  of 
simple  scarlatina.  Sound  children  should  be  sent  away  from  the  house 
and  isolated  lest  they  spread  the  disease.  If  they  remain  at  home, 
one-quarter  of  them  will  contract  scarlatina. 

II.  General  Treatment.  1.  Decubitus. — The  prone  position  is  im- 
perative, during  the  disease  and  the  first  two  weeks  of  apyrexia, 

2.  Room. — The  room  should  be  light,  well  ventilated,  dry  and  warm, 
especially  in  convalescence.  A  grate  fire  is  advisable  and  the  windows 
should  be  open  at  the  top. 

3.  Skin. — During  the  fever  the  skin  should  be  covered  with  linen, 
and  in  convalescence  with  wool.  The  eruption  may  be  brought  out, 
when  necessary,  by  mustard  baths.  During  the  fever,  the  patient  is 
washed  daily  with  warm  water  and  soap,  avoiding  unnecessary  exposure. 
The  tension  of  the  skin  is  thus  lessened,  the  fever  decreased  and  toxemic 
symptoms  allayed.  During  desquamation,  oil-rubs  were  once  employed 
to  decrease  the  dissemination  of  dry  scales,  but  they  decrease  the  func- 
tions of  the  skin,  which  are  of  great  importance  when  the  kidneys  are 
involved;  also,  infection  is  carried  by  means  of  throat  secretions.  Soap 
and  warm  water  serve  equally  well.  The  author  is  opposed  to  antiseptic 
soaps  because  of  the  chance  of  renal  injury. 


268  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

4.  Fever. — The  following  fever  formula  is  harmless: 

I^ — Liquoris  ammonii  acetatis giss 

Tincturse  aconiti lUxxiv 

AquEe q.  s.  ad.      §vj 

Fac  misturam  et  signa. 

One  to  three  teaspoonfuls  every  four  or  five  hours,  according  to  age. 

This  mixture  tranquilizes,  promotes  the  rash  and  allays  fever.  Hydro- 
therapy is  useful,  such  as  the  warm  sponge  or  full  warm  bath,  not  the 
full  cold  bath.  Special  care  is  indicated  in  adynamic  cases,  because  of 
danger  of  heart-failure,  in  pericarditis,  stenosis  of  the  air  passages  or 
dyspnea,  in  hemorrhagic  forms  and  nephritis. 

5.  Diet. — Water  should  be  given  freely.  A  fluid  diet  is  indicated  by 
the  fever,  the  renal  complications  and  the  dysphagia.  Concentrated 
foods,  milk,  soups  and  jellies,  and  in  defervescence,  milk-toast,  custard, 
puddings,  bread  and  butter  may  be  given.  Eggs  and  meats  should  be 
avoided.  In  severe  throat  complications,  rectal  feeding  is  indicated.  (See 
Gastric  Ulcer.) 

6.  Arthritis. — The  A-B-C  liniment  (aconite,  belladonna  and  chloro- 
form), warm  wool  and  flannel  bandages  are  helpful. 

I^— Tr.  opii 3iij 

Phenolis 3J 

Tr.  belladonnse 3iij 

01.  oKvae 3iv 

M.  et  S. — Apply  on  muslin  covered  by  cotton. 

Salicylates  are  beneficial,  but  unless  given  carefully,  may  injure  the 
kidneys.  If  the  arthritis  is  obstinate  or  purulent,  aspiration  with  all 
surgical  care,  and  even  drainage  may  be  indicated. 

7.  Angina. — Ice  in  the  mouth  and  Dobell's  solution  as  a  nasal  douche 
should  be  given.  Care  should  be  exercised  in  the  use  of  antiseptics, 
lest  children  swallow  them.  A  10  per  cent,  hydrogen  peroxide,  2  per 
cent,  chlorate  of  potash,  or  2  per  cent,  carbolic  gargle  may  be  used; 
formalin  is  too  irritating.     Caustics  are  contra-indicated. 

For  the  nose  the  following  formula  is  excellent: 

I^ — Phenolis 3ss 

Acidi  borici 3ss 

Glycerini 5J 

Tr.  myrrhse §j 

Aquse q.  s.  ad.  §v 

M.  et  S. — -Locally,  in  such  dilution  that  no  irritation  is  felt. 

A  10  per  cent,  nitrate  of  silver  solution  is  used  with  advantage  in  the 
early  stages  of  the  angina.  Coincident  diphtheria  (g.  v.)  is  treated  by 
antitoxin,  and  antistreptococcus  serum  may  be  exhibited  in  streptococcic 
angina. 

8.  Heart. — Cardiac  stimulants  may  be  exhibited  according  to  Rotch's 
dosage  table: 


SCARLET  FEVER 


269 


Age. 


3  months 
6 

9        "     - 
12 

2  years 
3 
4-10        " 
10-12 


Tincture  of 
digitalis. 


T(J-     2 

1(5  4 

^2 
^3 
1-5 
3-8 


Strychnine. 


2  000    1000  grain 

i_ i_ 

1500   oxro 

1 

700     3 


1  per  cent,  solution 
nitroglycerin. 


7*5—50  minim 
1      1        " 


^1 


Atropine. 


-Yis-Bo  gram 


200    100 


9.  Lymph  Glands. — Secondary  infection  is  decreased  by  prophylactic 
care  of  the*  mouth  and  throat.  Ice  is  applied  in  the  beginning  only,  and 
later,  hot  boric  acid  dressings  when  the  blood  and  lymph  streams  stag- 
nate. Iodine  or  ichthyol  salves  and  surgical  intervention  are  indicated 
in  the  order  named. 

10.  Otitis  is  treated  by  copious  boric  irrigations,  given  quite  hot  and 
at  low  pressure,  and  followed  by  equal  parts  of  glycerin  and  laudanum, 
or  5  per  cent,  carbolic  acid.  Leeches  over  the  mastoid  often  relieve  the 
pain.  Examination  of  the  drum  is  difficult  in  children  with  a  small, 
sensitive  meatus.  Early  puncture  under  cocaine  is  much  safer  than 
awaiting  spontaneous  rupture.  After  rupture  a  small  amount  of  boric 
powder  should  be  applied. 

11.  Nephritis  is  treated  (a)  according  to  the  old  prophylactic  rule, 
by  which  all  cases,  severe  or  light,  are  confined  to  bed  for  at  least  four 
weeks,  and  to  the  milk  diet.  Irritants,  like  cantharides,  always  are  to 
be  avoided.  Tepid  baths  lasting  a  quarter  of  an  hour  should  be  given 
daily.  Watch  the  temperature  and  the  urine  in  convalescence.  The 
results  with  urotropin  as  a  prophylactic  are  at  least  suggestive.  (6) 
Treatment  of  established  nephritis.  Hot  baths  increase  the  sweat  and 
flow  of  urine.  They  are  given  twice  daily,  for  half  an  hour,  and  the 
patient  kept  afterward  between  blankets.  Alkaline  diuretics,  such  as 
potas.  acet.  and  p.  citrat.,  may  be  given;  pilocarpine  for  a  child  two 
years  old,  -^  to  2"V  g^-j  and  calomel  as  a  laxative  and  diuretic  must  be 
used  with  great  care.    (See  Treatment  of  Nephritis.) 

IJ — Infusi  digitalis 5v 

Potassii  acetatis 3ss 

Syrupi  simplicis 3ij 

Aquse  destillatjE q.  s.  ad.  gij 

M.  et  S. — One  teaspoonful  everj'  two  hours. 

High  arterial  tension  indicates  nitroglycerin.  For  convulsions,  chloro- 
form, chloral  and  bromides  are  valuable.  For  vomiting,  iodine  is  effi- 
cacious.    Venesection  and  digitalis  are  necessary  in  pulmonary  edema. 


270  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

For  uremia,  two  drops  of  croton  oil  placed  undiluted  on  the  tongue, 
should  produce  free  cartharsis  in  two  hours.  If  not  successful  by  that 
time  it  should  be  repeated.  Pulvis  jalapse  compositus  (gr.  xv  to  5j) 
unloads  the  bowels  in  less  urgent  cases.  Early  evacuation  is  indicated 
in  streptococcic  pleurisy. 

12.  Tonics. — Such  tonics  as  iron,  arsenic  and  cod-liver  oil  are  indi- 
cated in  convalescence.  The  heart  must  be  watched  for  weeks,  because 
the  myocardium  is  often  degenerated.    Salvarsan  is  recommended. 

13.  Serum. — Diphtheria  antitoxin  apparently  benefits  some  scarla- 
tinal infections.  Streptococcic  sera  have  given  no  definite  results. 
Immunization  against  one  variety  of  streptococcus  does  not  produce 
immunity  against  other  varieties.  In  Vienna,  Moser's  serum  has 
apparently  been  efficacious;  the  mortality  was  8  per  cent.,  as  against 
14.5  per  cent,  without  serotherapy. 

MEASLES    (MORBILLI,    RUBEOLA). 

Definition. — An  acute,  highly  infectious  disease,  characterized  by  initial 
coryza,  inflammation  of  the  air  passages,  rapidly  spreading  eruption,  a 
fever-curve  with  a  double  summit,  and  by  toxemia. 

History. — Its  first  clear  description  dates  from  Rhazes  (980-1037  a.d.). 
It  was  widely  epidemic  in  the  eighteenth  century. 

Etiology. — (a)  Susceptibility  is  almost  universal  and  few  individuals 
escape  (14  per  cent.).  One  attack  generally  confers  immunity;  Maiselis 
collected  106  cases  with  a  second  attack;  third  and  fourth  attacks  are 
known.  (6)  Age:  It  is  rare  during  the  first  five  months  of  life,  and 
occurs  most  frequently  after  the  first  year.  It  is  more  common  in  adults 
than  is  scarlet  fever.  In  16,981  cases,  50.4  per  cent,  occurred  in  the  first 
five  years ;  42  per  cent,  between  five  and  ten  years;  5.2  per  cent,  between 
ten  and  twenty  years,  and  2.4  per  cent,  after  twenty  years  of  age. 
(o)  Season:  Measles  occurs  mostly  in  the  winter  and  spring,  (d)  The 
unknown  virus  exists  in  the  blood,  tears,  bronchial  and  nasal  secretions, 
and  in  the  skin  or  scales.  Monkeys  were  successfully  inoculated  by 
Anderson  and  Goldberg,  who  proved  that  the  virus  was  filterable  and 
that  infectivity  was  greatest  during  the  catarrhal  and  eruptive  stages. 
Propagation  occurs  by  personal  contact,  and  the  healthy  carrier  is  a 
most  important  mode  of  infection.  In  the  home  the  disease  usually 
runs  through  the  family.  The  most  frequent  means  of  dissemination 
is  the  school-room.  It  is  more  often  epidemic  than  scarlatina,  especially 
in  the  country.  After  smallpox  in  the  unvaccinated,  measles  is  the 
most  infectious  disease. 

General  Clinical  Course. — The  stages  are:  (1)  Incubation  of  nine 
or  ten  days;  (2)  initial  or  catarrhal  stage  of  three  or  four  days,  with 
fever,  catarrhal  symptoms  and  an  enanthem;  (3)  the  eruptive  stage, 
lasting  four  or  five  days,  with  renewed  fever,  intoxication,  eruption  and 
inflamed  mucosae;  and  (4)  the  desquamative  period. 

1.  Incubation. — The  incubation  lasts  nine  or  ten  to  fourteen  days. 

2.  Catarrhal  Symptoms. — Early  catarrhal  symptoms  are  more  com- 
mon in  measles  than  in  any  other  acute  infection  of  childhood.    Chilly 


MEASLES 


271 


sensations,  malaise  and  frontal  headache  precede  redness  of  the  eyes, 
lachrymation,  photophobia,  coryza  and  sneezing,  pain  in  the  nose, 
throat  and  bronchi,  and  cough,  which  develops  after  one  day.  Examina- 
tion of  the  mouth  reveals  Koplik's  spots  in  90  per  cent,  of  cases,  described 
by  him  in  1886  and  Filatow  in  1885  (Plate  IX).  They  are  found  on 
the  buccal  mucosa  near  the  molars,  on  the  first  day,  as  round,  bluish- 
white  spots,  surrounded  by  a  reddish  areola.  The  initial  fever  reaches 
102°  or  103°,  and  declines  gradually  during  the  third  and  fourth  days. 

3.  Eruption.— The  eruption  begins  on  the  fourth  day  with  papules 
on  the  temples,  cheeks,  forehead,  then  on  the  back,  wrists,  forearms, 
and  on  the  anterior  surface  of  the  body  and  legs,  in  order  of  progression 
as  named;  with  the  appearance  of  the  eruption,  the  fever  again  rises. 
The  eruption  disappears  on  pressure  and  is  palpable  and  superficial. 
There  are  always  islets  of  normal  skin.    The  glands  are  usually  enlarged. 


ll)ay 

TEMP. 

2 

3 

4 

5 

6 

104 

A 

103                 A 

a/ 

v 

10.        /\ 

A 

/ 

\ 

wy^S 

A 

A 

/ 

A 

100 

V 

a/^ 

\a 

99 

V 

f  V 

\ 

INITIAL 
RISE 

FALL 

RISE  WITH 
RASH 

EXTENSION 
OF  RASH 

Fig.  20. — Fever-curve  in  measles. 


All  symptoms  abate  on  the  sixth  day,  by  crisis.  In  severe  cases, 
diarrhea,  toxemia,  bronchiolitis,  pneumonia,  cyanosis  and  asphyxia, 
may  be  observed,  and  death  may  result  from  lung  involvement  or  mixed 
infection. 

4.  Desquamation.— The  skin  pales,  becomes  slightly  pigmented,  and 
fine  scales  form,  with  convalescence  in  eight  or  ten  days. 

Individual  Symptoms  in  Detail.— 1.  Eruption. — It  is  essentially  the 
same  on  the  skin  and  mucosae.  In  the  mouth  the  mucosa  is  red  on  the 
first  day  of  fever,  and  Koplik's  spots  are  found;  on  the  second  day 
redness  is  noted  on  the  tonsils  and  palate.  The  enanthem  may  reach 
the  larynx,  intestines  and  genitalia.  The  skill  eruption  {exanthem)  is 
circumscribed,  and  hyperemic  rather  than  exudative.  It  fades  on  press- 
ure; the  roseolse  may  not  fade  on  pressure  in  the  nodular  form  of  measles. 
The  roseolce  usually  are  discrete,  slightly  elevated,  light  to  dark  red  in 


272  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

color,  round  or  crescentic  in  shape,  and  average  2  to  6  millimeters  in 
diameter.  They  always  leave  islets  of  normal  skin  between  the  indepen- 
dent spots  of  eruption,  even  in  the  most  diffuse  types.  The  eruption 
follows  a  descending  order  and  reaches  the  lower  parts  of  the  body  last. 
When  the  eruption  develops  on  the  body  first,  the  course  is  usually 
anomalous.  Desquamation  follows  the  same  order  as  the  eruption  and 
is  usually  fine.  Scars  never  result.  The  eruption  is  rudimentary  in  those 
who  are  debilitated  by  chronic  diseases,  and  is  exuberant  in  the  healthy. 
The  varieties  are:  (a)  Morbilli  Iceves,  the  usual  form,  with  small 
elevations,  (b)  M.  vesiculosi  sen  miliares.  (c)  M.  papulosi,  the  nodular, 
slightly  "shotty"  induration  is  always  superficial,  (d)  M.  confiuentes 
sen  conferti.  (e)  M,  hemorrhagiccB,  benign  or  malignant  (black,  typhoid 
or  septic  type);  early  hemorrhage  into  the  eruption  is  almost  always 
fatal.  (/)  M.  sine  exanthemate;  sine  enanthemate.  "Recession,"  "strik- 
ing in"  of  the  eruption  usually  denotes  heart-failure. 

2.  The  Fever. — The  curve  begins  suddenly  without  a  chill,  and  falls 
on  the  second  day,  perhaps  to  normal,  usually  rises  again  with  the  erup- 
tion, and  reaches  its  maximum  in  thirty-six  hours,  thus  giving  a  curve 
with  a  double  summit.  It  usually  falls  by  crisis  before  the  eruption  disap- 
pears. The  temperature  is  normal  during  desquamation.  Fever,  after 
the  eruption  begins  to  fade,  indicates  complications.  In  rare  cases 
fever  is  absent. 

3.  The  Respiratory  Tract. —  Nasal  catarrh,  if  obstructive,  is  of 
special  moment  in  sucklings;  50  per  cent,  of  cases  suffer  from  erosions 
of  the  larynx,  16  per  cent,  from  pseudomembranous  laryngitis,  and  15 
per  cent,  from  simple  inflammation.  Bronchial  catarrh  may  reach  the 
smaller  tubules,  usually  late  in  the  disease.  It  produces  a  clear,  stringy, 
viscid  sputum  which  later  may  become  purulent  and  nummular.  The 
bronchial  glands  are  always  swollen.  Atelectasis  may  occasion  indeter- 
minate breathing  and  dulness,  which  decrease  with  change  of  posture 
or  deep  breathing.  Bronchopneumonia  occurs  in  6  to  12  per  cent,  of 
cases  and  is  the  most  frequent  fatal  complication;  patches  of  broncho- 
pneumonia occurring  in  every  fatal  case.  It  differs  from  other  lobular 
pneumonias  in  its  rapid  development,  and  its  greater  tendency  to  pus 
formation,  because  the  measles-catarrh  favors  mixed  infection.  Bron- 
chial breathing  and  other  physical  signs  are  not  always  detected  clinically. 
The  temperature  is  often  no  higher  than  in  bronchitis.  Toxemia  and 
carbon  dioxide  narcosis  accentuate  the  patient's  distress.  Broncho- 
pneumonia is  rapid  in  development,  but  slow  or  sometimes  incomplete 
in  resolution.  It  may  result  in  interstitial  pneumonia,  gangrene  or 
tuberculosis,  which  dreaded  sequel  of  measles  occurs  (a)  as  a  miliary 
invasion,  and  in  the  brain  more  frequently  than  in  the  lungs,  bacilli 
from  old,  caseated  bronchial  glands  being  released  by  solvent  substances 
reaching  them  from  the  lungs  by  way  of  the  lymph  vessels.  (6)  It  also 
occurs  as  a  fresh  tuberculosis  developing  upon  a  bronchopneumonia. 
Croupous  pneumonia  is  as  infrequent  as  pleurisy,  which  is  in  most  cases 
secondary  to  lobular  pneumonic  foci. 

4.  Cardiac  Symptoms. — Accidental  bruits  may  be  heard.  Toxemia 
exceptionally  causes  myocardial  degeneration. 


PLATE    IX 


Fia.  2 


FIO.  8 


The  Pathognomonic  Sign  of  Measles  (Koplik's  Spots). 

Fig.  1. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  showing 
the  isolated  rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  normally  colored 
mucous  membrane. 

Fig.  2. — Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks  and 
lips;  patches  of  pale  pink  interspersed  among  rose-red  patches,  the  latter  showing  numerous 
pale  bluish-white  spots. 

Fig.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles 
spots  completely  coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks. 
The  exanthem  on  the  skin  is  at  this  time  generally  fully  developed. 

Fig.  4. — Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane 
normal  in  hue.    Minute  yellow  points  are  surrounded  by  a  red  area.    Always  discrete. 


MEASLES 


273 


5.  Digestive  Tract.— The  tongue  is  coated.  There  is  thirst,  and 
aphthae  and  stomatitis  may  be  observed.  Diarrhea,  mucus  in  the  stools 
and,  anatomically,  swelling  of  Peyer's  patches,  have  been  described. 
The  liver  is  seldom  swollen. 

6.  Nervous  System. — -Delirium,  coma  or  convulsions  in  rare  cases, 
result  from  severe  toxemia,  though  even  the  delicate  nervous  system  of 
children  is  seldom  involved  in  measles.  Nervous  symptoms  in  protracted 
pneumonia,  may  arouse  suspicion  of  miliary  tuberculosis  or  tuberculous 
meningitis. 

7.  Genito-urinary  Tract. — Acetonuria  and  albuminuria  are  fre- 
quent. Ehrlich's  diazo  reaction  occurs  in  75  to  100  per  cent,  of  cases. 
Nephritis  is  ver}'-  uncommon;  gangrene  of  the  genitalia  has  been  observed. 

Differentiation  from  German  Measles  and  Scarlatina. 


German  measles. 


lucubatioa;  14  to  21  days. 
Prodromes;   absent,    short   or 

light. 
Invasion ;  very  mild. 


Exanthem ;  the  rash  is  the  first 
symptom,  usually  appear- 
ing on  the  first  or  second 
day  on  the  face;  as  small 
red  dots,  rosy  and  brighter 
than  in  measles;  small, 
little  elevated,  and  thick 
about  the  mouth.  They 
do  not  fuse.  Less  crescentic 
than  in  measles. 

Enanthera;  may  be  diffuse 
redness  of  throat  and  con- 
junctivae. 


Glands;  usually  enlarged, 
hard,  tender,  especially 
posterior  cervical,  also 
axillary  and  inguinal. 
Spleen  somewhat  enlarged. 

Constitutional  symptoms; 
few;  no  depression;  no 
leukocytosis;  little  pulse 
increase  and  fever. 


Complications; 
none. 


practically 


Convalescence;  rapid;  des- 
quamation rarely  copious, 
and-iriways  fim;:    •  • 

18  ^ 


Scarlatina. 


2  (1  to  7)  days. 

Brief,  a  few  hours  to  1  or  I5 
days. 

Sudden,  stormy,  vomiting, 
convulsions,  angina,  and 
adenitis. 

Appears  on  first  or  second 
day,  reaching  a  maximum 
on  second  to  fourth  day, 
first  below  clavicles,  in- 
volving face  later;  dusky 
red,  diffuse,  burning,  leav- 
ing mouth  and  eyes  free. 


Angina  proportionate  to 
skin  eruption;  dusky  red; 
tonsillar  plugs;  conjunc- 
tivae, bronchi,  intestines 
usually  intact. 

Proportionate  to  angina, 
hence  largely  cervical. 
Enlarged  spleen. 


Much  depression  with  rash, 
coated  tongue  with  peel- 
ing on  the  fourth  day 
(strawberry  tongue) ;  fever 
105°  to  106°;  pulse  in- 
creased more  than  fever; 
lysis  on  seventh  day ;  poly- 
nuclear  leukocytosis; 
eosinophilia. 

Nephritis,  arthritis,  endo- 
carditis, sepsis,  periaden- 
itis.    Diazo  in  10  per  cent. 

Prolonged ;  tardy ;  desqua- 
mation copious  and  usually 
in  shreds  (hands  and  feet). 


Measles. 


9  to  10  days. 

3  to  4  days,  generally  mark- 
edly catarrhal. 
Catarrhal  symptoms. 


Occurs  on  fourth  day,  great- 
est on  fifth  or  sixth  day 
on  the  face,  forehead,  and 
about  the  mouth;  biick- 
red,  elevated  papules  or 
crescentic  islets  of  erup- 
tion, always  with  areas  of 
healthy  skin  between. 


Koplik's  spots;  patchy  red- 
ness of  throat;  photo- 
phobia; conj-unctivitis, 
marked  bronchitis,  very 
often  bronchopneumonia ; 
diarrhea   in    some    cases. 

Mostly  at  angle  of  jaw; 
rarely  systematic  enlarge- 
ment. No  enlargement 
of  spleen. 

Depression,  coated  tongue, 
anorexia ;  fever-curve  with 
two  elevations;  crisis  on 
seventh  day;  no  leuko- 
cytosis.      No    eosinophilia. 


Catarrhal  pneumonia,  pleu- 
risj',  tuberculosis.  Diazo 
in  75  per  cent. 

Often  prolonged ;  desqua- 
mation rarely  copious  and 
always  fine. 


274  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

8.  Other  Symptoms. — The  spleen  and  lymph  nodes  are  but  slightly 
swollen;  bone  and  joint  complications  and  keratitis  are  infrequent; 
otitis  media  occurs  in  a  small  percentage  of  cases.  There  is  a  relative 
lymphocytosis,  with  an  absolute  leukopenia. 

Diagnosis. — The  diagnosis  depends  upon  the  consideration  of  all  the 
symptoms  (coryza,  cough,  fever,  enanthem)  rather  than  of  the  eruption 
alone.  Differentiation  from  typhus  is  made  by  the  greater  general  dis- 
turbance in  typhus,  its  more  violent  onset  and  the  roseolous  eruption 
becoming  petechial. 

Sepsis  with  a  morbilliform  exanthem,  influenza,  syphilis  and  variola 
{q.  V.)  sometimes  delay  the  early  diagnosis.  In  the  drug  eruptions  of 
turpentine,  iodide,  quinine,  chloral,  cubebs,  copaiba  and  antipyrin,  the 
fever,  Koplik's  spots,  catarrh,  and  central  elevations  in  the  eruption 
are  indicative  of  measles  (see  page  273). 

Prognosis.^ — The  mortality  is  very  great  among  aboriginal  races;  in 
the  Fiji  Islands  140,000  died  out  of  a  population  of  160,000.  The  usual 
prognostics  are:  (a)  The  genus  epidemicus:  The  mortality  may  be  30 
to  37  per  cent,  in  certain  epidemics;  or  as  in  a  German  epidemic  of 
2881  cases,  only  1  per  cent.  (6)  Individual  resistance:  It  is  higher  in 
institutional  practice  and  is  16  per  cent,  in  the  children's  hospitals,  as 
against  3  per  cent,  in  private  practice.  Measles  ranks  third  among  the 
exanthemata  in  mortality,  (c)  Age:  55  per  cent,  of  fatal  cases  occur 
in  the  first  two  years  of  life,  {d)  Complications  are  more  important 
than  the  disease  itself,  e.  g.,  tuberculosis  and  bronchopneumonia,  which 
is  the  worst  complication,  with  a  mortality  of  33  per  cent. 

Treatment. — 1.  Prophylaxis  is  important,  especially  in  weakly  chil- 
dren under  two  years,  in  severe  epidemics  with  pneumonia  and  in  cases 
of  pertussis.  It  is  of  no  advantage  for  the  young  to  contract  measles, 
and  the  prevalent  practise  of  allowing  the  disease  to  run  through  the 
family  must  be  condemned.  The  secretions  from  the  nose,  throat  and 
bronchi  must  be  disinfected,  and  general  sanitary  care  should  be  exercised 
as  in  smallpox  (g.  v.)  and  scarlatina;  quarantine  is  maintained  for  ten 
days  after  the  onset. 

2.  Hygiene. — The  patient  should  have  fresh  air,  warm  quarters,  rest 
in  bed  until  after  desquamation,  and  a  liquid  diet. 

3.  Catarrhal  Symptoms. — Photophobia  does  not  necessitate  a  dark 
room;  a  boric  acid  solution  should  be  dropped  frequently  into  the  eyes 
and  vaseline  applied  to  the  lids.  To  relieve  pain  in  the  ears,  belladonna, 
opium  and  a  1  per  cent,  cocaine  solution  may  be  used;  paracentesis  is 
indicated  for  gathering.  The  nose  should  be  douched  with  Dobell's 
solution.  Tr.  belladonnse,  TTlj-iij,  may  be  given  every  two  hours  for 
coryza  until  flushing  of  the  face,  increase  of  pulse-rate,  or  a  dry  red 
throat  develops. 

4.  Antipyresis. — In  high  fever  with  cerebral  toxemia  and  diffuse 
bronchitis  or  pneumonia,  baths  are  most  efficacious  with  cold  affusions 
to  the  head  and  neck;  wine,  mustard  plasters  and  laxatives  may  also  be 
indicated. 

5.  The  Circulation. — The  heart  rarely  requires  support  except  in 
pneumonia  (g.  v.),  when  camphor,  aromatic  spirits  of  ammonia,  strych- 
nine, or  coffee  is  indicated.    (See  dosage  table,  page  269.) 


RUBELLA  275 

6.  Respiratory  Sy^iptoms. — Care  of  the  mouth,  a  soft  or  hquid  diet, 
inhalations  of  steam,  hot  fomentations  over  the  larynx,  warm  baths 
and  possibly  intubation  or  tracheotomy,  are  indicated  for  laryngeal 
complications.  Bronchitis  should  be  treated  with  ipecac,  codeine, 
inhalations  of  steam,  massive  hot  packs  to  the  chest,  and  cold  aflfusions 
over  the  nape  of  the  neck.    (See  Acute  Broxchitis.) 

7.  Albientary  Tract. — ^Enemata  relieve  constipation.  When  diarrhea 
is  excessive,  opium,  hot  wine  or  cognac,  demulcents,  hot  applications,  and 
physiological  salt  solution  by  rectum,  are  indicated. 

8.  The  Skix. — The  skin  should  be  rubbed  with  olive  oil ;  a  2  per  cent, 
menthol  salve,  or  1  per  cent,  carbolic  solution,  relieves  itching. 

RUBELLA. 

Synonyms. — Rubeola  notha,  German  measles,  Rotheln.  By  the 
Germans  it  is  called  rubeola,  though  we  employ  rubeola  as  synonymous 
with  measles. 

History. — Rubella  was  first  described  by  Bergen  (1752)  and  its  existence 
as  an  independent  infection  was  established  by  ]\Iaton  (1S15).  It  is  more 
often  confused  with  at^'pical  scarlatina  thari  with  atypical  measles. 

Etiology. — Its  etiology  is  not  known.  ]Most  cases  occur  during  the 
first  half  of  the  year.    The  disease  most  frequently  attacks  children. 

Symptoms. — 1.  Ixcubatiox. — The  incubation  lasts  from  ten  to  twelve 
(perhaps  fourteen  to  twenty-one)  days. 

2.  Prodromes. — Prodromes  are  usually  lacking;  for  a  period  of  two 
hours  to  a  day,  there  may  be  cough,  photophobia,  sneezing,  slight  tem- 
perature, chilliness  or  headache. 

3.  Eruptiox. — The  eruption  appears,  as  the  first  symptom  of  the 
disease,  on  the  first  day,  usually  in  the  palate  and  throat,  and  consists 
of  hyperemic  punctate  red  spots  (Forchheimer's  spots) .  The  skin  is  red, 
and  the  spots,  which  are  more  rosy  than  in  measles,  disappear  at  first 
under  pressure,  then  become  darker  and  more  circumscribed;  later,  the 
eruption  does  not  entirely  disappear  under  pressure.  The  eruption  does 
not  fuse  as  in  measles,  and  erythema  is  not  present  about  the  points  of 
eruption  as  in  scarlatina.  It  advances  in  "jumps,"  and  fades  in  one 
place  while  it  blossoms  in  another.  It  appears  first  on  the  scalp  and 
face,  and  progresses  downward  to  the  neck,  body  (where  the  eruption  is 
greatest),  arms  and  lastly  to  the  legs  and  feet.  Unlike  scarlatina,  spots 
are  aggregated  about  the  mouth.  Its  average  duration  is  from  two  to 
four  days.  The  papillse  of  the  tongue  show  slightly  through  the  fur. 
Desquamation  is  minimal  and  fine.  Almost  characteristic  is  the  swelling 
of  the  yosterior  cervical  and  postauriciilar  glands.  There  may  be  some 
angina,  dysphagia,  anorexia,  tracheitis  or,  rarely,  bronchitis. 

4.  Coxstitutioxai.  Syaiptoms. — The  fever  is  usually  slight,  runs 
three  days,  and  falls  when  the  eruption  matures.  Except  in  a  few 
American  epidemics,  urgent  nervous  and  other  complications,  such  as 
icterus,  albuminuria,  nephritis  or  colitis,  have  rarely  been  observed. 

Diagnosis. — ^The  diagnosis  is  often  difficult  and  the  unity  of  the  disease 
is  sometimes  questioned.      The  "fourth  disease,"  of  Dukes  caimot  be 


276  IXFECTIOXS  OF  DOUBTFUL  ETIOLOGY 

admitted  to  our  nosology.  Erythema  infeciiosinn,  emphasized  by  Esche- 
rich,  is  a  weakly  contagious,  maculopapular  erythema,  prevalent  in 
the  spring  and  fall,  and  occurring  chiefly  on  the  extremities,  and  rarely 
on  the  trunk  iv.  page  273). 

Prognosis.- — ^The  prognosis  is  good,  and  therapy  is  symptomatic.  Isola- 
tion is  theoretically  advisable. 

TYPHUS    FEVER. 

Synonyms. — Typhus  fever;  exanthematous  tA"phus;  war,  prison,  ship 
or  famine  fever. 

Definition. — An  acute,  highly  contagious,  specific  infection,  with  a 
sudden  onset  and  a  high  cyclic  temperatiu-e,  falling  by  crisis,  a  character- 
istic eruption,  and  severe  nervous  s^TQptoms. 

Etiology. — All  stages  of  the  disease  are  highly  contagious.  Infection 
is  usually  direct  from  person  to  person.  The  danger  to  attending  nurses 
and  physicians  is  great.  The  more  intimate  the  contact  the  greater  is 
the  danger  of  direct  infection.  It  is  communicable  indirectly  by  a  third 
person,  fomites  and  fleas. 

Xicolle,  Ricketts,  Anderson  and  Goldberger  inoculated  monkeys  and 
noted  that  infection  from  animal  to  animal  occurred  by  the  body  lotise. 
The  bacteriology  of  typhus  is  undetermined. 

Geography. — Ireland,  Russia,  Galatia,  Hungary,  Italy,  Asia  ]\Iinor 
and  !\Iexico  are  its  most  frecjuent  homes.  It  is  endemic  in  Berlin  among 
the  lower  classes  and  vagabonds.  T^'phiis  was  one  of  the  greatest 
scourges  of  the  middle  ages,  with  its  wars  and  famines,  but  it  has  decreased 
in  the  past  century,  the  epidemics  in  Ireland  (1817  and  1S46),  in  the 
Turko-Russian  war  (1877-78)  and  the  present  European  war  being  the 
last  general  outbreaks.  Its  most  recent  occurrence  in  this  country  was  in 
New  York  (1881-82  and  1893  j,  in  Philadelphia  (1883),  and  in  Baltimore 
in  1901. 

Age.  —  ^lost  cases  occur  between  the  fifteenth  and  twenty-fifth 
years. 

General  Clinical  Picture. — 1.  The  incuhation  lasts  twelve  days  or  less, 
usually  withotit  symptoms. 

2.  The  invasion  is  sudden,  exhibiting  chills  and  high  temperature  on 
the  first  day.  Thirst  follows,  with  vomiting,  epigastric  oppression, 
suflusion  of  the  face,  conjunctivse,  nose  and  pharynx,  delirium,  backache, 
severe  pains  inthe  extremities,  rapid  pulse,  and  splenic  inttmiescence. 

3.  On  the  third  or  fifth  day  a  pale  red  and  ptirely  hyperemic  roseolous 
eruption  develops,  first  on  the  abdomen  and  chest,  extending  rapidly  to 
the  back  and  extremities.  The  eruption  then  becomes  petechial,  with 
some  serous  infiltration  in  the  flecks,  which  become  dirty  and  copper- 
colored.  It  lasts  seven  to  ten  days.  Pain  is  succeeded  by  apathy, 
prostration,  delirium  or  mania.  The  tongue  and  mouth  are  dry  and  dark. 
Catarrhal  inflammations  of  the  phanmx,  larynx  and  bronchi  develop, 
with  hoarseness  and  cough.  The  fever  is  contintious.  Coma-vigil, 
rapid  respiration  and  pulse,  and  hypostatic  pneumonia  may  end  the 
course. 


TYPHUS  FEVER  277 

4.  A  crisis  occurs  on  the  tenth  day.  The  pulse  becomes  slower;  the 
skin  often  desquamates  in  dusky  scales;  profuse  sweats  are  common;  and 
convalescence  is  established  in  two  weeks. 

Special  Symptomatology. — 1.  Fever. — After  a  rigor,  the  temperature 
rapidly  rises  to  103°,  105°  or  even  107°,  being  highest  on  the  fifth  day. 
No  other  acute  exanthematous  disease  produces  an  equall}^  high,  early 
temperature.  On  the  tenth  day  it  remits,  except  in  severe  cases,  usually 
with  a  crisis  in  two  or  three  days.  Death  occurs  with  a  preagonal  rise 
or  with  collapse  temperature. 

2.  The  Skin. — The  eruption  consists  of  two  elements:  Roseolse 
changing  to  petechise,  and  a  dusky  red  mottling  under  the  skin.  The 
roseolce  are  seen  on  the  third  or  the  fifth  day,  increase  rapidly  though 
never  in  recurrent  crops,  are  located  chiefly  on  the  lower  abdomen,  chest, 
back  or  shoulders,  are  least  abundant  on  the  thighs,  and  do  not  appear 
on  the  face  except  in  women  and  children  whose  skin  is  delicate.  The 
palms  and  soles  are  exempt.  The  hyperemic  roseolse  are  pale  red,  washed 
in  outline,  round  or  oval,  the  size  of  a  pin-head  or  a  lentil,  and  disappear 
on  pressure.  They  are  easily  overlooked  at  night.  They  last  one  to 
three  days,  later  becoming  livid,  copper-colored  jpetechicB  persisting  on 
pressure  and  after  death,  because  hemorrhagic.  The  petechise  occur 
mostly  on  the  back  or  in  the  groins.  The  hemorrhage  may  extend  more 
widely  into  the  skin  or  subcutaneous  tissue.  Many  petechise  are  ominous, 
especially  in  cachectic  and  alcoholic  subjects.  A  morbilliform  eruption 
on  the  arms  and  legs  is  occasionally  observed  before  the  usual  typhus 
rash,  especially  in  thin-skinned  individuals.  The  skin  is  usually  dry, 
but  miliaria  appear  in  10  per  cent,  of  cases,  notably  in  the  young.  Icterus 
without  decolorization  of  the  stools  is  a  frequent  and  unfavorable  sign. 
Desquamation  is  sometimes  profuse;  herpes  occurs  in  12  and  bed-sores 
in  3  per  cent,  of  cases.  The  skin  has  a  peculiarly  pungent,  offensive 
odor. 

3.  The  Nervous  System. — Toxemia  is  profound.  Headache  is  con- 
stant until  the  exanthem  appears;  it  is  usually  frontal  and  temporal 
and  radiates  into  the  neck  or  shoulders.  It  is  associated  with  vertigo, 
backache  and  hyperesthesia  of  the  fingers  and  toes.  The  sensorium  first 
shows  depression,  apathy,  insomnia,  incoherent  speech  or  disturbing 
dreams,  which  increase  as  the  pains  disappear.  In  the  second  week  coma- 
vigil,  low  delirium,  mania  and  hallucinations,  involuntary  evacuations 
and  noisy  cerebral  respiration  often  develop.  Tremor  of  the  forearms 
and  hands  is  almost  constant.  Convulsions  are  rare,  but  ominous, 
chiefly  in  alcoholic  subjects  and  children.  Paraplegia  and  aphasia  are 
recorded. 

Special  Senses. — There  is  conjunctival  catarrh  and  the  "pin-head 
pupil"  of  Graves.     The  ears  are  involved  in  32  per  cent,  of  cases. 

4.  Circulation. — The  heart  and  vasomotor  system  suffer  greatly. 
The  pulse  is  small  and  reaches  100  to  120,  or  more.  It  is  slow  only  in 
light  cases.  Acute  myocarditis  may  occur  with  acute  dilatation 
(v.  Typhoid).  In  fatal  cases  the  heart  muscle  is  granular  and  deep  red. 
The  l)lood  is  dark  and  fluid;  the  red  cells  and  hemoglobin  are  decreased, 
and  the  white  cells  are  increased. 


278  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

5.  Respiration. — Bronchitis  and  tracheitis  are  present  at  the  onset, 
increase  with  the  fever  and  are  evidenced  by  cough  and  shght  expec- 
toration; and  with  weak  heart  result  in  hypostasis  and  lobular  pneu- 
monia. Pneumonia  occurs  in  15  per  cent,  of  typhus  cases,  usually  in 
the  second  week  and  is  frequently  atypical. 

6.  Gastro-intestinal  Tract. — ^The  tongue,  at  first  moist  and  white, 
becomes  dry  and  dark — the  "parrot  tongue."  Nausea  and  vomiting 
are  common,  but  meteorism  is  infrequent.  The  epigastrium  only  is 
tender.  The  liver  is  swollen,  soft  and  grayish.  There  is  constipation 
in  90  per  cent,  of  cases;  diarrhea  may  appear  at  the  crisis.  Gastro- 
intestinal hemorrhage,  a  hemorrhagic  diathesis,  parotitis,  ulceration  of 
the  esophagus  and  pharynx,  and  phlegmons  are  infrequent. 

7.  Genito-urinary  Tract. — The  urine  is  febrile.  The  urea  is 
increased.  Albumin  frequently  appears  in  the  second  week.  Nephritis 
(in  6  per  cent.)  is  dangerous.  Uremia  and  hematuria  are  rare.  The 
urine  frequently  shows  the  diazo  reaction. 

8.  Spleen  and  Glands. — An  early  splenic  tumor  is  palpable  in  50 
per  cent,  and  disappears  in  the  second  week.  The  splenic  pulp  is  fluid. 
Rupture  has  been  described.  Lymphadenitis  was  noted  during  the 
Crimean  and  Turko-Russian  epidemics. 

Anomalous  Courses. — Light'  forms  run  a  course  of  six  to  ten  days, 
with  less  fever,  fewer  nervous  symptoms,  and  less  rapid  pulse,  and 
include  the  abortive  type  without  eruption,  and  the  ambulatory  type. 
Very  severe  forms  are  the  hyperpyretic  (fatal  in  two  to  three  days),  or 
the  adynamic. 

"Brill's  Disease."  In  1910  W.  E.  Brill,  of  New  York,  described 
a  febrile  affection  characterized  by:  (i)  a  short  incubation  of  4-5  days; 
(ii)  brusque  onset;  (iii)  chills,  intense  headache,  and  a  facies  expressing 
pain  and  apathy;  (iv)  fever,  which  rises  suddenly,  reaching  103-104° 
on  the  third  or  fourth  day  and  continuing  until  the  eleventh  to  fourteenth 
day  when  it  falls  by  crisis ;  (v)  an  eruption,  developing  on  the  sixth  day, 
which  is  maculopapular,  dark  red,  and  does  not  disappear  on  pressure 
nor  appear  in  crops;  and  (vi)  by  negative  Widal  reaction,  blood  cultures 
and  at  autopsy,  by  the  absence  of  typhoid  lesions.  The  pulse  runs 
86-100  and  the  white  cells  average  11,000.  Anderson's  and  Goldberger's 
immunity  experiments  identify  the  disease  with  European  typhus  and 
the  Mexican  type — Tabardillo,  in  investigating  which  Howard  Ricketts 
lost  his  life.  The  Manchurian  typhus  is  mild  like  Brill's  disease,  but 
Tabardillo  is  virulent.  Brill's  type  has  been  found  in  most  of  our  larger 
cities. 

Differentiation. — This  is  not  difficult  if  the  case  is  seen  from  beginning 
to  end,  or  during  an  epidemic.  There  are  no  absolute  pathological  or 
bacteriological  criteria.  Mistakes  in  the  diagnosis  of  sporadic  cases 
are  often  inevitable.  In  the  initial  stage  only  a  probable  diagnosis  can 
be  made. 

In  smallpox  the  initial  scarlatiniform  eruption  in  the  angles  of  the 
arms  and  groins  is  characteristic.  Morbilliform  eruptions  occur  in  both. 
Smallpox  invades  the  face  more  than  does  typhus,  and  the  relation 
of  the  eruption  to  the  temperature  remission  is  not  observed  in  typhus. 


EPIDEMIC  PAROTITIS  279 

Even  at  postmortem  examinations,  differentiation  between  the  hemor- 
rliagic  form  of  typhus  and  purpura  variolosa  is  frequently  impossible. 

Typhus.  Typhoid. 

Invasion:  sudden;    chill,  coryza.  Slower  and  more  gradual;   no  coryza. 

Roseola:  more  numerous  and  earlier,  second  Usually  less  points  of  eruption  (are  excep- 

to  fifth  day.  tions,  e.  g.,  measles-like) ;   on  extremities, 

as  in  Franco-German  war. 

Never  in  crops.  In  successive  crops. 

Distribution  on  body  and  extremities.  On  body;   rarely  on  extremities. 

Sparingly  on  face.  Almost  never  on  face. 

Flat,   pale,   washed,   hyperemic,   not  disap-  Papular,    pink,    sharply    outlined,     always 

pearing  upon  pressure  when  they  become  hyperemic,  disappearing  upon  pressure. 

petechial. 

Course:  more  rapid.  Slower. 

Face  and  eyes  injected.  Paler;  conjunctivitis  rare. 

Fever:  abrupt  rise,   higher,   less  remission.  Slow  rise  and  regular  stages. 

if  any;    shorter;    crisis,  or  short  lysis,  on 

fourteenth  day. 

Soon  bed-ridden.  Oftener  ambulatory. 

Earlier  and  severer  nervous  symptoms.  Second  week  or  later,  and  less  severe. 

Pulse:  rapid  and  not  dicrotic.  Dicrotism  and  slowness. 

Spleen:  early  swelling,  but  less  fiequent.  Later,  but  lasts  longer;    more  frequent. 

Less  meteorism.  Meteorism. 

Stools:  not  characteristic.  Ochre  stools. 

Blood:  leukocytosis.  Leukopenia,    Widal    reaction;     bacteria   in 

blood,  urine,  roseolee. 
Diazo  reaction  in  both. 

Prognosis. — The  prognosis  depends  upon  the  intensity  of  the  toxemia 
and  the  complications — especially  pneumonia.  Death  from  toxemia 
usually  occurs  in  the  second  week;  from  pneumonia  in  the  third  week. 
The  mortality  varies  between  6  and  20  per  cent.,  but  reaches  50  per 
cent,  in  virulent  epidemics  and  in  patients  over  fifty  years  of  age. 

Treatment. — The  treatment  is  that  of  typhoid,  with  the  added  indica- 
tion of  strict  isolation.  Open-air  treatment  in  tents  is  indicated,  with 
thorough  disinfection  of  everything  coming  in  contact  with  the  patient. 
Cardiac  stimulants  are  often  required.  Tr.  iodi,  TTliv,  t.  i.  d.,  appears 
to  be  beneficial. 

EPIDEMIC  PAROTITIS  (MUMPS). 

Definition. — An  acute  specific  infection,  characterized  by'  a  primary 
inflammation  of  the  parotid  glands. 

History. — Hippocrates  described  every  essential  of  mumps,  but  later 
it  was  confused  with  other  parotitides. 

Etiology. — (a)  Its  cause  is  unknown.  (6)  Most  cases  occur  between 
six  and  fifteen  years  of  age;  isolated  cases  are  seen  in  adults,  (c)  Most 
cases  occur  in  the  cold,  moist,  spring  months,  {d)  Contagion  is  more 
frequently  direct — perhaps  before  parotitis  sets  in — from  person  to 
person,  than  indirect,  (e)  It  prevails  largely  in  epidemics.  Immunity 
is  usually  conferred  by  one  attack,  yet  Catrin  observed  recurrence  in 
6  per  cent. 

Symptoms. — After  an  incubation  of  two  or  three  weeks,  the  disease 
begins  with  fever  (101°  or  even  104°),  and  in  two  days  parotid  i7itumes- 
cence  and  pain.    The  severity  of  certain  epidemics  determines  such  severe 


280  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

initial  symptoms  as  vomiting  or  convulsions  in  children;  or  a  typhoidal 
condition  in  adults.  The  characteristic  yarotitis  is  clearly  inflammatory — 
swelling,  pain,  temperature  and  interference  in  function.  It  is  bilateral; 
Bouchoud  said  "]\Iumps  have  no  singular;"  in  rare  epidemics  the  paro- 
titis is  unilateral.  In  the  early  unilateral  involvement,  the  face  inclines 
to  the  affected  side  to  relax  the  swollen  tissues;  in  the  later  bilateral 
parotitis,  the  head  is  often  bent  forward  to  the  same  end.  We  know 
little  of  its  pathology"  beyond  what  Virchow  described — ^hyperemia  of 
the  parenchyma,  interstitial  swelling,  catarrhal  secretion  in  the  ducts 
and  contiguous  lymphadenitis.  The  swelling  about  the  gland  may 
reach  the  eyelids,  forehead,  mastoid  region  or  even  the  clavicle,  effacing 
the  features  and  even  invading  the  pharynx  and  larynx;  it  is  due  less 
to  periparotitis  than  to  pressure  on  the  facial  and  other  veins.  It  is 
soft  and  does  not  pit.  Compression  of  the  masticatory  muscles  by  the 
swollen  glands  makes  opening  the  mouth  difficult;  chewing  elicits  pain 
because  it  excites  salivary  secretion  which  often  cannot  pass  the  turgid 
ducts.  Compression  of  the  Eustachian  tube  or  external  meatus  may 
occasion  tinnitus.  The  salivary  secretion  may  be  normal,  increased  or 
decreased.  Suppuration  is  due  to  mixed  infection.  Wile  maintains 
that  a  lymphocytosis  of  over  50  per  cent,  is  pathognomonic. 

In  severe  cases  the  suhmaxillary  and  suhlingual  glands  are  swollen 
(in  50  per  cent,  of  some  epidemics);  they  may  be  the  sole  seat  of  the 
disease.  The  parotitic  swelling  reaches  its  acme  within  four  days  and 
an  equal  period  is  necessary  for  its  subsidence.  The  fever  is  remittent 
or  intermittent,  and  falls  by  lysis. 

Complications  and  Sequels. — 1.  The  most  important  are  metastatic 
orchitis  and  epididymitis,  described  by  Hippocrates.  In  about  a  week 
fever  returns  (102°  to  105°).  Swelling,  redness  and  pain  in  the  testicle 
develop,  often  accompanied  by  general  symptoms.  In  some  epidemics, 
orchitis  precedes  or  even  occurs  without  parotitis.  Urethritis  is  some- 
times observed,  analogous  to  the  catarrh  of  the  parotid  duct.  Testicular 
localization  occurs  in  the  sexually  active  testis,  whence  its  rarity  in 
children  or  the  aged.  Comby  observed  it  in  30  per  cent,  of  mumps 
among  French  soldiers.  Orchitis  or  epididymitis  is  usually  unilateral. 
Testicular  atrophy  occurs  in  50  per  cent,  and  if  bilateral  may  occasion 
sterility.  In  women,  ovaritis  and  vulvovaginitis  are  infrequent.  Mastitis 
is  rather  more  frequent,  and  may  also  be  observed  in  men  and  boys. 

2.  Other  glandular  organs.  Of  these  the  lachrymal  glands  are  most 
often  affected,  then  the  thyroid,  with  acute  Graves's  disease,  pancreas, 
thymus  and  spleen. 

3.  Other  complications  are  very  rare.  These  are  meningitis,  otitis, 
polyneuritis,  optic  neuritis,  endocarditis,  nephritis,  bronchopneumonia; 
suppuration  or  gangrene  of  the  parotid  or  testis. 

Diagnosis. — Osteomyelitis  of  the  jaw,  periostitis,  lymphadenitis,  jugular 
thrombophlebitis  and  furuncle  should  be  excluded.  Epidemic  parotitis 
must  not  be  confused  with  secondary  parotitis,  which  results  from  trauma, 
or  pus  burrowing  from  the  middle  ear,  or  with  mercurial,  iodide  or  lead 
parotitis,  and  purulent  metastasis  in  typhoid,  pneumonia  and  erysipelas, 
in  which  the  pyogenic  virus  enters  by  the  ducts  or  settles  from  the  blood 


ACUTE  ARTICULAR  RHEUMATISM  281 

current.  In  postoyerati've  parotitis,  after  laparotomy,  trauma  to  the 
gland,  from  holding  up  the  jaw,  may  promote  infection. 

Prognosis. — The  prognosis  is  good;  but  7  deaths  occurred  in  58,331 
cases.    The  course  is  lighter  in  children  than  adults. 

Treatment. — The  fever  is  controlled  as  in  other  fevers,  and  diet,  isola- 
tion, hygiene  and  rest  abed  for  ten  days  are  the  same.  Pain  often 
necessitates  the  use  of  opiates.  The  local  parotid  or  testicular  inflam- 
mation is  self-limited,  and  resists  all  attempts  at  abortion  or  mitigation. 
Local  heat  is  soothing  and  better  tolerated  than  the  ice-bag.  Complica- 
tions are  treated  symptomatically . 

ACUTE    ARTICULAR   RHEUMATISM    (RHEUMATIC   FEVER). 

Definition. — An  acute,  febrile,  non-contagious  disease,  with  multiple 
articular  involvement  and  with  a  tendency  to  heart  complications. 

Etiology. — Rheumatism  is  an  acute  infection,  as  evidenced  by  its 
occasional  epidemiology;  its  tendency  to  recur  like  pneumonia  and 
erysipelas;  the  autopsy  findings  of  exudation,  hemorrhage,  cloudy 
swelling  and  acute  splenic  tumor;  the  frequency  with  which  an  atrium 
may  be  observed,  such  as  an  angina,  and  its  indubitable  affiliation  with 
endocarditis,  whose  mycotic  origin  is  established.  The  vims  is  unknown; 
Schottmiiller's  Streptococcus  viridans,  Border's  saprophytic  strepto- 
coccus and  other  streptococcoid  organisms  are  under  suspicion. 

Common  symptoms  occur  in  rheumatism  and  septicopyemia — tem- 
perature, anemia,  articular  metastases,  endocarditis,  leukocytosis  and 
peptonuria.  Some  explain  the  presence  of  organisms  by  bacterial  inva- 
sion during  the  death  agony,  since  bacteria  are  seldom  obtained  by 
aspiration  of  the  joints  during  life. 

Predisposing  Factors. — 75  per  cent,  of  cases  occur  in  the  first  half 
of  the  year;  heredity  is  conspicuous  in  25  per  cent.;  70  per  cent,  occur 
in  males.  The  greatest  susceptibility  exists  between  ten  and  thirty 
years  (50  per  cent.) ;  M.  Miller  collected  19  cases  in  nurslings.  Trauma, 
overexertion,  exposure  and  occupation  account  for  its  frequency  in 
sailors,  divers,  bakers  and  laborers.  Rheumatism  constitutes  2  per 
cent,  of  American  hospital  admissions,  as  agamst  3  to  7  per  cent,  in 
London  hospitals. 

Acute  articular  rheumatism  was  described  by  Boerhaave,  who  suffered 
from  the  disease,  and  elaborated  by  his  pupil,  Van  Swieten.  Sydenham 
gave  an  admirable  account. 

General  Clinical  Picture  and  Course. — The  onset  is  sudden,  with  mod- 
erate fever,  prostration,  drenching  sweats  and  polyarthritis.  The  joints 
are  involved  in  succession,  the  inflammation  lasting  a  few  days  in  one  joint 
and  then  passing  to  many  others.  In  adults  and  adolescents  there  is  febrile 
urine,  constipation,  conjunctival  injection,  coated,  moist  tongue,  irritability, 
restlessness,  and  fever  which  revives  as  fresh  joints  are  involved.  There 
is  marked  anemia  and  loss  of  weight.  If  endocarditis  occurs,  valvular 
disease  is  the  usual  sequence.  The  usual  duration  without  therapy  is 
three  or  four  weeks.  Recovery  is  usual,  but  death  may  result  from 
hyperpyrexia  and  toxemia.    Recurrence  and  a  family  tendency  to  rheu- 


282  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

matism  and  valvular  lesions  are  noted.    The  articular  disease  is  directly 
influenced  by  the  salicylates,  cardiac  localizations  much  less  so. 

Sjonptoms  in  Detail. — 1.  Prodromal  Syjmptoms.^ — Regarding  the 
angina  or  tonsillitis  (12  per  cent.),  there  are  two  conceptions:  (a)  that 
the  angina  is  primary  and  rheumatic,  and  (b)  that  the  arthritis  following 
angina  is  pseudorhemnatism  (polyarthritis  anginosa),  characterized  by 
exanthems,  occurring  chiefly  in  the  arms  and  reacting  poorly  to  salicy- 
lates. Other  possible  prodromes  are  laryngitis,  chorea,  erythema  nodo- 
sum, albuminuria  or  gastro-enteritis. 

2.  Polyarthritis. — (a)  Localization. — ^The  most  frequently  involved 
joints  are  those  of  the  lower  extremity,  particularly  the  knee  (70  per 
cent.);  usually  one  side  is  affected  after  the  other;  the  ankles,  elbows 
and  wrists  are  next  most  frequently  affected.  Rheumatism  may  early 
involve  the  smaller  articulations,  such  as  the  carpus — thought  by  Trous- 
seau to  promote  endocarditis;  it  also  may  invade  the  spine,  jaw,  sterno- 
clavicular joints,  synchondroses  of  the  ribs,  sacro-iliac  or  pubic  articula- 
tions and  the  larynx.  Rheumatism  may  be  localized  by  the  occupation, 
e.  g.,  in  the  arms  of  washerwomen.  If  a  joint  of  an  upper  extremity  is 
first  involved,  the  opposite  arm  is  usually  next  inflamed,  (b)  In  general 
the  arthritis  is  ascending  and  invariably  polyarticular;  Van  S-^deten 
spoke  of  it  as  "migratory  inflammation"  or  "fleeting  gout."  Persistency 
in  one  joint  always  suggests  pseudorheumatism  (symptomatic  or  sec- 
ondary forms),  (c)  Sigtis  and  symjAoms:  Polyarthritis  is  a  better  term 
than  polysynovitis  because  the  inflammation  pervades  all  structures 
of  the  joint,  the  periarticular  bursse,  cellular  tissue,  muscular  insertions 
and  tendons — indeed,  the  external  edema  is  usually  greater  than  the 
synovial  effusion.  The  joints  are  swollen,  red,  tender  and  painful. 
Pain  is  the  most  prominent  and  frequent  articular  finding.  Lasegue 
attributes  pain  to  inflammation  in  the  associated  muscles  and  tendons, 
aflirming  that  if  these  be  suitably  supported  the  joint  can  be  moved 
freely  (Lasegue's  phenomenon).  The  contiguous  tendon  reflexes  are 
lessened  or  abolished,  {d)  Duration:  The  inflammation  remains  in 
one  joint  from  one  to  eight  daj^s,  seldom  longer,  and  its  involution  is 
shorter  than  its  evolution,  (e)  Sequels:  The  joints  become  normal, 
and  ankylosis  reflects  doubt  upon  a  previous  diagnosis  of  rheumatism. 
Suppuration  results  only  from  a  most  infrequent  mixed  infection. 

3.  Temperature. — ^The  fever  is  directly  related  to  the  intensity  of 
infection,  the  number  of  articulations  involved,  and  to  the  development 
and  progression  of  visceral  complications.  As  Wunderlich  noted,  it  is 
usually  highest  when  the  patient  is  first  examined.  The  fever  curve  is 
in  nowise  cyclic  and  rarely  exceeds  102°  or  104°.  The  fever  rises  with 
each  new  localization,  be  it  arthritic,  endocarditic  or  pericarditic.  The 
temperature  drops  when  the  sweats  occur,  and  averages  ten  days.  The 
fever  is  longer  when  treatment  is  commenced  late.  Kahler  held  that 
fever  could  occur  independently  of  joint  inflammation  (febris  rheu- 
matica).  Simple  fixation  of  the  joints  reduces  the  fever,  tachycardia  and 
tachypnea.  Chills  suggest  septicopyemia  rather  than  rheumatism. 
Hyperpyrexia  is  exceptional;  with  Dr.  Lackner,  the  writer  saw  a  patient 
with  a  fever  of  112°  who  recovered.     Severe  nervous  symptoms,  coma, 


ACUTE  ARTICULAR  RHEUMATISM  283 

convulsions,  rapid  pulse,  transitory  paralysis,  stertorous  breathing  and 
hyperpyrexia  constitute  "cerebral  rheumatism;"  it  is  less  frequent  since 
the  introduction  of  the  salicylates.  The  pulse  exceeds  100.  The  respira- 
tion follows  the  fever. 

4.  Heart  Complications. — These  are  an  integral  part  of  rheuma- 
tism and  constitute  visceral  as  distinguished  from  articular  rheumatism. 
Heredity  seems  to  be  a  factor  in  certain  cases.  Heart  lesions  occur 
as  frequently  in  light  as  in  severe  forms.  They  are  most  frequent  and 
most  dangerous  at  puberty  and  increase  in  frequency  with  repeated 
attacks  of  rheumatism.  Lasegue  says  "Acute  rheumatism  licks  the 
joints,  pleura  and  even  the  meninges,  but  it  bites  the  heart." 

1.  Endocarditis.— This,  the  most  vital  complication,  was  first  described 
by  Pitcairn  (1788).  Bouillaud  (1832)  held  that  in  every  severe  rheuma- 
tism, endocarditis  was  the  rule.  The  frequency  of  endocarditis  is  about 
20  per  cent.  Mackenzie  finds  endocarditis  in  58  per  cent,  of  first  attacks, 
63  per  cent,  of  second  attacks  and  71  per  cent,  of  third  attacks.  We 
might  divide  McCrae's  series  into  thirds;  in  one  third  the  heart  is  nor- 
mal; in  another  third,  it  is  doubtful;  and  in  the  last  third,  it  is  diseased. 
Hospital  statistics,  however,  represent  the  severest  cases.  Clinically, 
endocarditis  often  escapes  recognition  and  is  found  more  frequently  at 
the  autopsy  table  than  at  the  bedside.  It  is  usually  verrucose,  and 
rarely  ulcerative  even  in  the  fatal  cases.  To  be  certain  that  an  endo- 
carditis exists,  two  points  are  absolutely  necessary:  (a)  Continued 
observation  after  convalescence;  and  (b)  attention  to  signs  of  valvular 
disease  other  than  the  murmur,  such  as  dilatation,  hypertrophy,  etc. 
Therapeutically  we  must  protect  the  patient  and  ourselves  by  keeping 
him  sufficiently  long  in  bed.  We  may  interpret  the  disappearance  of  a 
murmur  in  two  ways:  first,  as  the  disappearance  of  a  functional  mur- 
mur; or,  second,  as  the  healing  of  a  slight  endocarditis,  always  the  less 
probable  issue. 

Valves  Affected. — The  mitral  valve  is  involved  in  95  per  cent,  of  the 
cases,  the  aortic  in  23  per  cent.,  and  both  valves  in  18  per  cent.  The 
fever  of  fresh  or  recurrent  endocarditis  may  be  continuous  with  that  of 
the  arthritis  but  is  often  higher.  A  patient  with  an  old  valvular  lesion 
and  recent  temperature  more  often  has  recurrent  endocarditis  than 
malaria,  pyemia  or  tuberculosis,  which  are  commonly  confused  with 
endocarditis.     Endocarditis  exceptionally  antedates  the  polyarthritis. 

Masked  or  atypical  rheumatism  embraces  rheumatism  masquerading 
under  the  guise  of  an  endocarditis  or  trifacial  neuralgia  and  yielding  to 
salicylate   treatment.      Rheumatic   pericarditis    or    endocarditis    rarely 
occurs  without  arthritis — polyarthritis  rheumatica  sine  arthritide — the  ' 
rheumatic  equivalent. 

2.  Pericarditis. — Rheumatism  explains  more  cases  of  pericarditis 
than  all  other  causes  combined.  Its  frequency  is  given  as  5  to  10  per 
cent.  In  children,  especially,  a  subacute  or  latent  course  is  most  com- 
mon. Baginsky  found  that  adhesive  pericarditis  was  the  most  common 
autopsy  finding  in  rheumatic  children. 

3.  Myocarditis. — Disturbance  of  the  heart  in  the  acute  stage  is  myo- 
cardial and  toxic  or  mycotic.      Some  dilatation  occurs  in  every  case. 


284  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

Acute  interstitial  myocarditis^  (in  28  per  cent.),  coronary  disease  and 
myocardial  invasion  by  contiguity  from  endocarditis  in  the  later  stages 
are  possible  causes.  Recovery  is  more  common  than  chronic  fibrous 
myocarditis.  Myocarditis  may  cause  sudden  heart  pain  with  weakness 
— the  "heart  rheumatism"  of  the  laity — or  transient  palpitation,  cardiac 
oppression,  tachycardia  or  bradycardia. 

The  right  heart  may  be  dilated  as  in  other  fevers,  but  it  disappears 
with  convalescence.  When  accompanied  by  a  murmur  it  may  lead  to 
an  incorrect  diagnosis  of  endocarditis.  French  writers  describe  an  acute 
arteritis  with  severe  pain  over  the  artery  and  pain  over  its  smaller 
branches  in  the  extremities;  pathologically  only  part  of  the  vessel  wall 
is  affected  and  healing  usually  follows;  gangrene  may  follow  complete 
arterial  occlusion.    Endophlebitis  is  more  common. 

5.  Skin. — Sweating  is  most  profuse,  constant  and  characteristic;  its 
odor  is  sour  or  mouse-like.  The  skin  is  frequently  macerated  and 
sudamina  alba  or  rubra  are  common.  Rheumatic  nodes  are  subcutane- 
ous, as  large  as  buckshot,  on  the  fingers,  hands,  wrists,  elbows  and 
spine  and  are  aggregations  of  round  or  spindle  cells;  their  structure  is 
identical  with  that  of  endocarditic  vegetations.  They  may  appear 
during  or  after  an  attack,  or  independently  of  acute  seizures.  They 
sometimes  number  even  sixty  and  are  symmetrical,  hard  and  usually 
tender.  Nodes  occur  most  often  in  chronic  cases  or  in  88  per  cent.,  with 
severe  endocarditis  or  pericarditis.  If  very  numerous  or  large  they 
indicate  an  unfavorable  prognosis.  Hillebrecht  collected  80  cases  in 
children  under  fifteen  years  and  37  cases  in  adults.  In  contradistinction 
to  these  fixed  nodosities,  Fereol  has  described  more  fugitive  and  less 
indurated  nodes  {nodosities  cutanees  ephemeres).  Erythema  polymor- 
phum  is  regarded  as  an  independent  affection  but  in  rheumatism  the 
nodose  form  may  occur.  Some  eruptions  are  septic  or  anginose.  Pur- 
puric eruptions  are  not  uncommon. 

6.  Muscles  and  Bones. — Myositis  is  infrequent,  though  myalgia  is 
common.  Muscular  atrophy  may  follow  inflammatory  extension  from 
the  joints  to  the  muscles.  "Muscle  scars"  are  much  more  often  due  to 
trauma  or  other  infections  than  to  rheumatism.  Some  cases  of  albuminous 
periostitis  are  clearly  rheumatic. 

7.  Respiratory  Tract. — Laryngitis  may  be  the  atrium  for  rheu- 
matic invasion,  or  may  occur  later  as  diffuse  catarrh  or  local  nodes. 
The  rare  acute  edema  of  the  larynx  is  very  dangerous.  Pleurisy  may 
result  from  rheumatic  or  secondary  infection  (in  2  per  cent.).  Pleurisy 
is  found  in  54  per  cent,  of  cases  of  endopericarditis.  The  so-called  rheu- 
matic pleurisy  (g.  v.)  is  almost  always  tuberculous.  Pneumonia  occurs 
in  but  1  per  cent,  of  cases  of  rheumatism  not  involving  the  heart,  and  in 
66  per  cent,  of  cases  with  endopericarditis.    Most  so-called  pneumonias 

1  Romberg,  Bret,  Aschoff  and  Tawara  describe  nodules  in  the  heart  as  rheumatic  myo- 
carditis; their  specificity  is  disputed  but  all  observers  found  them.  They  are  perivascular, 
subendocardial  nodules  containing  large  cells  and  giant  cells,  and  surrounded  by  a  zone  of 
lyniphoid  elements,  plasma  cells,  and  fibroblastic  cells.  The  adjacent  muscle  bundles 
suffer  from  pressure,  so  that  functional  heart  disturbance  may  result.  They  tend  to  cicatri- 
zation.    The  same  heart  nodes  have  been  observed  in  streptococcic  sore  throat. 


ACUTE  ARTICULAR  RHEUMATISM  285 

are  pulmonary  infarction,  stasis  or  compression  from  pleural  or  pericardial 
exudates. 

8.  Digestive  Tract. — Angina  or  tonsillitis  occurs  chiefly  as  a  pro- 
drome («.  s.).  The  tongue  is  coated,  and  moist  except  in  the  severest 
cases.  Gastric  symptoms  are  rare,  though  Damash  considers  them  the 
most  frequent  prodrome.  Constipation  is  the  rule.  Diarrhea  occurs 
as  prodromal  enteritis  or  as  a  rare  complication. 

9.  Genito-urinary  Tract. — Albuminuria  is  transitory,  late  in  the 
course,  and  mostly  after  thirty  years  of  age.  The  percentage  ranges 
up  to  30.  Albumosuria  is  frequent,  especially  during  resorption.  Cylin- 
druria  may  occur  without  albuminuria.  Renal  infarction  usually  occurs 
late  in  the  course  of  cardiac  cases.  Acute  neyhritis  is  seldom  seen  (0.3 
to  1  per  cent.) ;  it  occurs  early,  chieflv  in  endopericarditis,  and  is  usually 
benign.  But  few  of  the  author's  cases  in  private  practice  show  nephritis, 
though  it  is  present  in  50  per  cent,  of  hospital  patients;  it  is  probably 
latent  until  awakened  by  the  fresh  toxemia  and  is  probably  due  to 
exposure  and  alcoholism.  Hematoporphyrin  has  been  found  and  the 
characteristics  of  fever  urine,  and  reduction  of  the  chlorides. 

10.  Blood. — The  red  disks  are  reduced  25  per  cent.  The  fever, 
anemia  and  intensity  of  articular  involvement  run  more  or  less  parallel. 
The  white  cells,  in  moderate  cases,  range  between  10,000  and  15,000, 
and  higher  figures  (20,000)  are  only  reached  in  extensive  endocarditis, 
pericarditis,  pleurisy  or  pneumonia.  The  increase  is  in  the  polymor- 
phonuclear neutrophiles.  The  eosinophiles  vanish,  but  reappear  with 
articular  improvement;  if  increased  in  a  florid  case,  the  course  will  be  mild. 

11.  Nervous  SYSTEM.^The  relation  of  chorea  to  rheumatism  is 
unsettled;  chorea,  rheumatism  and  endocarditis  are  associated  in  50 
per  cent,  of  cases.  Cases  of  chorea  with  rheumatic  or  endocarditic  asso- 
ciation usually  run  a  slow  and  often  a  relapsing  course.  Cerebral  rheuma- 
tism is  very  infrequent;  developing  acutely  at  the  acme  of  the  disease, 
with  psychical  alteration,  hyperpyrexia,  delirium,  convulsions  and 
coma,  it  frequently  results  in  death.  High  fever  may  be  a  cerebral 
symptom,  but  cerebral  symptoms  may  occur  without  high  temperature. 
The  author  has  seen  three  recoveries  after  mania,  convulsions,  meningeal 
symptoms  and  coma.  Chronic  psychoses,  hallucinations,  mania,  melan- 
cholia or  convulsions,  may  occur  in  convalescence;  they  are  due  to 
toxemic  inanition  and  generally  terminate  in  recovery.  Brain  embolism 
from  endocarditis,  hemorrhage  and  rheumatic  meningitis  are  infrequent. 
Spinal  rheumatism  may  be  confused  with  myelitis,  multiple  neuritis, 
local  myopathies  adjacent  to  the  joints  involved,  or  cerebral  embolism. 
In  Kraus's  clinic  the  author  saw  one  fatal  case  characterized  pathologically 
by  meningomyelitis.  Multiple  neuritis  may  be  rheumatic;  usually 
following  it,  neuritis  presents  the  usual  characteristics,  as  pain  and 
tenderness  over  the  muscles  and  nerve  trunks,  paralysis,  muscle  atrophy, 
reaction  of  degeneration,  anesthesia  and  abolished  reflexes.  The  prognosis 
is  good  in  multiple  and  mononeuritis. 

The  Eye. — Rheumatism  may  result  in  benign  episcleritis,  iritis  or 
iridocyclitis.  Optic  neuritis,  with  or  without  atrophy,  and  retinal 
embolism  or  thrombosis  occur  exceptionally. 


286  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

Acute  thyroiditis  is  uncommon.  Lymphadenitis  is  rarely  marked.  It 
occurs  with  arthritis,  erythemata,  endocarditis  or  pericarditis. 

Prognosis. — The  prognosis  as  to  Hfe  is  excellent  and  is  generally  propor- 
tionate to  the  severity  and  duration  of  the  infection  and  the  number  of 
joints  involved.  The  mortality  is  2  per  cent,  but  hospital  figures  are 
higher  than  in  general  practice.  The  causes  of  death  are  hyperpyrexia, 
the  most  important;  cerebral  rheumatism,  chorea,  peri-,  endo-  and 
myocarditis,  pneumonia  and  lung  infarcts.  Recurrence:  a  second  attack 
occurs  in  25  per  cent.,  a  third  in  12,  a  fourth  in  4,  and  five  to  eight  recur- 
rences in  1  per  cent.  The  prognosis  is  less  favorable  in  children.  Salicy- 
late therapy  influences  the  disease,  its  relapses,  and,  to  some  extent, 
the  heart  complications.  At  the  onset  it  is  impossible  to  declare  the 
case  light  or  severe.  Involvement  of  the  small  joints  of  the  hands  and 
feet  presages  a  severe  course. 

Diagnosis. — 1.  Rheumatism  in  Childhood.- — In  the  very  young  the 
disease  is  most  rare  (3  cases  in  85,000  nurslings)  but  becomes  more 
common  after  the  fifth  year.  Heredity  is  most  potent  in  the  young. 
Generally  speaking,  the  joints  are  less  susceptible  and  the  arthritis  less 
intense,  while  the  skin,  nervous  system  and  heart  are  more  often  involved. 
The  various  phases  of  rheumatism  occur  separately — first  arthritis, 
then  endocarditis,  later  chorea,  subcutaneous  nodules,  pericarditis  and 
so  on.  The  child  rarely  lies  quietly,  but  tosses  about;  the  tendons  and 
fasciae  are  involved  more  often  than  the  joints.  The  pain  is  less  and 
the  arthritis  may  entirely  escape  recognition.  The  lower  temperature 
is  remarkable  at  this  epoch  of  life,  when  high  fever  is  often  excited  by 
trivial  lesions.  There  is  much  less  sweating,  the  urine  is  more  nearly 
normal,  and  the  anemia  is  especially  marked.  The  differential  possi- 
bilities are  acute  osteomyelitis  (causing  monarthritis),  pyemia,  gonorrheal 
arthritis.  Barlow's  disease,  syphilis  and  hemophilic  joints.  Endocarditis 
may  not  directly  follow  the  polyarthritis,  but  develops  more  slowly, 
insidiously,  later  and  twice  as  frequently  as  in  adults.  Watson  knew  but 
three  instances  of  acute  rheumatism,  before  puberty,  which  escaped  severe 
heart  disease.  This  is  due  to  the  greater  functional  demands  on  the 
child's  heart  and  to  the  aorta  being  narrow  at  the  isthmus.  Pericarditis 
occurs  later  in  what  Cheadle  terms  the  "rheumatic  progression,"  after 
the  valvular  lesion  has  developed,  and  is  almost  always  found  in  necrop- 
sies on  children  with  valvular  disease.  Rheumatic  heart  disease  at  this 
epoch  leads  to  greater  hypertrophy  because  of  greater  nutrition,  to  more 
marked  dilatation  because  of  greater  tissue  elasticity,  and  to  more 
frequent  recurrence.  In  the  diagnosis,  functional  murmurs  are  not 
frequent  in  children.  The  pulse  is  often  irregular;  the  precordium  more 
readily  bulges;  and  left-sided  pleurisy  is  more  frequent.  Oppression 
over  the  heart,  pain,  cyanosis,  dropsy,  hepatic  congestion,  pulmonary 
infarction,  dyspnea  and  fever  are  infrequent.  Rheumatic  children  are 
more  nervous.  More  marginate,  papular  and  urticarial  erythemata  and 
more  purpura  develop  in  children.  Large  subcutaneous  nodes  (rheuma- 
tismus  nodosus)  are  serious  prognostically  and  suggest  severe  intercurrent 
valvulitis.  Chorea  is  prone  to  develop  with  arthritis,  heart  disease,  nodes 
or  erythemata. 


ACUTE  ARTICULAR  RHEUMATISM  287 

2.  Rheumatoides. — Rheumatoides  or  pseudorhewnatism  are  symp- 
tomatic arthritides  resembling  rheumatism.  The  nomenclature  of 
Quincke,  who  speaks  of  polyarthritis  gonorrhoica,  scarlatinosa,  etc.,  is 
the  least  objectionable,  (a)  Polyarthritis  gonorrhoica  (q.  v.)  resembles 
rheumatism  very  closely  and  most  frequently,  (b)  Polyartliritis  scarla- 
tinosa often  most  closely  resembles  rheumatism  (v.  page  265).  With 
it  have  been  observed  endopericarditis,  nodes,  erythema  and  chorea. 
(c)  Polyarthritis  may  complicate  many  other  infections;  e.  g.,  measles, 
smallpox,  erysipelas,  typhoid,  angina,  appendicitis,  diphtheria,  syphilis, 
pneumonia,  etc. 

3.  Severe  Types. — In  grave  types  the  visceral  findings  are  least 
confusing  when  secondary  in  development  to  the  arthritis.  In  the 
primary  visceral  type  the  findings  {e.  g.,  cardiac)  antedate  the  arthritis, 
but  diagnosis  is  uncertain,  until  the  joints  are  involved. 

4.  Gout  (g.  v.).  5.  Arthritis  DEroR]\iANs  (q.  v.).  6.  Tuberculous 
Polyarthritis  (q.  v.). 

The  number  of  joints  involved  is  highly  suggestive,  but  not  diagnostic. 
Rheumatism  and  gonorrheal  rheumatism  are  often  polyarticular;  diag- 
nosis of  the  latter  in  women  is  often  difficult  for  notable  reasons.  Puer- 
peral infections  and  an  acute  monarticular  osteo-artliritis  in  pregnancy 
or  lactation  may  cause  difficulty. 

Treatment. — 1.  Diet. — B lot's  results,  with  a  strict  milk  diet,  were 
extremely  good;  arrow-root,  gruels,  etc.,  may  be  given. 

2.  Clothing. — The  patient  should  wear  a  flannel  gown  and  blankets 
are  more  comfortable  than  sheets  on  account  of  the  sweating.  Macera- 
tion of  the  skin  by  the  drenching  sweats  can  be  avoided  by  dusting 
talcum  powder  in  the  axillae,  etc.,  and  sponging  with  warm  water  and 
alcohol. 

3.  Local  Treatment. — Hot  boric  fomentations  and  salicylic  salve 
are  useful  (I^ — Acidi  salicylici  Zj,  adipis  lanse  hydrosi  5  j).  Cantharides 
blisters  are  indicated  for  tardy  involution. 

4.  Rest. — Fixation  in  the  most  comfortable  position  lessens  pain, 
fever,  pulse  and  respiration-rate.  The  absolute  dorsal  decubitus  for 
three  weeks  must  be  enforced  because  of  the  weak  heart.  Muscular 
atrophy  may  result  from  the  use  of  plaster-of-Paris  casts. 

5.  Salicylates. — Buss  (1875)  remarked  their  antipyretic  affects, 
and  Strickler  and  Maclagan  (1876)  discovered  their  remarkable  action 
in  rheumatism. 

(a)  Effect  on  the  Arthritis. — The  pain  and  swelling  are  usually  relieved 
after  three  to  five  full  doses — within  twenty-four  hours.  Salicylates 
are  the  best  analgesic  in  rheumatism,  and  morphine  is  rarely  necessary 
after  the  first  twelve  hours.  Salicjdates  are  thought  to  cause  articular 
hyperemia. 

(6)  Effect  on  the  Temperature. — The  fever  falls  coincidently  with  relief 
of  the  articular  symptoms,  and  in  the  great  majority  of  cases  the  acute 
stage  is  over  within  tliree  days.    In  hyperpyrexia  less  influence  is  noted. 

(c)  Effect  on  the  Endocarditis. — The  weight  of  opinion  is  that  endocar- 
ditis occurs  as  frequently  with  the  use  of  salicylates,  i.  e.,  salicylates 
are  only  analgesic  and  antipyretic.    The  writer  believes  that  the  salicyl- 


INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

ates  are  practically  specific  and  that  heart  complications  are  lessened 
by  shortening  of  the  acute  stage. 

(d)  Relapses. — Relapses  are  not  more  frequent  with  the  administration 
of  the  salicylates  than  with  the  alkaline  treatment.  They  are  less  fre- 
quent under  the  use  of  salicylates  for  two  weeks  after  the  initial  symptoms. 

(e)  Physiological  Action. — The  smallest  doses  produce  cinchonism, 
as  fulness  of  the  head  or  roaring  in  the  ears.  After  larger  doses  dulness, 
headache,  giddiness,  a  dusky  and  moist  skin,  disturbed  hearing,  and 
tremor  develop.  Toxic  doses  also  produce  eye-muscle  paralysis,  pupil 
dilatation,  amaurosis,  deafness,  increased  reflexes,  restlessness,  delirium, 
dyspnea,  disturbed  circulation,  skin  eruptions  and  green  urine  (indican 
and  pyocatechin) .  Postmortem,  visceral  congestion  and  serous  ecchy- 
moses  are  seen. 

(/)  Administration. — Sodium  salicylate  is  the  most  prompt,  certain, 
soluble  and  least  irritating  preparation.  Where  it  fails,  other  prepara- 
tions are  usually  unsuccessful.  All  salicyl  preparations  are  absorbed  as 
sodium  salicylate,  produced  by  the  alkaline  intestinal  juices.  Grains  xv 
of  the  natural  or  synthetic  acid — as  both  are  equally  good — or  grains  xx 
of  the  sodium  salt,  are  given  every  three  hours  until  salicylism  appears, 
i.  e.,  until  slight  dullness,  dyspnea  and  deafness  develop;  5ij~iiss  are  given 
the  first  day,  when  the  interval  between  doses  is  lengthened  to  six  hours. 
The  effects  are  better  in  proportion  as  the  disease  is  more  acute,  the 
inflammation  greater,  the  number  of  involved  joints  larger,  and  the 
fever  higher.  It  usually  can  be  given  by  mouth  in  fluid,  if  the  taste  be 
disguised  by  wintergreen  oil,  syrup  of  ginger  or  syrup  of  orange;  even 
then  it  is  frequently  nauseating. 

I^ — Sodii  salicylatis 5vj 

Sodii  bicarbonatis 5iv 

Syrupi  zingiberis Sj 

Syrupi  aurantii 3J 

Aquae q.  s.  ad.  gviij 

M.  et  S. — Shake.    Two  teaspoonfuls  every  thiee  hours. 

Capsules  may  irritate  the  stomach,  but  powders  are  well  tolerated, 
taken  in  starch  wafers.  In  case  the  stomach  is  intolerant,  salicylates 
may  be  administered  by  rectum  in  peptonized  milk.^  Inunctions  are 
uncertain.  Aspirin  (acidum  acetylsalicylicum)  is  much  less  irritating 
to  the  stomach  than  salicylate  of  soda,  less  antipyretic  and  less  analgesic 
but  more  sudorific;  it  is  given  in  doses  of  twenty  grains  at  the  same 
intervals.  Aspirin  rarely  occasions  -an  angioneurotic  edema  of  the  face, 
lids  or  oral  mucosa  and  urticarial,  scarlatiniform  or  pemphigus  erup- 
tions. Salol  (phenylis  salicylas)  is  given  in  the  same  dose  at  the  same 
interval,  but  the  kidneys  must  be  carefully  watched,  because  of  the 
phenol  component;  it  is  far  less  efficacious. 

The  claim  that  the  alkaline  treatment  decreases  the  heart  complications 
and  shortens  the  disease,  is  not  proved,  yet  in  the  above  prescription,  the 
sod.  bicarbonate  lessens  the  gastric  and  renal  irritation  of  the  salicylates. 

*  Hypodermic  injections  of  the  saHcylates  in  rheumatism  are  advocated  (10  c.c.  of  a  20 
per  cent,  sterilized  solution  of  sodium  salicylate  to  100  pounds  of  body  weight,  fifteen 
minutes  after  a  cocaine  injection,  every  twelve  hours). 


DENGUE  289 

Baginisky  thinks  the  administration  of  gr.  xv-xl  of  potassium  iodide 
dail}^  produces  better  results  in  children  than  do  the  salicylates. 

{(j)  Unusual  Results. — 1.  Nervous. — Delirium  has  been  observed  in 
chlorotics,  neurotics  and  alcoholics.  It  may  be  violent  and  protracted. 
Convulsions  are  infrequent. 

2.  Cardiac. — -Small  doses  stimulate  the  heart,  and  5  ij  per  diem  seldom 
affect  the  heart,  even  with  old  valvular  lesions.  If  the  heart  becomes 
weak  or  irregular,  acute  myocarditis  is  probably  developing  and  the 
heart  muscle  must  be  stimulated  by  coffee,  strychnine  or  camphor. 
Slight  irregularity  without  weakness  is  no  contra-indication.  Thorne 
has  observed  collapse  from  aspirin. 

3.  Respiratory. — With  antecedent  or  concomitant  bronchitis  or  tuber- 
culosis, the  lungs  should  be  explored  for  possible  congestion  due  to  the 
remedy.  Cardiac  depression,  sudden  respiratory  failure  and  violent 
expiratory  dyspnea  are  observed  in  a  few  cases. 

4.  Renal. — Caution  is  necessary  in  old  nephritics,  because  the  salicy- 
lates are  excreted  by  the  kidneys  as  salicylic  or  salicyluric  acid;  how- 
ever, albuminuria  or  nephritis  directly  due  to  the  rheumatic  virus, 
indicates,  rather  than  contra-indicates,  the  salicylates. 

5.  Alimentary. — Vomiting  and  diarrhea  may  result  from  salicylic 
irritation  or  inhibition  of  the  digestive  ferments. 

Diagnostic  Therapy. — Senator  claimed  that  salicylates  are  specific 
in  true  rheumatism  and  inert  in  pseudorheumatism ;  there  are  certain 
exceptions — some  rheumatics  resist  salicylates,  and  salicylates  are  of 
some  value  in  the  arthritic  type  of  grippe,  but  usually  are  useless  in 
other  arthritides. 

Convalescence. — Absolute  rest  must  be  enforced  for  three  weeks  to 
save  the  heart.    Antecedent  tonsillitis  indicates  tonsillectomy. 


DENGUE. 

Definition. — An  acute  specific  infection,  extremely  contagious,  and 
characterized  by  fever,  prodromal  eruption,  violent  articular  and  mus- 
cular pains,  and  a  secondary  polymorphous  eruption. 

Etiology  and  Epidemiology. — The  actual  cause  is  uncertain.  Graham 
found,  in  the  blood  cells,  an  organism  resembling  the  Plasmodium 
malarise,  but  small  and  unpigmented.  It  is  transmitted  by  the  bite  of 
the  Culex  fastigans.  Contagion  is  disseminated  by  indirect  infection, 
fomites,  bites,  etc.  It  is  carried  by  pilgrims,  sailors  and  emigrants. 
The  disease  spreads  with  remarkable  rapidity.  Its  home  is  in  the  tropical 
and  subtropical  zones  and  it  prevails  chiefly  in  the  hot  months.  It  is 
remarkable  that  the  coast  ports  are  chiefly  invaded,  and  closely  con- 
tiguous inland  towns  and  higher  places  are  exempt.  The  first  epidemic, 
in  1779,  in  Java,  was  described  b}^  Brylon,  and  Benjamin  Rush  wrote 
of  the  Philadelphia  epidemic  in  1780;  it  was  called  "Front  Street  Fever," 
on  account  of  the  squalid  condition  of  the  houses  along  the  river  front. 
It  has  invaded  Europe,  Asiatic  Turkey,  South  America  and  the  United 
States.  It  has  reached  Savannah,  New  Orleans,  Ohio  and  Virginia. 
19 


290  IXFECTIOXS  OF  DOUBTFUL  ETIOLOGY 

Xo  immunity  is  conferred  by  one  attack,  and  it  may  recur  two  or  even 
four  times. 

Symptoms. — Incubation  lasts  one  or  two  days. 

1.  Febrile  Stage. — The  fever  rises  quickly  to  102°,  104°  or  even  107°, 
with  a  chin,  severe  frontal  headache  and  intense  pains  in  the  back  and 
limbs,  especially  the  knees,  which  incapacitate  the  patient.  The  names 
"break-bone  fever,"  of  Rush's  description,  and  "dandy  fever,"  given 
because  of  the  mincing  gait  which  results,  bring  out  this  salient  feature. 
The  pulse  averages  100.  ]\Iany  joints  are  stcollen,  one  after  another. 
The  muscles  are  painful,  the  face  is  suffused  and  swollen,  the  conjunctivse 
are  injected  and  the  flow  of  tears  is  increased.  Total  anorexia,  coated 
tongue,  and  great  thirst  de\'elop;  vomiting  is  occasional  and  constipa- 
tion the  rule.  The  prodromal  hyperemic  rash  lasts  one  to  five  hours, 
and  is  frequently  absent.  Prostration,  delirium,  convulsions  and  coma 
may  develop.  This  stage  lasts  three  days  ("three-day  fever")  and  ends 
with  profuse  sweating.    Fever  is  absent  in  the  lightest  cases. 

2.  Ex^ANTHEMATOUS  Stage. — The  polymorphous  eruption  on  the 
fourth  day  on  the  face,  hands,  forearms  and  chest,  is  scarlatiniform, 
morbilliform,  urticarial,  erysipelatoid,  vesicular  or  even  pustular.  It 
is  present  in  80  per  cent,  of  cases,  lasting  three  days,  and  followed  by 
desquamation,  itching,  sometimes  by  falling  of  the  hair.  An  inflamed 
throat,  lymph-gland  enlargement,  parotitis  and  orchitis  occasionally 
occur.  The  temperature  varies  from  subnormal  to  high.  The  pain 
recurs  often.  Herpes,  splenic  tumor,  otitis,  albuminiu-ia  and  leukocytosis 
are  absent. 

3.  Cox^'alescexce  begins  in  seven  days.  There  is  prostration, 
emaciation  and  anemia.  In  no  other  disease  of  equal  duration  is  such 
marked  constitutional  disturbance  noted. 

Complications. — Gastric  hemorrhage,  endocarditis,  nephritis,  pneu- 
monia, pleurisy  or  ulcers  very  rarely  develop. 

Prognosis. — Though  the  morbidity  is  enormous,  the  highest  recorded 
death-rate  is  0.5  per  cent.  (10  deaths  in  100,000  cases  in  Smyrna). 
Relapse  may  occur  in  one  or  two  weeks. 

Diagnosis. — The  geography  and  the  presence  of  an  epidemic  are 
significant.  The  exanthemata,  rheumatism,  yellow  fever  {q.  v.)  and 
epidemic  erythema  exudaticum  multiforine  may  be  suggested.  Influenza 
is  differentiated  by  its  occurrence  in  all  climates,  seasons  and  inland 
as  well  as  on  seaboard,  its  usual  respiratory  catarrh  and  complications, 
its  more  severe  nervous,  intestinal  and  cardiac  symptoms,  and  the 
greater  frequency  of  herpes,  splenic  tumor,  otitis  and  albuminuria.  In 
the  rare  acrodynia,  observed  in  France,  Belgium,  Turkey,  Persia  and 
^lexico,  Scheube  gives  the  following  differential  points:  Digestive  dis- 
turbance; facial  swelling;  pains  in  the  extremities,  sometimes  with 
anesthesia;  spastic  symptoms;  afebrile  course;  and  erythema  multiforme. 

Treatment. — Isolation  and  quarantine  are  necessary.  Pain  is  the 
prominent  indication,  for  which  acetphenetidinimi  and  salicylates  serve 
fairly  well,  though  they  are  much  inferior  to  opium. 


YELLOW  FEVER  291 


YELLOW  FEVER. 


Definition. — A  specific  infection,  transmitted  by  the  mosquito,  endemic 
in  the  American  tropics  and  subtropics,  and  characterized  pathologically 
by  degeneration  of  the  liver  and  kidneys,  and  clinically  by  fever,  icterus, 
albuminuria,  adynamia,  and  hematemesis. 

Etiology. — Transmission  by  the  mosquito  {Stegomyia  calopus)  was  sus- 
pected by  Carlos  Finlay,  in  1881,  but  was  demonstrated  by  the  investi- 
gating board  composed  of  Walter  Reed,  James  Carroll,  A.  Agramonte 
and  J.  W.  Lazear.  Dr.  Carroll  recovered  from  a  severe  attack,  but  Dr. 
Lazear  and  Dr.  Myers,  of  the  English  Commission,  died  from  inocula- 
tion. The  Stegomyia  breeds  not  only  in  stagnant  street  pools,  but  also 
in  cesspools  and  sewers,  whence  its  special  danger  in  unhygienic  tropical 
towns.  Voluntary  inoculations  by  mosquitoes,  which  twelve  days  pre- 
viously had  bitten  yellow-fever  patients,  produced  yellow  fever  in  non- 
immunes; Finlay  failed  to  prove  his  suspicion  because  he  allowed  the 
mosquitoes  only  three  to  six  days  in  which  to  develop  the  germs  which 
they  had  ingested,  whereas  they  must  live  twelve  days  before  they  can 
convey  infection.  The  mosquito  carries  infection  only  when  it  bites  the 
patient  in  the  first  three  days  of  the  disease.  Transfusion  of  blood  of 
an  infected  person,  taken  in  the  first  three  days  of  the  disease,  also 
conveys  infection.  The  virus  is  filterable.  As  in  malaria,  the  tropical 
foci,  the  hot  summer  and  autumn  seasons,  the  invasion  of  low  altitudes, 
river  courses  and  coast  towns,  humidity,  and  exposure  to  night  air,  are 
merely  conditions  suitable  to  the  mosquito.  Frost  stops  infection  be- 
cause it  kills  the  mosquito.  Direct  contagion  does  not  occur.  Nurses 
and  physicians  are  not  infected  from  contact  with  yellow-fever  patients. 
Persons  going  from  the  City  of  Mexico  to  Vera  Cruz  may  acquire  the 
disease,  but  on  coming  home  with  it  they  do  not  cause  its  dissemination, 
because  the  mosquito  is  not  present.  Reed's  committee  exploded  the 
theory  that  fomites,  clothing,  etc.,  were  infective.  Volunteers  remained 
in  rooms  occupied  by  vellow-fever  patients  and  slept  in  their  soiled 
linen  without  contracting  the  disease.  During  the  American  occupa- 
tion. Col.  Gorgas  stamped  out  the  disease  in  Havana,  but  405  cases 
developed  in  1905-8,  from  the  New  Orleans  epidemic.  No  cases  devel- 
oped since  December,  1908. 

Predisposition. — The  lighter  races  are  more  prone  to  infection.  Im- 
munes  are  merely  those  who  have  had  light  and  unrecognized  infe(^tions. 
Yellow  fever  is  kept  alive  in  endemic  foci  by  mild  cases,  especially  among 
the  Creole  children. 

Foci  and  Epidemiology. — The  habitats  of  yellow  fever  are  (1)  Mexico, 
the  Antilles,  Mexican  Gulf  and  Caribbean  Sea;  and  (2)  Africa,  from 
Senegal,  through  Sierra  Leone,  to  the  Gold  Coast.  The  first  clear  descrip- 
tion of  yellow  fever  was  in  1686,  but  yellow  fever  was  known  before 
the  discovery  of  America.  It  reached  this  country  in  the  sixteenth 
century  and  has  extended  as  far  north  as  Boston,  St.  Louis,  Quebec  and 
Chicago.  In  Philadelphia  (1793,  1797-1798),  4041  died  in  a  year;  in 
New  York,  2080;    and  in  New  Orleans,  in  1853,  8000  died.     In  New 


292  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

Orleans,  in  1905,  there  were  about  9000  cases  and  1000  deaths.  Europe 
is  seldom,  but  South  America  is  frequently  invaded. 

General  Clinical  Description. — Incubation  averages  three  days.  Pro- 
dromal symptoms  last  less  than  a  day;  they  are  malaise,  fatigue,  head- 
ache, dyspepsia  or  colic.    The  disease  is  divided  into  the  following  stages : 

I. — The  stage  of  congestion  begins  with  frontal  or  retroocular  head- 
ache, the  earliest  and  most  prominent  symptom,  sometimes  a  chill,  and 
flushed  face;  the  conjunctivae  are  injected  and  sometimes  icteric;  the 
eyes  are  sensitive  to  light,  the  lids  puffed  and  the  expression  denotes 
pain,  restlessness  and  confusion,  comparable  to  the  alcoholic  facies: 
backache  radiating  into  the  calves,  fever  rising  to  104°,  and  a  full,  tense 
pulse  of  100  to  110.  The  tongue  is  slightly  coated  dorsally.  The  febrile 
urine  is  very  early  albuminous.  The  skin  is  intensely  red  and  dry. 
The  epigastrium  is  tender  early  and  there  is  marked  gastric  intolerance 
of  food,  water  and  medicine.     This  stage  averages  two  daj's. 

II. — The  remission  stage,  or  deceptive  stage,  occurs  in  some  cases 
and  is  so-called  because  of  the  subsequent  severe  symptoms.  The 
fever,  pulse  and  the  pain  remit.     Slight  jaundice  may  appear. 

III. —  The  Reaction  Stage. — Slight  temperature,  the  "black  vomit" 
{vomito  negro)  of  blood,  hemorrhage  into  the  nose,  intestines,  uterus 
or  skin,  hiccough,  epigastric  pain  and  tenderness,  liver  enlargement,  and 
icterus  mark  this  period.  The  urine  becomes  scant  and  laden  with 
bile  pigment,  or  its  secretion  is  suppressed;  the  pulse  becomes  weaker, 
and  insomnia,  prostration  and  restlessness  may  appear. 

Various  issues  are  possible:  Gradual  amelioration;  fatal  anuria; 
profuse  hemorrhages,  which  end  in  collapse,  and  rarely  in  recovery; 
profound  icterus,  which  results  usually  in  death;  or  death  from  cardiac 
insufficiency. 

(.4)  Variations  in  intensity  include  (1)  abortive,  ambulatory,  atypi- 
cal forms,  especially  in  children;  (2)  the  usual  severe  forms;  and  (3) 
the  foudroyant  type,  rapidly  lethal  in  one  to  two  days. 

{B)  Visceral  Forms:  (1)  The  hepatic  type,  with  two  weeks  of  the 
status  typhosus,  often  with  normal  temperature  and  sometimes  with 
hemorrhages;  (2)  the  uremic  type;  (3)  the  hemorrhagic;  (4)  the  cardiac; 
and  (5)  nervous  or  atactic  type. 

Special  Symptomatology. — 1.  Fever. — Fever  is  highest  in  the  first 
stage,  and  averages  104°.  It  may  fall  on  the  second  or  third  day  to 
nearly  normal  in  benign  cases  or  in  the  ominous  uremic  type.  High 
fever  after  the  second  day  is  a  poor  prognostic.  In  the  second  stage 
fever  is  usually  99°  to  100°.  In  the  third  stage  a  high  antemortem  rise 
is  frequent.    In  convalescence  it  is  subnormal. 

2.  Nervous  Symptoms. — Nervous  symptoms  are  often  absent  in  both 
benign  and  malignant  cases.  Headache  is  common  in  the  congestive 
period.  Delirium  is  infrequent,  and  in  80  per  cent,  of  cases,  is  uremic. 
In  children,  alcoholics  and  in  the  debilitated  the  status  typhosus  or 
meningo-encephalitic  symptoms  (convulsions,  unequal  pupils,  Cheyne- 
Stokes's  breathing  and  coma)  are  possible.  Pathologically,  few  changes 
are  found  except  the  slight  degenerations  common  to  the  febrile  state, 
punctate  hemorrhage  or  bile  tinging. 


YELLOW  FEVER  293 

3.  Circulatory  Symptoms. — (a)  The  pulse  in  the  congestive  stage 
is  100  to  110  and  tense;  on  the  third  day,  70  to  80;  in  the  second  stage 
it  is  still  lower  in  benign  and  more  rapid  in  severe  cases  (110  to  140) 
and  is  small;  in  convalescence  it  is  slow  (50  to  60,  or  even  30).  Faget 
considers  slowing  of  the  pulse  with  maintenance  of  the  fever  almost 
pathognomonic,  (h)  In  severe  forms  the  first  tone  of  the  heart  becomes 
weak  and  embryocardia  is  found.  The  heart  is  rarely  irregular  or  inter- 
mittent. In  the  third  stage,  cardiac  dilatation  is  common  (in  70  per 
cent,  of  autopsies),  due  to  myocardial  degeneration.  Cardiac  action  is 
exaggerated  when  uremia  is  present,  (c)  There  is  no  anemia.  The 
white  cells  are  decreased;  the  polynuclears  are  relatively  increased. 

4.  Respiratory  Symptoms. — Respiratory  symptoms  may  be  due  to 
interciu-rent,  or  more  often  to  cardiac  or  renal,  complications. 

5.  Digestive  Tract. — Hiccough,  epigastric  pain,  tenderness  and 
anxiety  may  be  symptomatic  of  cardiac  distress,  premonitory  of  the 
black  vomit,  or  indicative  of  disturbed  circulation  in  the  medulla. 

6.  Icterus  (Yellow  Fever,  Typhus  Icteroides). — Jaundice 
usually  develops  on  the  third  to  fifth  day;  its  pathogenesis  is  obscure. 
It  is  frequently  absent  in  children,  in  early  death  from  uremia  and  in 
50  per  cent,  of  cases  which  recover. 

7.  Liver. — ^The  liver  is  slightly  enlarged  and  tender.  Pathologically, 
it  has  a  light  cooked,  fatty  and  anemic  appearance. 

8.  Urine. — Albuminuria  occurs  in  88  per  cent,  of  cases  in  the  first 
three  days.  Leucin,  casts  and  bile  pigment  are  common.  The  kidneys, 
anatomically,  are  pale  or  yellowish,  and,  microscopically,  show  great 
fatty  degeneration  of  the  tubules,  which  in  severe  cases  are  choked  by 
desquamated  epithelium  and  casts.     The  glomeruli  show  few  changes. 

Uremia  causes  33  per  cent,  of  fatalities;  it  is  marked  by  delirium,  ner- 
vousness, convulsions,  decreased  or  suppressed  urine  (fatal  in  97  per 
cent,  of  cases),  rapid  or  Cheyne-Stokes's  breathing,  and  a  tense  pulse. 
Death  in  coma  may  occur  on  the  third  day.    Uremia  is  rare  in  children. 

9.  Hemorrhages. — They  result  from  fatty  degeneration  or  actual 
rupture  of  the  bloodvessels.  Hemorrhages  may  occur  from  the  mouth, 
stomach  or  intestine.  The  black  wmit,  gradually  transuded  blood  altered 
by  the  gastric  acid,  occurs  on  the  fourth  to  sixth  day,  the  "  coffee-grounds" 
vomit;  the  stomach  at  autopsy  shows  the  black  contents  and  dark 
discoloration,  epithelial  desquamation  and  fatty  change  in  the  muscu- 
laris.  Hemorrhage  from  the  small  intestine  is  equally  frequent.  Epistaxis 
is  often  profuse.  Uterine  hemorrhages  are  severe  and  in  pregnant  women 
cause  abortion.  Less  frequent  are  skin  petechise  and  muscular  hemor- 
rhages. 

Complications  and  Sequels. — These  include  secondary  infections  such 
as  endocarditis,  pericarditis,  pneumonia,  erysipelas,  parotitis,  arthritis, 
suppuration  and  gangrene;  coincident  typhoid,  malaria,  influenza  and 
insolation;    and  postfebrile  psychoses. 

Diagnosis.— The  diagnosis  is  readily  made  from  (1)  the  flushed,  semi- 
intoxicated  facies;  (2)  icterus;  (3)  the  early  albuminuria — the  most 
valuable  finding  in  doubtful  cases;  (4)  black  vomit,  gastric  intolerance 
and  epigastric  tenderness;   (5)  hemorrhages,  and  (6)  the  slow  pulse,  which 


294  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

is  absent  in  some  severe,  but  therefore  clear,  cases.  Pernicious  malaria, 
with  icterus,  is  distinguished  by  the  blood  (plasmodium  and  anemia), 
enlarged  spleen  (always  absent  in  yellow  fever),  the  infrequency  of  early 
icterus,  albuminuria  and  hemorrhages  (except  hematuria).  This  form 
of  malaria  is  rare  in  cities,  whence  the  constant  suggestion  of  yellow 
fever,  when  more  than  sporadic  cases  are  reported.  Weil's  disease  and 
acute  yellow  atrophy  are  readily  distinguished. 

Prognosis. — ^The  mortality  of  epidemics  varies  from  10  to  85  per  cent. 
The  death-rate  averages  30  per  cent.  The  mortality,  according  to  age, 
is  33  per  cent,  (one  to  three  years),  14  (four  to  eighteen  years)  and  37 
per  cent,  (nineteen  to  forty  years).  Unfavorable  events  are  hepatic, 
renal  or  cardiac  insufficiency,  the  typhoid  state,  high  fever  with  hepatic 
symptoms  and  hemorrhages. 

Treatment. — 1.  Prophylaxis. — No  greater  triumph  of  hygiene  exists 
than  the  stamping  out  of  yellow  fever  during  the  American  occupation 
of  Havana.  It  illustrates  not  only  the  efficiency  of  the  investigating 
commission,  but  also  the  possibilities  of  medicine  in  administrative 
capacity  with  unlimited  discretionary  power.  In  Havana  the  death- 
rate  was  500  yearly,  until  Gorgas  cut  it  down  to  nil.  The  patient  should 
be  isolated,  not  to  prevent  direct  personal  contagion  but  to  keep  mos- 
quitoes from  the  infected  person.  Healthy  individuals  avert  infection  by 
the  mosquito  by  the  same  measures  employed  in  malaria,  e.  g.,  screens, 
and  extermination  of  breeding  foci.  The  Stegomyia  is  found  outside  the 
habitual  yellow-fever  foci,  and  after  biting  patients  from  abroad,  may 
inoculate  other  persons. 

2.  Symptomatic  Treatment. — (a)  In  the  first  stage,  fluidextractum 
aconiti,  TTliij,  and  sodium  salicylat.,  gr.  xx,  may  be  given  every  two  to 
four  hours,  until  the  congestion  and  pains  are  relieved.  Coal-tar  pro- 
ducts are  depressant.  Calomel,  gr.  |  every  hour  for  five  doses  is  followed 
by  castor  oil.  Overmedication  is  to  be  avoided  because  of  the  gastric 
irritability.  Violent  cerebral,  uremic  or  pulmonary  symptoms  are  some- 
times treated  by  phlebotomy.  (6)  In  the  last  stage,  the  black  vomit 
contra-indicates  any  fluid,  food  or  medication  by  mouth;  warm  pepton- 
ized milk  and  normal  salt  solution  are  given  by  rectum;  morphine  by 
mouth  is  dangerous,  (c)  Digitalis  is  especially  good,  and  is  beneficial 
even  when  cardiac  failure  is  absent;  saline  solution,  by  rectum  or  sub- 
cutaneously,  is  better  than  intravenous  transfusions.  The  patient  must 
be  kept  absolutely  quiet,  (d)  Uremic  symptoms  are  treated  in  much  the 
same  way.  Water  is  given  freely  by  the  bowel,  (e)  Nervous  manifesta- 
tions necessitate  cool  spongings,  bromides,  morphine  and  hyoscine,  as 
in  typhoid,  (f)  Vomiting  is  relieved  most  efficaciously  by  chopped  ice. 
(See  Typhoid.) 

HYDROPHOBIA  (LYSSA;  RABIES). 

Definition. — ^An  acute  specific  infection,  peculiar  to  carnivora,  the 
bites  of  which  convey  infection  to  other  animals  and  man.  The  disease 
is  characterized  by  tonic  and  clonic  spasms  of  the  esophagus,  respiratory 
and  other  muscle^  and  by  a  fatal  evolution.  It  was  described  in  ancient 
Jewish,  Egyptian  and  Indian  writings  and  by  Democritus  in  the  fourth 


HYDROPHOBIA  295 

and  fifth  centuries,  B.C.  The  first  adequate  account  was  by  Youatt 
(1828). 

Etiology. — In  Germany,  from  1887  to  1894,  only  16  cases  occurred 
because  of  the  strict  laws.  In  Russia,  France  and  America  it  is  far 
more  common.  The  disease  has  been  eradicated  in  England,  Denmark, 
Norway,  Sweden,  Switzerland  and  Australia.  Dogs  are  most  frequently 
aft'ected  and  the  chief  cause  of  dissemination  (90  per  cent.);  next  come 
wolves,  cats  and  cattle;  and  finally  skunks,  horses,  deer,  pigs,  rabbits 
and  even  fowl  may  be  inoculated.  The  virus  is  found  in  the  nervous 
tissues  most  abundantly ,  in  the  saliva  and  also  in  small  quantities,  in  tears, 
sputum,  semen,  urine  and  milk,  and  in  the  adrenals.  Its  propagation 
is  along  the  nerve  trunks,  thus  reaching  the  salivary  glands  (not  by 
way  of  the  blood  stream).  Noguchi  cultivated  small  granular  pleo- 
morphic bodies  which  produce  the  disease  on  inoculation.  Inoculation 
occurs  from  bites  of  infected  animals,  which  transmit  the  disease  even 
during  incubation.  Punctured  or  deep  wounds  and  those  in  the  nerves 
or  muscles  are  most  dangerous;  10  per  cent,  of  those  bitten  by  mad  dogs 
and  62  per  cent,  of  those  bitten  by  rabid  wolves  and  cats  die.  In  excep- 
tional cases,  rabies  results  from  being  licked  by  an  infected  dog,  kissing 
an  infected  person  or  dissecting  an  infected  body.  The  disease  prevails 
chiefly  in  warm  weather  in  the  "dog  days"  and  most  laws  are  based  on 
this  assumption;  but  it  is  also  common  in  cool  weather.  In  Paris  most 
cases  occur  in  March  and  May.  Sixty  per  cent,  of  cases  occur  in  males 
and  40  per  cent,  under  fifteen  years  of  age. 

The  incubation  period  varies,  averaging  40  days:  (a)  It  is  shorter  in 
children;  (6)  if  the  wound  is  on  the  face  or  head,  incubation  is  very 
short  and  the  symptoms  very  severe;  (c)  it  is  longer  and  the  symptoms 
less  intense  when  the  point  of  infection  is  on  the  body,  because  the 
clothing  tends  to  clean  the  virus  off  the  teeth. 

Symptoms. — Three  somewhat  arbitrary  stages  are  described: 

First  or  Prodromal  Stage. — ^The  scar  may  become  painful.  Psychical 
alteration  is  expressed  by  depression,  irritability  or  extreme  anxiety. 
Headache,  hyperesthesia,  anorexia  and  some  elevation  of  the  temperature 
and  pulse-rate  are  usual.  Sometimes  the  voice  is  hoarse,  the  pupils  are 
somewhat  dilated  and  premonitions  of  dysphagia  are  experienced.  This 
stage  lasts  one  or  two  days. 

Second  or  Excitation  Stage, — (a)  The  excitement  is  more  motor 
than  psychical.  The  cutaneous  and  deep  reflexes  are  increased.  There 
is  such  hyperesthesia  that  the  least  sound  or  light,  the  slightest  breath  of 
air,  or  food  and  water  in  the  throat,  induce  violent  reflex  spasms,  whence 
the  patient's  dread  of  these  excitants  (photophobia,  aerophobia,  hydro- 
phobia). Tonic  spasms,  following  attempts  at  swallowing  aft'ect  chiefly 
the  muscles  of  the  mouth,  the  hyoid  elevators  and  the  laryngeal  and 
respiratory  muscles.  Even  without  laryngeal  involvement  the  respira- 
tion is  labored,  with  jerky,  deep  or  sighing  inspirations,  during  which 
the  shoulders  are  lifted  and  the  epigastrium  protruded.  The  spasms 
may  extend  to  the  trunk  and  limbs,  (b)  The  psychical  excitement  is 
marked  at  the  time  of  the  spasm  by  restlessness  and  later  by  horror  or 
even  mania.    Delirium  tremens  may  be  simulated.    The  mind  is  usually 


296  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

clear  between  the  spasms.  The  patient  rarely  attempts  to  injure  at- 
tendants, although  such  an  impression  may  be  made  by  the  peculiar 
growling  sounds  occasioned  by  pharyngeal  and  laryngeal  spasm  and  the 
"frothing  at  the  mouth,"  due  to  inability  to  swallow  the  increased  flow 
of  saliva.  Less  constant  symptoms  are  fever,  salivation  and  lachryma- 
tion;  tremor,  erection  and  ejaculation;  increased  pulse-rate;  scanty, 
albuminous  urine  (25  per  cent.),  often  with  casts.  The  excitation  stage 
lasts  one  and  a  half  to  three  days. 

Third  or  Paralytic  Stage. — This  stage,  less  common  in  human 
rabies,  in  animals  may  be  marked  from  the  beginning  and  the  other 
stages  may  be  lacking  or  rudimentary — the  "dumb"  rabies  as  contrasted 
with  the  furibund  type.  The  spasms  and  excitement  cease,  the  pulse 
becomes  fast,  small  and  irregular,  the  pupils  are  wide  and  irregular, 
sweating  is  profuse,  swallowing  becomes  impossible  and  paralyses  develop, 
mono-,  para-  or  hemiplegic,  or  of  the  acute  ascending  type  of  Landry. 
The  patient  dies,  unconscious,  of  cardiac  collapse,  rarely  of  asphyxia 
or  convulsions.  The  third  stage  seldom  lasts  more  than  eighteen 
hours. 

Autopsy  Findings. — Pathologists  are  not  unanimous  in  regard  to 
specific  findings.  Minute  hemorrhages  and  special  congestion  of  the 
medulla  and  cord  characterize  all  convulsive  states.  Babes's  rahic  tubercles 
are  aggregations  of  leukocytes  around  the  vessels  and  nerve  cells.  The 
latter  may  degenerate.  Rapid  diagnosis  of  rabies  may  be  made  accord- 
ing to  von  Gehuchten  and  Nelis,  by  examination  of  the  sympathetic  and 
cerebrospinal  ganglia,  under  the  capsules  of  which  are  found  accumula- 
tions of  epithelioid  and  lymylioid  cells,  in  animals,  only,  which  die  of  the 
disease.  The  bodies  described  by  Negri  and  Pavia  (1903)  in  the  cell 
processes  may  be  protozoal  parasites  or  artefacts. 

Course  and  Prognosis. — In  twelve  hours  to  ten  days — on  the  average 
two  to  four  days — all  untreated  cases  die,  10  per  cent,  in  the  first  day 
and  60  per  cent,  in  the  first  three  days.  Hogyes's  is  the  only  recovery 
verified  by  inoculations  of  the  saliva.  Paltauf's  autopsies,  on  persons 
under  Pasteur  treatment  and  dying  from  accidental  causes,  indicate 
that  9  out  of  10  persons  bitten  destroy  the  virus  in  the  central  nervous 
system,  for  the  inoculated  medulla  gives  rabies  to  guinea-pigs;  and  that 
the  tenth  case  fails  to  destroy  it  and  therefore  dies.  Tonin  alleges  a  cure 
under  salvarsan. 

Diagnosis. — After  bites  by  supposedly  rabid  animals,  microscopic 
examination  of  the  plexiform  ganglion  of  the  vagus  can  be  made  and  also 
subdural  inoculations  in  rabbits,  which  die  in  two  or  three  weeks  with 
paralytic  symptoms.  Tetanus  of  the  cephalic  and  hydrophobic  type  is 
distinguished  by  the  invariable  trismus.  Hysteria  (pseudohydrophobia, 
lyssophobia)  in  one  bitten  by  a  dog  may  at  first  cause  suspicion,  but 
rarely  any  protracted  doubt;  the  initial  spasmodic  dysphagia  and 
irritability  are  not  followed  by  other  symptoms  of  hydrophobia,  and  the 
clinical  evolution  alone  is  distinctive. 

Treatment. — Prophylactic. — Pasteur,  in  1881,  found  the  rabic  virus 
in  the  nervous  tissues.  "The  virus  of  the  street,"  as  Pasteur  called 
it,  varies  in  virulence  and  subdural  inoculations  from  the  brains  of 


HYDROPHOBIA  297 

rabid  dogs,  into  rabbits,  killed  them  in  periods  varying  from  fourteen 
to  twenty  days.  By  inoculating  a  series  of  rabbits,  the  incubation 
period  is  progressively  shortened  to  a  fixed  period  of  seven  days;  this 
"fixed  virus"  is  attenuated  by  desiccating  the  spinal  cord  of  the  rabbit 
with  caustic  potash.  Animals  w^ere  inoculated  with  virus  which  had 
been  desiccated  for  two  weeks,  then  w^ith  virus  a  little  stronger,  until 
finally  immunization  was  secured  against  inoculations  which  previously 
would  have  been  fatal.  In  1885  human  bemgs  bitten  by  rabid  beasts 
were  thus  treated  by  two  inoculations  daily  for  fifteen  days  and  immuni- 
zation was  secured,  for  the  slow  rabic  incubation  gives  ample  time  for 
treatment.  Statistics  show  that  the  former  mortality  of  80  per  cent,  in 
untreated  bit^s  in  the  head  or  face  has  been  reduced  to  1.25  per  cent.; 
the  mortality  of  60  per  cent,  in  those  bitten  in  the  hands  is  reduced  to 
0.75  per  cent.;  the  mortality  of  80  per  cent,  in  those  bitten  in  the  cov- 
ered parts  of  the  arm  and  trunk,  and  of  15  per  cent,  in  those  bitten  in 
the  leg,  is  reduced  to  0.25  per  cent.  The  total  mortality  has  been  reduced 
to  0.5  per  cent.  Treatment  requires  two  weeks.  As  Park  says,  "it  is 
a  contest  of  speed  between  the  passage  of  the  virus  from  the  wound  to 
the  brain  by  w^ay  of  the  nerves  and  the  development  of  immunity  by 
absorption  of  vaccines  through  the  circulation;"  if  "the  patient  escapes 
infection  up  to  the  end  of  two  weeks,  few,  following  the  full  course, 
develop  the  disease  (2  or  3  per  1000)."  As  sequences  of  Pasteur's  treat- 
ment, neuritis,  bulbar  or  spinal,  and  Landry's  paralysis  are  very  rarely 
found  (Babes,  1905).  One-half  of  those  treated  by  Pasteur's  method 
are  treated  unnecessarily.  W.  H.  Park  formulates  the  indications  thus: 
(i)  Keep  the  animal  and  if  it  has  rabies,  give  the  treatment,  (ii)  Xo  treat- 
ment is  necessary  if  at  the  end  of  the  week,  the  dog  has  not  developed 
rabies,  (iii)  If  the  animal  has  escaped,  judge  as  far  as  one  can  by  its 
conduct  (giving  the  patient  advantage  of  any  doubt) .  (iv)  If  the  animal 
has  been  killed  and  no  Negri  bodies  are  found,  give  the  treatment,  as 
microscopic  examination  is  negative  in  3  per  cent  of  cases,  (v)  If  the 
dog  has  been  killed  and  no  microscopic  examination  made,  give  the 
treatment  if  rabies  prevails. 

2.  Pkimary  Wound  Treatment. — The  wound  may  be  sucked  by 
the  victim,  but  by  no  other  person.  It  should  be  washed  with  strong 
antiseptics,  burned  with  nitric  acid  (the  best  remedy),  formalin,  pure 
phenol,  etc.,  and  exposed  surgically,  treated  w^ith  the  live  cautery  and 
packed  with  gauze,  so  that  healing  may  be  delayed  for  over  a  month. 

3.  Late  Treatment. — In  developed  cases  the  mortality  is  100  per 
cent.,  whence  curative  therapy  is  out  of  the  question.  The  treatment 
of  the  convulsions  is  similar  to  that  of  tetanus,  and  nutrition  is  main- 
tained by  nutritive  rectal  enemata.  Morphine  and  inhalation  of  chloro- 
form are  better  than  chloral  and  bromides  and  should  be  given  until 
they  show  their  full  physiological  effects.  Cocainization  of  the  mouth 
and  pharynx  may  overcome  the  pharyngeal  spasm  incident  to  swallowing 
milk  and  water  and  to  medication.  Tracheotomy  is  useless  for  the  respi^ 
ratory  spasm,  which  reaches  further  than  the  larynx  and  involves  the 
muscles  of  the  chest  and  diaphragm. 


298  INFECTIOXS  OF  DOUBTFUL  ETIOLOGY 


FEBRICULA. 

Definition. — A  fever  of  short  duration.  If  only  of  twenty-four  hours' 
duration  it  is  called  ephemeral  ferer;  when  it  lasts  a  few  days,  it  is  called 
fehricula;  when  attended  by  herpes,  fehris  herpefica;  or  when  accompanied 
by  gastric  disorder,  febris  gastrica. 

Febricula  is  no  morbid  entity,  but  embraces  (a)  benign  or  abortive 
forms  of  various  infections,  such  as  rheumatism,  typhoid,  paratyphoid, 
malaria,  scarlatina,  tonsillitis  and  pneumonia;  infections  with  the 
Bacillus  coli,  proteus  or  pyocyaneus;  and  {b)  febrile  dyspepsias,  especially 
those  in  children.  Gastric  fever  or  febrile  gastritis  is  possibly  produced 
by  toxins  in  the  food.    Sewer  gas  never  causes  gastro-mte%tinal  fever. 

Symptoms. — The  three  common  symptoms  are  (a)  chill  or  chilliness; 
(h)  sudden  rise  of  temperature;  and  (c)  a  slow  crisis.  The  onset  is 
abrupt,  usually  without  prodromes.  The  fever  rises  quickly  to  101°  to 
103°,  or  higher  in  the  young,  with  the  usual  signs  of  toxemia,  headache, 
coated  tongue,  anorexia  and  febrile  urine.  Herpes  is  frequent.  Bron- 
chitis, acute  splenic  tumor,  albuminuria  and  in  children,  cerebral  toxemia, 
are  sometimes  present.  The  term  ephemeral  is  inappropriate,  as  the 
average  duration  is  three  days. 

Diagnosis  and  Treatment. — ^The  diagnosis  is  by  exclusion,  and  the 
treatment  is  expectant.  Rest  in  bed  is  advisable  as  a  precaution  against 
some  longer  and  insidious  malady;  the  bowels  should  be  unloaded,  the 
diet  restricted. and  a  drop  or  two  of  tincturte  aconiti  and  spts.  eetheris 
nitrosi  qss  given  every  three  or  four  hours. 

GLANDULAR    FEVER. 

Definition. — An  acute  infection,  characterized  by  pharyngeal  infec- 
tion, short,  high  fever  and  painful  cervical  lymphadenopathy.  It  was 
described  as  Driisen  fieber  by  Pfeiffer,  in  1889.  Its  etiology  is  unknoT\TL 
but  it  is  evidently  an  infection  and  frequently  epidemic.  It  is  usually 
seen  between  five  and  eight  years  of  age,  and  during  the  colder  months. 
Park  West  observed  an  epidemic  of  96  cases  m  Bellaire,  Ohio.  Hoch- 
singer  and  Kretz  mamtain  that  the  adenopathy  is  the  first  obvious  sign 
and  sequel  to  nasopharyngeal  infection. 

Symptoms. — ^The  symptoms  begin  without  prodromes,  with  fever 
of  101°  to  103°,  pain  in  the  head  and  neck,  redness  of  the  throat,  dys- 
phagia, nausea,  vomiting,  pain  in  the  limbs  and  abdomen.  On  the 
second  day  the  cervical  lymph  glands  become  swollen  and  tender  bilater- 
ally, especially  back  of  the  upper  part  of  the  stemomastoid.  The  inguinal 
and  axillary  glands  are  involved  in  75  per  cent,  of  cases.  The  glands 
may  reach  the  size  of  an  egg.  After  ten  to  twenty  days  the  swelling 
subsides,  having  lasted  longer  than  the  fever,  which,  after  a  few  days, 
falls  by  crisis.  In  some  instances  a  persistent,  dry  cough  suggests  involve- 
ment of  the  bronchial  glands,  and  umbilical  pain  of  mesenteric  localiza- 
tion (in  about  40  per  cent.).  The  spleen  is  enlarged  in  60  and  the  liver  in 
90  per  cent.  Suppuration  is  exceptional.  Acute  nephritis,  endocar- 
ditis, herpes  and  otitis  media  are  occasionahy  observed. 


WEIL'S  DISEASE  299 

Prognosis  and  Treatment. — The  prognosis  is  good.  The  absence  of  a 
rash  excludes  the  adenopathies  of  varicella,  scarlatina  and  measles,  and 
the  generalized  glandular  swelling  excludes  the  local  swelling  due  to 
simple  pharyngitis.    The  treatment  is  expectant. 

MILIARY   FEVER. 

Definition. — An  acute  infection,  marked  by  fever,  sweating,  miliary 
eruption,  nervous  symptoms  and  precordial  anxiety.  It  first  appeared 
in  England  after  the  Battle  of  Bosworth  (1486)  and  was  known  as  the 
"English  sweats"  {sudor  Anglicus);  its  mortality  reached  50  to  80  per 
cent.  In  1529  it  caused  3000  deaths  in  Dantzig.  There  have  been  200 
epidemics  between  the  epidemic  in  Picardy,  in  1718,  and  that  in  Poitou, 
in  1887.  It  is  highly  contagious.  Short  epidemics  have  occurred  in 
Italy,  Switzerland,  Germany  and  Austria,  with  a  death-rate  of  5  to 
25  per  cent.  In  1906  an  epidemic  of  over  6256  cases  prevailed  in  northern 
France. 

Symptoms  and  Treatment. — In  mild  outbreaks  the  symptoms  are 
fever,  profuse  periodic  sweating  and  miliary  eruptions.  The  eruption 
may  be  erythematous  or  morbilliform  (miliaria  rubra),  or  without  red- 
ness of  the  skin  (miliaria  alba) ;  desquamation  follows.  In  severe  cases 
there  are  marked  cerebral  toxemia,  rapid  pulse,  precordial  distress, 
palpitation,  splenic  tumor,  prostration  and  hemorrhages  into  the  skin; 
death  results  in  a  day  or  two.  Its  duration  averages  ten  days.  Convales- 
cence is  tardy  and  treatment  supportive  and  expectant. 

WEIL'S   DISEASE    (ACUTE    FEBRILE   JAUNDICE). 

Definition. — An  acute  infection,  characterized  by  fever,  jaundice, 
herpes,  enlarged  spleen  and  liver,  sore  throat,  muscle  pain  and  albu- 
minuria. It  was  especially  described  by  Weil  (1886).  Nicolaysen 
describes  63  epidemics  in  Norway  and  Sweden  in  the  last  fourteen  years; 
the  morbidity  was  3  to  28  per  cent. 

Etiology. — Its  etiology  is  unknown,  whence  it  may  be  a  morbid  entity 
or  may  include  several  diseases.  It  occurs  in  90  per  cent,  in  men  between 
twenty-five  and  forty,  especially  in  butchers  and  alcoholics,  in  the  warmer 
seasons.  The  Proteus  fluorescens  has  been  found,  but  the  intravitam 
findings  are  usually  negative.  Some  cases  have  occurred  in  this  country; 
the  author  saw  9  cases  in  Chicago. 

Symptoms.— The  symptoms  begin  suddenly  with  fever,  chill,  head- 
ache and  severe  pains  in  the  extremities.  The  fever  reaches  103°;  it 
remits  and  falls  by  crisis  or  lysis  after  five  to  eight  days.  The  nervous 
symptoms  may  resemble  typhoid.  Jaundice  develops  on  the  third 
day,  due  to  catarrhal  angiocholitis ;  bile  appears  in  the  urine  and  the 
stools  are  often  acholic;  the  author  has  twice  seen  deep  jaundice  without 
bile  obstruction.  Muscular  pain  and  tenderness  are  intense,  especially 
in  the  calves.  Articular  pains  are  not  uncommon.  Herpes  is  very  com- 
mon. The  rapid  pulse  contrasts  sharply  with  the  slow  pulse  of  simple 
catarrhal  icterus.    In  2  cases  the  author  observed  blood-stained  bronchitic 


300  INFECTIONS  OF  DOUBTFUL  ETIOLOGY 

sputum.  Digestive  symptoms  are  common,  as  furred  tongue,  vomiting, 
epigastric  pain,  abdominal  distention  and  diarrhea.  The  liver  is  enlarged 
and  tender  in  more  than  50  per  cent,  of  cases,  the  spleen  in  over  66  per 
cent.,  and  the  lymph  nodes  are  frequently  affected.  The  urine  is  albu- 
minous in  over  50  per  cent. ;  acute  nephritis  is  frequent;  hematuria  occurs 
occasionally  and  uremia  exceptionally;  the  urea  and  the  amount  of  urine 
are  decreased  during,  and  increased  after,  the  seizure  (Chauffard's 
nitrogenous  and  polyuric  crises). 

Diagnosis. — Weil's  disease  must  be  differentiated  from  recurrent  fever, 
sepsis,  tvphoid,  suppurative  angiocholitis  {q.  v.)  and  acute  vellow  atrophv 
(q.T.).    ' 

Prognosis. — Convalescence  is  usually  established  in  two  weeks;  the 
mortality  may  reach  11  per  cent.  Recurrence  in  40  per  cent,  may  be 
anticipated  if  the  splenic  tumor  persists;  renal  or  hepatic  insufficiency, 
pregnancy  and  hemolysis  render  the  prognosis  less  favorable. 

Treatment. — The  treatment  is  directed  to  (a)  the  intoxication,  for 
which  calomel  and  salines  are  indicated;  cold-water  enemata  increase 
the  renal  flow,  and,  with  it,  the  excretion  of  toxins;  (b)  the  jaundice, 
for  which  salines  are  given  to  lessen  duodenal  catarrh;  (c)  the  albumin- 
uria, for  which  a  milk  diet  is  indicated;  and  (d)  muscular  pains,  for 
which  heat  and  massage  with  chloroform  liniment,  are  most  beneficial. 

MILK   SICKNESS. 

Definition. — A  disease  acquired  by  man  from  the  milk  or  meat  of 
cattle  suftering  from  the  "trembles."  Cows  with  the  disease,  after 
being  driven  too  rapidly,  suft'er  from  anorexia,  injection  of  the  eyes, 
vertigo,  trembling  and  convulsions  ending  in  death.  Young  horses 
and  sheep  may  also  acquire  the  disease.  Milk  sickness  occurs  chiefl}' 
in  newly  settled  countries,  as  in  the  Southwestern  states,  and  it  is  still 
seen  in  North  Carolina.  Its  origin  and  pathology  are  unknown.  Jordan 
and  Harris  describe  a  Bacillus  lactimorbi. 

Symptoms. — In  man  the  nervous  symptoms  are  frequently  conspic- 
uous, as  restlessness,  convulsions  or  coma,  which  appear  after  a  few 
days  of  malaise.  The  tongue  is  swollen  and  heavily  coated,  the  breath 
fetid,  the  stomach  painful  and  irritable,  the  fever  low,  high  or  sometimes 
typhoidal.  The  issue  is  either  fatal,  in  acute  forms,  within  a  few  days, 
or  recovery  may  result  after  weeks.  Flesh,  butter,  cheese  and  milk, 
from  infected  animals  may,  even  when  boiled,  cause  death  when  given 
to  dogs. 

ROCKY   MOUNTAIN    FEVER. 

It  occurs  in  the  Bitter  Root  Valley  of  Montana  and  also  in  Wyoming, 
Nevada  and  Idaho.  Howard  Ricketts  found  the  disease  was  inoculable 
and  he  and  King  found  the  medium  of  infection  was  the  wood-tick 
(Dermacentor  occidentalis) .  Ricketts  (1909)  discovered  a  bacillus  like 
that  of  hemorrhagic  septicemia.  Cases  develop  in  the  early  spring,  and 
are  marked  by  chill,  fever  lasting  one  or  two  weeks,  rapid  pulse,  epistaxis, 
albuminuria,  rapid  breathing,  bronchitis,  splenic  tumor,  rapid  anemia, 


RAT-BITE  DISEASE  301 

moderate  leukocytosis,  slight  icterus,  muscular  pains  and  a  widely  diffused 
macular  rash,  which  develops  on  the  third  day,  disappears  on  pressure . 
at  first,  but  afterward  persists  on  pressure.  The  liver  and  spleen  are 
enlarged.  Quinine  may  be  beneficial  in  some  cases.  The  death-rate 
may  reach  70  to  90  per  cent,  in  Montana,  yet  in  Idaho  it  runs  between 
2  and  3  per  cent.  T.  B.  McClintic  died  a  martyr  to  the  disease,  as 
Ricketts  died  of  typhus. 

FOOT-AND-MOUTH   DISEASE. 

Definition. — Epidemic  stomatitis,  aphthous  fever,  or  aphtha?  epizo- 
oticse  is  one  of  the  zoonoses.  Loeffler  and  Frosch  have  shown  that  the 
virus  is  ultramicroscopic,  passing  in  full  virulence  through  porcelain 
filters.  The  disease,  first  described  by  von  Valentini,  in  1695,  chiefly 
affects  cattle,  sheep  and  pigs,  but  sometimes  also  goats,  horses,  dogs, 
and  even  fowl.  In  cattle  there  is  fever,  swelling  of  the  mouth,  salivation 
and  the  formation  of  small,  clear  vesicles  on  the  tongue,  gums,  lips, 
udders  and  hoofs.  These  vesicles  soon  become  opaque,  and  bursting, 
form  small  ulcers;  emaciation  is  rapid,  and  the  milk  becomes  yellowish 
and  mucoid.  Embolism  or  fatal  apoplexy  may  result.  Recovery  is 
usual  in  ten  days.  The  disease  spreads  very  rapidly.  It  is  observed  in 
Hungary,  Germany,  France,  Switzerland,  England  and  America,  Chicago 
being  the  centre  of  a  wide  epidemic  in  1914. 

Etiology  and  Symptoms. — hi  man  infection  occurs  from  diseased 
milk  (as  proved  on  himself  by  Hertwig),  butter  and  cheese,  but  not 
by  diseased  meat.  Open  wounds  may  be  directly  infected.  Cattle 
have  been  inoculated  from  man.  The  incubation  is  three  to  five  days. 
There  are  fever,  salivation,  aphthous  ulcers,  angina,  nausea,  vomiting 
and  vesicles  on  the  skin — which  have  caused  confusion  with  vaccinia. 
Hemorrhages  occur  in  severe  epidemics.  Ebstein  suggested  that  foot- 
and-mouth  disease  may  be  kindred  with  the  ordinary  aphthous  stoma- 
titis of  nurslings  or  pregnant  women.  Children  are  more  endangered 
than  adults.  The  death-rate  is  2  to  8  per  cent.  Recovery  is  usual  in 
three  weeks. 

Trea,tment. — Prophylaxis  concerns  the  boiling  of  suspected  milk,  the 
segregation  of  diseased  animals  or  human  subjects,' and  vaccination,  as 
discovered  by  Loeffler.  A  dram  of  5  per  cent,  solution  of  potas.  chlorate, 
t.  i.  d.,  should  be  given,  and  the  aphthae  should  be  touched  with  borax 
or  silver. 

RAT-BITE   DISEASE. 

Rat-bite  fever,  known  as  Sokudu  in  Japan,  closely  resembles  recurrent 
fever  and  in  some  ways,  lues.  The  bite  heals,  and  after  two  to  five 
weeks,  inflammation,  even  ulceration  develops  at  its  site,  with  inter- 
mittent fever,  chills,  headache,  vomiting,  an  erythematous  eruption, 
eosinophilia  and  local  and  general  lymphadenopathy.  After  a  fever-free 
interval  of  three  to  five  days,  the  symptoms  recur;  the  mortality  is 
10  per  cent.,  usually  from  nephritis.  Crohn  (1915)  coflected  52  cases. 
Salvarsan  is  recommended. 


302  METAZOAN  INFECTIONS 

PSITTACOSIS. 

Psittacosis  is  a  disease  of  birds,  characterized  by  loss  of  appetite, 
general  weakness,  diarrhea,  convulsions  and  death.  It  is  communicable 
to  man,  infection  being  commonly  acquired  from  parrots.  The  disease 
occurs  in  England,  Germany,  France  and  Italy.  It  is  characterized  by 
atypical  pneumonia,  attended  by  profound  and  usually  fatal  toxemia. 


METAZOAN  INFECTIONS. 

DISEASES    CAUSED   BY   CESTODES. 

Tape-worms  were  known  to  the  Egyptians,  Hindus  and  probably  the 
Jews.  They  may  cause  s^TQptoms  by  the  presence  of  the  mature  parasite 
in  the  bowels  or  of  the  larval  form  in  the  viscera. 

I.  Tenia  Solium. — The  Tenia  solium  or  pork  tape-worm  (Linnaeus, 
1752)  exists  as  the  cysticercus  cellulosse  in  hogs  and  rarely  in  dogs, 
rats  or  deer,  as  "measles."  .The  adult  form  is  peculiar  to  man.  Cysti- 
cerci  (the  larvse),  found  in  the  intermuscular  tissue,  particularly  of  the 
undersurface  of  the  tongue,  in  the  masseters,  shoulders,  neck  and  dia- 
phragm, are  easily  seen  with  the  naked  eye  and  very  easily  with  a  low-power 
lens,  as  small,  opaque,  white  bodies.  They  are  vastly  more  frequent  in 
Asiatic  and  German  than  in  American  pork.  Man  is  infected  by  eating 
raw  or  partly  cooked  "measley"  pork;  the  cysticerci  develop  in  the 
upper  ileum  into  the  tenia  ("band  or  ribbon-like")  solium  (referring  to 
its  usual  solitary  appearance,  though  2  or  3,  and  even  20  or  41,  have 
been  found).  The  worm  measures  2  to  8  meters  in  length.  Its  head 
(scolex)  is  round,  often  gray  or  black  in  its  upper  part,  is  smaller  than  a 
pin-head,  and  is  attached  to  the  upper  ileum;  it  has  4  sucking  disks  and 
20  to  30  booklets,  arranged  in  an  anterior,  more  numerous  row,  and  a 
posterior  row,  whence  the  name  "armed"  tape- worm;  it  has  no  real 
mouth.  Its  neck  is  thin  and  not  jointed,  to  which  the  segments,  "pro- 
glottides," are  attached.  These  number  800  or  900;  the  segments 
measure  10  mm.  in  length  by  5  or  6  mm.  in  width;  those  near  the  neck 
are  narrower  and  shorter.  About  a  yard  from  the  neck  they  become 
squarer,  and  lower  down  they  are  smaller  again.  Each  proglottis  is 
hermaphroditic,  containing  male  and  female  reproductive  elements. 
The  uterus  is  central  and  vertical,  with  7  to  15  lateral  branches;  only 
a  few  of  them  mature,  chiefly  those  in  the  lower  links;  the  ova  (31  to 
36/i)  are  very  numerous  in  each  maturing  segment  and  each  one  shows 
a  shell  and  an  embryo  armed  mth  six  booklets.  The  tenia  reaches  its 
full  length  of  two  to  four  yards  in  three  or  four  months,  when  the'  lower 
segments  are  detached  and  voided;  if  the  worm  breaks  and  a  yard  or  so 
appears  in  the  feces,  segments  do  not  reappear  in  the  feces  until  three 
months  later.  An  ovum  ingested  by  a  hog  or  man  loses  its  shell  in  the 
stomach  and  the  freed  embryo  passes  into  the  tissues,  where,  encysted, 
it  becomes  again  the  cysticercus  cellulosse  (or  larva). 


DISEASES  CAUSED  BY  CESTODES  ■  303 

Symptoms  of  the  Tenia  Solium  in  the  Human  Intestine  (Intestinal  Teniasis). 
— Many,  possibly  most,  cases  present  no  symptoms;  they  may  first 
develop  after  passing  segments  are  noted  by  neurotic  subjects.  In  other 
cases  headache,  itching,  pupillary  inequality,  emaciation  and  dyspeptic 
disturbances  arise,  as  anorexia  (or  less  often  ravenous  appetite),  nausea, 
abdominal  pains,  constipation  or  diarrhea.  Stiles,  in  an  experimental 
infection  on  himself,  thought  that  he  could  feel  the  parasite  move. 
Several  feet  of  tape- worm  have  been  vomited;  in  these  rare  instances 
the  individual  suffers  from  both  the  intestinal  and  larval  stages.  Anemia 
is  uncommon.  In  children  reflex  convulsions  are  possible.  The  parasite 
may  live  for  10  to  15  years.  The  diagnosis  is  determined  by  the  segments 
and  ova  and  the  i^rognosis  is  good. 

Treatment. — As  to  prophylaxis:  segments  of  the  tape-worm  should 
be  burned;  meat  inspection  should  be  general;  "interstate"  meat  is 
well  inspected;  pork  should  always  be  thoroughly  cooked.  Hogs  obtain 
ova  from  human  feces. 

1.  To  cure  the  disease  a  light  and  chiefly  _^md  diet  should  be  given  for 
two  days,  when  food  is  withheld  for  eighteen  hours;  this  often  causes 
the  parasite  to  release  its  hold  on  the  mucous  membrane;  a  meal  of 
onions  and  herring  may  be  given  just  before  drugs  are  administered. 

2.  A  preliminary  cathartic  cleanses  the  bowel,  allows  more  direct  access 
of  the  vermifuge  to  the  parasite  and  prevents  its  regaining  its  hold  when 
once  detached. 

3.  Anthelmintics:  Of  these  pomegranate  (granatum)  ranks  first;  a 
decoction  is  made  of  3  ounces  of  the  root  with  8  ounces  of  water, 
reduced  to  4  ounces  by  evaporation  and  taken  in  divided  doses 
within  three  or  four  hours;  its  active  principle  is  the  expensive  pelle- 
tierine,  which  is  given  in  doses  of  3,  5  to  10  grains  and  is  followed  by  a 
purge  in  an  hour  (pelletieringe  tannas) .  Male  fern  (f elix  mas)  is  almost 
equally  efl^ective;  it  is  given  as  the  oleoresina  aspidii,  or  extr.  felicis 
maris  ether.,  5iss-iiss;  it  may  be  given  in  syrup;  both  are  followed  by  a 
saline  purge  in  three  or  four  hours.  Castor  oil  is  never  used,  because  it 
promotes  absorption  of  the  male  fern,  which  causes  toxic  symptoms,  as 
icterus,  claudication  or  amaurosis;  Sidler  collected  78  cases  of  poisoning 
with  15  per  cent,  mortality  and  lasting  blindness  in  25  per  cent. ;  Leich- 
tenstern  advises  that  more  than  10  gm.  (5iiss)  of  the  ethereal  extract 
should  never  be  given  to  adults  (5  j  or  less  to  children) ;  that  it  never  be 
given  on  an  empty  stomach  or  given  two  days  in  succession.  The  drug 
decomposes  easily,  whence  reliable  preparations  must  be  obtained. 
Combinations  may  be  made  by  giving  after  the  decoction  of  pomegranate, 
spts.  chloroformi  (Hlxv)  for  four  doses  or  croton  oil  (lUij)  for  one  dose; 
thymol  {v.  i.)  is  effective.  Search  should  be  made  for  the  head  of  the 
parasite,  without  removal  of  which  treatment  is  unsuccessful.  If  it  is 
not  found  another  trial  should  be  made  after  a  few  weeks. 

I^ — Oleoresinse  aspidii, 

Tr.  vanillse aa     gtt.  xlv 

Acacije, 

Sacchari  albi aa      3J 

Aquce ■       ■       5J 

M.  et  fac  emulsum. 
S. — Take  in  one  dose. 


304  METAZOAN  INFECTIONS 

Symptoms  of  the  cysticercus  cellulosoe  (somatic  teniasis)  result  when 
ova  of  the  Tenia  solium  are  taken  into  the  stomach;  ova  may  reach 
the  stomach  from  the  intestines  by  antiperistaltic  movements  during 
vomiting  or  indirectly  by  handling  worms  voided  from  the  bowels. 
Cysticerci  in  the  hog  produce  few  symptoms.  In  man,  symptoms  depend 
largely  on  the  number  and  localization  of  the  larvae,  (a)  In  the  muscles 
and  six  in,  a  few  cysticerci  cause  no  symptoms;  numerous  cysticerci 
cause  pain,  tenderness  and  difficult  movement.  Diagnosis  is  possible 
only  on  excision  of  the  subcutaneous  nodules.  In  Stiles's  collection  of 
155  cases  the  localization  was  muscular  in  20  per  cent,  and  cutaneous 
in  3  per  cent.  (6)  In  the  brain  (in  75  per  cent,  of  Stiles's  series)  symptoms 
depend  on  their  location;  they  are  often  absent;  if  the  location  is  in 
the  cortex,  Jacksonian  epilepsy  is  frequent,  and  if  in  the  medulla,  diabetes 
may  develop,  (c)  Other  localizations.  They  may  be  found  clinically  in 
the  eye  (v.  Graefe)  and  at  autopsy  in  the  lungs,  kidneys  or  liver.  There 
is  no  treatment  except  surgery. 

II.  Tenia  Saginata  (Mediocanellata). — This  form  (Goeze,  1782)  is 
the  most  frequent  of  large  tape-worms  in  America  and  Europe.  It  is 
the  "fat,"  "unarmed"  or  beef  tape-worm.  Its  cysticercus  hovis  is  found 
in  masseters  of  beef  seven  times  as  frequently  as  in  other  muscles  or  in 
the  heart  or  brain.  They  are  not  so  readily  seen  with  the  naked  eye  as 
the  cysticerci  in  pork.  Ingestion  of  rare  beef  containing  cysticerci 
produces  the  Tenia  saginata  in  man,  in  whom  alone  the  adult  worm  is 
found. 

The  intestinal  parasite  differs  from  the  T.  solium  in  the  following 
points:  (a)  its  head  is  larger,  measuring  2  mm.  and  is  square;  it  has 
no  booklets  but  four  sucking  disks,  which  are  larger,  more  forward  and 
are  surrounded  by  pigment,  (b)  Its  neck  is  much  shorter,  (c)  Its 
proglottides  are  longer  (16  to  22  mm.)  and  broader  (5  to  10  mm.);  even 
1000  segments  have  been  found,  (d)  The  uterus  contains  15  to  35 
branches,  which  are  less  dendritic  than  pronged  or  forked;  in  diagnosis 
the  uterus  is  more  important  than  the  ova  or  size  of  the  segments,  which 
are  hard  for  the  practitioner  to  distinguish  (Stiles),  (e)  The  ova  measure 
30-40  by  20-30fx.  (/)  The  parasite  is  larger  and  longer,  measuring  4 
to  10  meters.  Its  symptoms  and  treatment  are  those  of  the  Tenia  solium. 
Ingestion  of  the  ova  or  segments  from  human  feces  produces  the  cysti- 
cercus mediocanellata,  which  is  common  in  beef  but  extremely  rare  in  man. 

in.  Other  Teniae  Occurring  in  Man. — The  Dibothriocephalus  latus 
(Linnaeus,  1782),  or  the  Russian  tape- worm,  is  found  chiefly  in  Russia, 
Poland,  Norway,  Sweden,  Switzerland  and  Japan.  It  is  rarely  found 
in  this  country  unless  imported  (30  cases  reported,  Stiles),  but  fish  in 
Lake  Superior  have  recently  been  infected.  Its  cysticerci  are  found  in 
the  muscles  and  peritoneum  of  the  pike,  trout,  salmon  and  perch  and  in 
man's  intestines  develop  into  the  dibothriocephalus.  Its  head  is  flat 
or  ovoid,  possesses  no  booklets  and  attaches  itself  to  the  intestines  by 
two  lateral  grooves  (suckers).  Its  neck  is  long  and  its  segments  broad, 
square  and  may  number  3000  to  4200.  It  is  long,  measuring  8  to  10 
yards.  It  may  produce  a  profound  anemia  which  in  severe  cases  closely 
resembles  the  pernicious  type  in  its  general  symptoms  and  blood  findings. 


DISEASES  CAUSED  BY  CESTODES  305 

The  Tenia  eUiptica  or  cucumerina  (Dipylidium  caninum)  is  a  form, 
the  larvae  of  which  develop  in  the  lice  of  dogs  and  the  adult  form  exists 
in  the  intestines  of  dogs,  sometimes  in  those  of  cats  and  rarely  in  man. 

The  Tenia  flavo-pundata  (Hymenolepsis  diminuta),  the  larvae  of  which 
exist  in  beetles  and  Lapidoptera,  exists  in  rats  and  12  human  cases  are 
recorded  (Rausom). 

The  Tenia  nana  (Hymenolepis  nana)  is  the  dwarf  tape-worm.  It 
measures  but  ^  to  2  inches  in  length.  Its  cj^sticercus  stage  is  in  the 
intestinal  wall  of  the  rat  and  its  adult  stage  in  the  rat's  intestine.  Stiles 
decided  that  it  is  much  more  frequent  in  man  than  previous  accounts 
would  indicate  and  in  some  places  is  the  most  common  type.  Its  head 
contains  four  suckers  and  one  row  of  booklets.  It  may  occur  singly  or 
in  myriads.    Aspidium  alone  is  of  therapeutic  benefit. 

Tenia  Echinococcus  (Echinococcus  Disease)  (Zeder,  1803). — We  may 
first  consider  the  adult  parasite  as  inhabiting  the  intestine  of  the  dog  chiefly 
and  rarely  of  the  wolf,  fox  or  jackal.  The  head  is  small  and  is  provided 
with  four  suckers,  and  from  30  to  50  booklets  arranged  in  a  double  row. 
The  segments  number  only  three  or  four,  and  only  the  end  one  matures; 
it  measures  but  0.6  by  2  mm.  but  contains  even  5000  ova.  The 
worm  is  small,  measuring  but  4  to  5  mm.  in  length,  is  very  delicate  and 
white,  so  that  it  readily  escapes  detection.  When  the  ovum  reaches 
the  stomach  of  another  animal,  the  hog  and  ox  chiefly,  and  less  often 
the  horse,  sheep  or  man,  it  loses  its  shell  and  migrates  to  the  various 
organs.  The  geography  of  echinococcus  disease  and  mode  of  infection  is 
as  follows :  In  Iceland,  where  dogs  and  men  live  together,  every  seventh 
person  becomes  infected.  In  Australia  both  men  and  sheep  are  often 
infected.  In  Europe  the  malady  is  much  more  common  than  in  America, 
where  the  reported  cases  in  1901  numbered  241  (Lyon);  most  of  these 
were  foreigners.    Icelanders  brought  the  disease  to  Manitoba  in  1874. 

Infection  occurs  by  licking  of  the  hands  by  the  dog,  the  tongue  and 
anus  of  which  often  come  in  contact.  Infection  by  contaminated  drink- 
ing water  or  vegetables  is  less  common. 

General  Symptoms  and  Pathology. — The  small  embryo,  freed  of  its 
shell,  penetrates  the  intestinal  wall  and  wanders  into  the  muscles,  peri- 
toneum or  radicles  of  the  portal  vein  or  cava,  so  that  any  tissue  or  organ 
may  be  infected,  and  stops  when  it  reaches  vessels  too  small  for  it.  Once 
lodged,  its  booklets  disappear  and  a  cyst  develops,  which  is  small  at 
first  but  gradually  reaches  large  or  enormous  proportions;  cysts  may  con- 
tain 30,  even  70  pints  of  fluid.  Its  layers  consist  of  a  granular  endocyst 
and  an  outer  finely  lamellated  structureless  capsule;  a  fibrous  layer 
develops  outside  from  reaction  of  the  tissues  to  the  foreign  body.  After 
a  while  a  number  of  "daughter"  cysts  arise  from  the  endocyst;  these 
are  first  "buds"  and  then  miniatures  of  the  original  mother  cyst;  from 
these  daughter  cysts,  which  number  about  a  dozen,  "granddaughter" 
cysts  arise  by  an  identical  process.  Allen  in  one  case  found  8000  daughter 
cysts.  Finally  from  the  endocyst  of  the  maternal  and  daughter  cysts 
there  develop  "brood  capsules,"  in  which  small  buds  arise,  which  grad- 
ually become  scolices  (the  heads  of  which  will  be  intestinal  tenise  in  the 
animal  which  ingests  them).  Some  cysts  do  not  develop  scolices  and 
20 


306  METAZOAN  INFECTIONS 

are  called  sterile.  In  animals  the  daughter  cysts  may  grow  outward 
(exogenous  cysts) .  The  well-grown  cyst  contains  fluid  {v.  Liver  Echino- 
coccus);  it  is  clear  and  neutral,  has  a  specific  gravity  of  1005-15  and 
contains  succinic  acid,  inosite  (possibly  sugar)  and  much  sodium  chloride 
but  no  albumin,  unless  the  parasite  dies  and  cystic  inflammation  develops, 
then  the  fluid  may  become  buttery,  gelatinous,  purulent,  brownish  or 
grumous;  the  cysts  disappear  as  well  as  the  membrane,  though  the 
booklets  remain  a  long  time.  When  the  parasites  are  alive  a  toxin  is 
present,  for  collapse  often  develops  when  the  cyst  ruptures  or  is  punc- 
tured (anaphylaxis) . 

The  parasite  lives  for  years,  in  one  instance  for  twenty  years;  after 
a  variable  time,  unless  suppuration  intervenes,  the  cysts  become  cheesy, 
perhaps  calcified  or  ossified. 

The  parasite  may  rupture  into  the  serous  sacs,  bloodvessels  (causing 
embolism),  air  passages,  urinary  tract  or  externally  (see  pages  580  and 
665) ;  in  50  per  cent,  it  is  fatal  within  five  years. 

Visceral  Localization. — In  1912  cases  (the  total  reported  by  Davaine, 
Finsen,  Mosler,  Neisser  and  Cobbold)  the  liver  was  involved  in  51  per 
cent.,  genito-urinary  organs  in  10,  intestinal  canal  in  9,  lungs  or  pleurae 
in  9,  brain  or  cord  in  7,  bones  in  3,  heart  and  vessels  in  3,  and  other 
organs  in  8  per  cent.  Vegas  and  Cranwell  reported  970  Argentine  cases 
of  which  64  per  cent,  were  hepatic.  Thomas,  in  809  Australian  cases  of 
single  hydatid  cyst,  found  the  lungs  involved  in  16.5  per  cent.  Hook- 
lets  have  been  obtained  by  lumbar  puncture.  There  are  reported  142 
cases  of  renal  echinococcus,  78  cases  with  localization  in  the  bones  and 
23  in  the  pelvic  bones,  25  in  the  pancreas,  80  in  the  spleen  and  55  cases 
with  cardiac  or  pericardial  localization;  23  thyroid  cysts  have  been 
reported. 

EcJwiococciis  of  the  Lung. — Many  cases  produce  no  symptoms  and 
are  unexpected  findings  at  the  postmortem.  Dieulafoy  described  three 
clinical  stages:  (a)  the  initial,  (6)  the  tumor  stage  and  (c)  the  suppura- 
tive or  rupture  stage,  (o)  The  initial  stage  often  has  no  symptoms, 
but  may  be  marked  by  scanty  hemoptysis,  cough,  emaciation  and  pos- 
sibly fever,  all  of  which  may  closely  simulate  incipient  phthisis.  (6)  In 
the  tumor  stage,  there  are  bronchial  (or  weak)  breathing,  increased  fremi- 
tus and  circumscribed  dulness,  which  occur  in  the  lower  lobes  and  twice 
as  frequently  on  the  right  side  as  on  the  left;  it  sometimes  causes  bulging 
of  the  chest  wall.  There  is  a  sharp  transition  betw^een  it  and  the  note 
of  the  sound  contiguous  lung.  Dislocation  of  the  heart  and  compres- 
sion of  the  lung  may  occur.  The  .r-rays  often  confirm  the  physical 
signs.  The  dulness  curves  upward,  but  is  quite  difterent  from  the  curve 
of  pleuritic  eft'usion  which  is  concave  upward.  Tumor  of  the  lung  gives 
a  larger,  harder  flatness.  Puncture  reveals  a  clear,  aseptic  fluid  (v.  s.). 
(c)  In  the  third  stage,  as  in  liver  echinococcus,  rupture  may  occur  into 
the  pleura  (in  which  primary  disease  is  25  times  as  rare).  Pneumo- 
thorax may  result.  Far  oftener  rupture  into  a  bronchus  occurs,  with 
pain,  dyspnea,  collapse  and  sudden  "mouthful"  expectoration  of  pus, 
small  vesicles,  lamellated  cyst  wall  and  booklets.  At  the  time  of  rupture 
a  curious  urticaria  develops  (Finsen)  which  is  probably  toxic,  as  the  fluid 


DISEASES  CAUSED  BY  NEMATODES  307 

from  echinococcus  cysts  produces  it  when  inoculated  into  animals. 
Profuse  hemoptoe  is  common.  If  it  comes  from  the  liver,  the  sputum 
is  ochre-yellow  from  undissolved  bilirubin,  even  when  there  is  no  direct 
connection  with  the  bile  vessels;  cholesterin  is  often  present.  The 
vesicles  or  cyst  wall  may  cause  suffocation.  Rupture  may  also  occur 
into  the  pericardium,  stomach  or  peritoneum.  In  this  stage  hectic 
fever  is  usual. 

There  is  an  unusual  form  of  echinococcus,  the  multilocular  form, 
probably  due  to  a  separate  worm,  the  clinical  features  of  which  are 
described  under  hydatid  disease  of  the  liver,  to  which  it  is  almost 
exclusively  confined.  Virchow  first  described  it  in  1856.  It  occurs  in 
Bavaria,  Wiirtemburg,  Switzerland,  Austria,  Austrian  Tyrol  and  Russia; 
6  imported  cases  have  occurred  in  America.  It  is  unknown  where  the 
ordinary  form  is  most  common.  It  is  rare,  few  more  than  100  cases 
being  recorded.  Sixty  per  cent,  occur  in  males  between  20  and  50  years 
of  age.  The  ova  are  spheroidal  and  measure  100  to  170  micromilli- 
meters.  The  great  difference  from  the  ordinary  form  is  the  outward 
(exogenous)  growth  of  the  cysts.  The  irregular  and  diffuse  cystic  pro- 
liferation is  an  unfavorable  feature.  The  cysts  contain  a  gelatinous 
material  (sometimes  simulating  colloid  cancer),  surrounded  by  intersect- 
ing fibrous  strands,  which  gives  the  liver  a  porous  appearance,  like  a 
sponge  or  cheese  with  air  cavities.  In  some  vesicles  there  is  cheesy 
material,  with  some  resemblance  to  the  granulomata.  The  vesicles 
sometimes  suppurate. 

Echinococcus  cysts  belong  to  surgery,  though  spontaneous  recovery 
is  not  infrequent;  the  operative  mortality  is  10  per  cent.,  the  expectant, 
60  per  cent. 

DISEASES    CAUSED   BY   NEMATODES. 

I.  The  Ascaris  Lumbricoides. — This  most  common  intestinal  parasite 
in  man,  described  by  Linnseus,  1758,  occurs  oftenest  in  children  and 
with  relative  frequency  in  the  insane.  Unlike  the  cestodes,  no  inter- 
mediate host  is  required.  The  female  measures  7  to  12  and  the  male 
4  to  8  inches  in  length;  it  is  smooth,  pointed  at  both  ends  and  has  trans- 
verse rings  and  four  longitudinal  ridges,  a  white  one  dorsally  and  ventrally 
and  two  brownish  ones  laterally.  The  oval  reddish  ova  measure  0.075 
X  0.058  mm.  and  have  a  thick  capsule;  60,000,000  eggs  may  develop  in 
a  single  female.  Its  mode  of  infection  is  obscure.  Though  they  usually 
occur  singly  or  in  pairs,  in  the  upper  small  intestine,  they  may  exceptionally 
develop  in  such  numbers  that  they  obstruct  the  intestine.  The  ascaris 
may  rarely  rupture  through  an  intestinal  ulcer.  It  has  passed  through  a 
perforated  appendix.  With  or  without  vomiting,  ascarides  may  pass 
from  the  stomach  into  the  esophagus,  nose,  bronchi,  lungs,  middle  ear, 
the  common  or  hepatic  duct,  causing  asphyxia,  gangrene  of  the  lung,  etc. 

Symptoms  are  not  usually  pronounced,  though  anorexia,  salivation, 
offensive  breath,  constipation,  colic  and  diarrhea  occur  in  some  cases. 
Malnutrition  is  sometimes  marked.  The  parasite  secretes  irritating, 
volatile  aldehydes  and  fatty  acids,  which  may  cause  constitutional 
symptoms.     Irritability,  grinding  the  teeth,  muscular  twitchings,  con- 


308  METAZOAN  INFECTIONS 

vulsions  or  even  meningeal  symptoms  may  develop  in  nervous  children. 
The  author  doubted  the  existence  of  the  typholumbricosis  of  ChaflFard, 
Marie  and  Tauchon,  until  in  one  adult  case,  with  fever  and  nervous 
toxemia,  instantaneous  subsidence  of  all  symptoms  occurred  when  the 
parasites  were  removed. 

Treatment. — After  a  fast  of  one-half  to  one  day,  santonin  should  be 
given,  gr.  ss-j,  for  a  child,  and  gr.  ij,  iij  or  v,  for  an  adult,  followed  by 
a  saline  cathartic  (never  by  castor  oil) ;  if  unsuccessful  it  may  be  repeated 
on  two  or  three  successive  days,  though  toxic  symptoms  sometimes 
develop,  as  xanthopsia  (yellow  vision),  collapse,  urticaria  (which  may 
result  from  the  parasite  itself),  vomiting  or  convulsions.  The  fluid- 
extradum  spigelice  (5j)  may  be  given  with  or  without  the  santonin  or 
calomel.  These  remedies  do  not  kill  the  parasite,  but  merely  render  it 
uncomfortable. 

II.  Oxyuris  Vermicularis  (Seat-worm,  Pin-  or  Thread-worm). — 
The  female  in  length  measures  10  and  the  male  4  mm.  Ingested 
ova  develop  in  the  small  intestine,  where  the  worms  mature  and  cohabit; 
afterward  they  exist  chiefly  in  the  lower  colon  and  rectum.  The  eggs 
remain  in  the  mother  until  the  worm  is  expelled,  though  she  occasionally 
"aborts"  in  the  bowel.  Infection  occurs  in  those  who  are  the  most 
uncleanly,  as  in  children  and  the  insane.  Infection  may  occur  from 
water  and  green  vegetables,  and  reinfection  is  not  uncommon  from 
scratching  the  anus  during  sleep  and  thus  crushing  the  parasite;  Eich- 
horst  frequently  found  ova  in  the  minute  fecal  particles  about  the  anus 
and  Zenker  repeatedly  demonstrated  their  presence  under  the  finger 
nails.  As  the  parasites  migrate  at  night,  the  symptoms  are  greatest  at 
that  time;  they  may  be  found  on  the  bed  sheet.  The  anal  itching  and 
rectal  irritation  are  often  excessive;  periproctal  suppuration  may  be 
excited.  If  a  vaginal  discharge  moistens  the  perineum  (and  only  then) 
they  can  wander  into  the  vagina,  causing  irritation,  sexual  stimulation 
or  masturbation.  Disturbance  of  sleep  and  appetite,  nervous  symp- 
toms and  anemia  may  result.  Diarrhea  is  due  to  large  numbers  of 
parasites. 

Treatment. — Santonin  may  be  given  in  obstinate  cases,  but  local 
measures  are  usually  sufficient,  as  high  enemata  containing  small  pro- 
portions of  carbolic  acid,  quassia  or  turpentine.  They  should  be 
repeated  daily  for  two  weeks.  Itching  is  palliated  by  application  of 
0.5  per  cent,  carbolic  salve  to  or  within  the  anus.  A  thj'^mol  salve  on 
the  anus  kills  worms  and  eggs. 

III.  Trichina  (Trichinella)  Spiralis;  Trichinosis. — Though  Tiedemann 
(1822),  Hilton  (1832)  and  Paget  (1835)  saw  the  parasite,  Owen  (1835) 
first  fully  described  it.  Leidy  saw  it  in  the  hog  in  1847.  Zenker 
(1855-60)  first  described  its  pathological  and  clinical  bearings;  he  found 
4  cases  in  136  autopsies. 

Swine  are  infected  probably  from  eating  offal.  From  the  clinical  and 
etiological  stand-point,  the  (a)  muscular  or  larval  stage  in  hogs  should 
be  considered  first.  The  small  encapsulated,  "hair-like"  (trichina) 
worm  lies  in  the  abdominal,  diaphragmatic,  psoas,  laryngeal  and  other 
muscles.     It  lives  for  a  long  while,  even  twenty  to  twenty-five  years, 


DISEASES  CAUSED  BY  NEMATODES  309 

without  causing  symptoms;  calcification  rarely  occurs  in  swine.  Man 
is  infected  by  eating  smoked,  "cured"  or  insufficiently  cooked  pork; 
animals  may  be  accidentally  or  experimentally  inoculated,  especially  the 
rat,  guinea-pig,  rabbit,  less  often  the  cat  and  rarely  the  dog.  Rela- 
tive to  its  alleged  presence  in  fish  or  worms,  the  trichina  has  been  con- 
fused with  other  parasites,  (b)  The  adult  or  intestinal  stage  in  man  is 
the  next  phase.  When  eaten  by  man,  the  small  capsules  (larval  form 
in  swine)  are  digested  and  the  worms  liberated;  in  the  small  intestine 
they  mature  (the  females  measure  3  or  4  mm.,  and  the  males  are  half 
as  long)  and  the  females  are  fecundated  in  two  or  three  days.  The 
female  trichinae  produce  1000  to  2000  embryos  at  once  or  possibly 
in  succession,  which  stage  requires  another  week  (from  fecundation  of 
the  female  to  birth  of  the  embryos) .  At  the  end  of  the  second  week  the 
embryos  migrate,  entering  the  lymph  vessels  and  then  the  veins,  by 
which  they  reach  the  voluntary  muscles,  which  they  seek  for  their 
glycogen.  They  lodge  between  the  muscle  fibers,  enter  them  and  attain 
(c)  the  mature  larval  form.,  which  is  identical  with  the  larval  stage  (a)  in 
hogs.  They  measure  0.5  to  1  mm.  in  length.  As  a  result  of  tissue  reac- 
tion against  the  foreign  bodies,  a  capsule  develops  in  about  six  weeks, 
which  surrounds  one  or  more  parasites.  The  capsules  at  first  trans- 
parent, grow  opaque  and,  after  months,  calcify  and  later  the  trichinae 
calcify  also. 

Frequency. — Though  trichinae  are  about  20  to  40  times  as  frequent  in 
American  as  in  German  swine,  the  disease  is  more  common  in  North 
Germany  where  raw  sausage,  Westphalian  ham  and  smoked  ham  are 
freely  eaten.  Seymour  reports  infections  in  Boston  among  Italians 
eating  raw  ham  (prosciutto) .  Frankel  denies  that  German  trichinosis 
results  from  American  pork.  Williams  of  Buffalo,  in  505  autopsies, 
found  trichinosis  in  5  per  cent.  Miiller  of  Dresden  found  it  in  0.98 
per  cent,  of  1939  postmortem  examinations.  Other  statistics  usually 
show  lower  figures  than  Miiller's,  and  like  the  above,  are  taken  from 
accidental  postmortem  findings.  The  disease  occurs  sporadically  or 
epidemically.  Perhaps  a  thousand  epidemics  occurred  in  America. 
In  Germany  the  epidemic  at  Hedersleben  numbered  337,  and  that  at 
Emmersleben  250  cases. 

Symptoms. — Symptoms  may  be  absent  or  slight,  particularly  in  sporadic 
cases,  and  with  moderately  severe  infection,  as  evidenced  by  accidental 
autopsy  finding  of  encapsulated  parasites. 

In  clear  cases  the  symptoms  are  divisible  into  two  stages:  (a)  The 
preliminary,  g astro-intestinal  stage,  which  begins  in  two  or  three  days 
after  eating  the  diseased  meat;  the  symptoms  are  not  constant  either 
in  sporadic  or  severe  epidemic  cases;  they  are  anorexia,  nausea,  vomit- 
ing, colic  and  sometimes  diarrhea,  which  may  resemble  the  evacuations 
of  cholera.  (6)  The  invasion  symptoms  begin  in  one  or  two  weeks  and 
correspond  to  the  parasitic  migration,  (i)  Fever  is  usual,  but  seldom 
rigors.  It  results  from  some  toxin  the  parasites  elaborate;  it  may 
rise  to  102°,  104°  or  106°,  its  course  is  remittent  and  intermittent,  it  lasts 
a  few  days  to  even  two  or  three  months,  and  falls  by  lysis.  Symptoms 
attendant  on  any  fever  may  be  present,  as  headache,  febrile  urine  or 


310  METAZOAN  INFECTIONS 

quickened  pulse.  In  severe  cases,  as  in  Zenker's,  typhoid  may  be  sug- 
gested by  delirium,  epistaxis,  dry  tongue,  status  typhosus,  diazo  reac- 
tion (in  80  per  cent.),  bronchitis,  albuminuria  and  kindred  toxemic 
symptoms.  Typhoid  and  trichinosis  coexisted  in  the  cases  of  Zenker, 
Fischer  and  McCrae,  (ii)  Acute  diffuse  myositis  is  always  most  sugges- 
tive. Its  intensity  varies  from  mild  forms  of  "muscular  rheumatism" 
to  the  most  severe  and  characteristic  involvement;  there  are  pain, 
tenderness,  swelling,  flexion  to  relieve  muscular  tension,  and  edema 
(25  per  cent.)  in  the  face  and  other  locations.  The  worms  most  curiously 
select  only  the  striated  muscles,  so  that  the  edema  observed  in  the 
abdomen  and  thighs,  for  example,  never  invades  the  scrotum  or  vulva. 
The  eyelids  are  often  affected  greatly  and  early.  Invasion  of  the  eye 
muscles  causes  pain  on  moving  the  eyes;  pain  during  mastication, 
phonation  and  deglutition  marks  penetration  of  the  masseteric,  laryn- 
geal and  pharyngeal  muscles  by  the  parasite;  dyspnea  (25  per  cent.) 
results  from  involvement  of  the  diaphragm  and  intercostal  muscles. 
W.  G.  Thompson  records  frequent  corneal  hemorrhages.  The  tendon 
reflexes  may  disappear.  (c)  The  blood  presents  two  striking  features: 
first,  the  leukocytosis  (15,000  to  30,000)  and  second,  the  eosinophUes, 
normally  0.3  to  4  per  cent,  of  the  leukocytes,  rise  as  high  as  30  or  86 
per  cent,  and  though  they  increase  in  the  other  parasitic  diseases,  this 
rise  is  most  peculiar  if  not  pathognomonic.  The  eosinophilia  averaged 
over  20  per  cent,  in  more  than  half  the  cases  (Thompson)  and  is  greatest 
at  the  time  when  the  trichinse  enter  the  muscles.  (See  Plate  XVI,  Fig. 
5.)  In  an  experimental  study  Graham  observed  the  embryos  in  the 
arteries  of  rats  and  in  hemorrhagic  lesions  in  the  lungs,  and  Staubli 
found  them  in  the  heart's  blood  and  in  the  blood  from  the  ear  of  infected 
guinea-pigs.  His  method  consisted  in  laking  the  blood  with  3  per  cent, 
acetic  acid,  centrifugating  and  examining  the  sediment.  W.  W.  Herrick 
and  T.  C.  Janeway  (1909)  using  Staubli's  method,  found  the  parasites 
in  the  human  blood  in  2  cases  of  trichiniasis.  The  blood  is  best  obtained 
from  a  vein  at  the  elbow  by  means  of  a  small  syringe.  They  thought 
it  is  certain  they  also  migrate  along  the  connective-tissue  spaces,  (d) 
Profuse  siveats,  polyuria,  paresthesia,  urticaria  and  anemia  are  inconstant 
manifestations.    On  the  24th  day  a  second  edema  appears. 

Diagnosis. — This  is  based  on  (a)  the  possibility  of  infection,  as  by 
eating  poorly  cooked  pork,  (b)  the  discovery  of  trichinse  in  the  blood,  the 
uneaten  portions  of  suspected  meat  or  perhaps  in  the  feces  or  cerebro- 
spinal fluid ;  (c)  their  detection  by  removal  of  small  slivers  of  the  biceps 
or  pectorals  for  microscopic  examination,  especially  the  parts  near  the 
muscular  insertion;  (d)  the  myositis  with  edema;  (e)  signs  of  insuffi- 
ciency, e.  g.,  in  the  ocular  or  diaphragmatic  muscles  and  (/)  leukocy- 
tosis with  eosinophilia. 

Prognosis. — This  depends  on  the  number  of  parasites  ingested.  Chol- 
eraic and  typhoidal  symptoms,  dyspnea  and  pneumonia  are  most  ominous. 
Moderately  severe  early  diarrhea  is  favorable.  Children  die  less  often 
than  adults.  Of  the  15,000  recorded  cases,  830  resulted  fatally.  Accord- 
ing to  Stiles,  the  German  mortality  averages  5.6  per  cent.  In  the  epidemic 
at  Weimar  there  were  no  fatalities  in  108  cases.     In  the  epidemic  at 


DISEASES  CAUSED  BY  NEMATODES  311 

Haderslebeii  30  per  cent.  died.  In  certain  epidemics  the  mortality  was 
70  to  100  per  cent. 

Treatment. — (a)  Prevention  comprises  the  feeding  of  hogs  with  clean 
food,  government  inspection  of  meat,  and  thorough  cooking  (160°  F.). 

(b)  In  the  'preliminary  stage,  active  and  repeated  purgation  should  be 
ordered,  for  moderate  and  early  spontaneous  diarrhea  is  prognostically 
favorable;  calomel  should  be  followed  by  salts  and  castor  oil;  male 
fern,  santonin  {v.  s.),  thymol  gr.  v,  t.  i.  d.  benzene  lUij-v,  t.  i.  d.  and 
oil   of  turpentine  TUv-x  are  recommended;   glycerin  is  now  discarded. 

(c)  In  the  stage  of  muscular  invasion,  the  fever  is  treated  as  in  other 
infections,  the  myositis  by  local  applications  of  ice  and  by  narcotics, 
and  the  general  nutrition  by  food  and  stimulants. 

IV.  Ankylostoma  (Uncinaria). — A  disease,  due  to  the  hook-worm, 
whose  development  is  favored  by  warmth  and  filth;  attacking  those 
coming  in  contact  with  damp  earth  or  water  infected  with  the  larvae; 
and  characterized  by  the  ova  in  the  stools,  progressive  anemia,  weakness, 
and  alimentary,  developmental  and  other  disorders.  The  uncinaria 
duodenalis  (ankylostoma  duodenale)  exists  in  two  forms,  that  of  the 
old  and  that  of  the  new  world.  Ankylostomiasis  was  first  well  described 
by  Piso  (1648)  in  Brazil  and  the  parasite  was  recognized  in  Milan  by 
Dubini  (1838).  It  occurs  chiefly  in  the  tropics  and  subtropics,  including 
the  Philippine  and  Sandwich  Islands;  according  to  Thornton,  it  is  the 
most  dangerous  of  all  tropical  diseases.  In  Egyptian  chlorosis  it  was 
found  by  Bilharz  and  Griesinger,  and  is  said  to  be  present  in  nearly 
every  autopsy  made  there.  It  is  endemic  in  Italy  ("bricklayers'  anemia") 
and  also  in  Belgium,  France,  England,  Germany,  Hungary  and  the  Bal- 
kans. In  India  it  is  found  in  even  80  per  cent,  of  the  healthy  coolies  and 
in  300  autopsies  in  Assam  it  was  present  299  times.  Stiles  (1902)  described 
the  new- world  type,  caused  by  the  Uncinaria  (or  Necator)  Americana, 
which  is  also  found  in  Africa  and  East  Indies.  Thirty  per  cent,  of  Porto 
Rican  deaths  result  from  uncinariasis,  and  Ashford  and  King  state  that 
90  per  cent,  of  the  rural  and  50  per  cent,  of  the  urban  population  have 
the  disease;  during  six  months  in  1905,  18,865  cases  were  treated  in 
Porto  Rico,  of  which  33  per  cent.  died.  Capps  in  1903  collected  50 
American  cases  of  the  European  type.  It  is  possibly  the  most  important 
disease  of  our  Southern  States.  Dock  and  Bass  estimate  that  over  a 
quarter  of  the  Southern,  apparently  healthy,  population,  suffer  from  this 
malady. 

In  the  Westphalian  mines,  Tenholt  himself  treated  over  4000  cases. 
It  was  the  cause  of  the  "tunnel  anemia,"  observed  in  building  the  St. 
Gothard  tunnel.  It  is  disseminated  by  Italian  and  Polish  workmen. 
Infection  comes  from  the  food,  drinking  water  and  earth  which  are 
infected  by  dejections  from  persons  suft'ering  from  the  disease.  Looss 
and  C.  A.  Smith  proved  that  it  may  enter  by  the  skin,  producing 
the  "ground  itch,"  common  in  the  Southern  States.  Dock  and  Bass 
believe  the  skin  to  be  the  sole  mode  of  infection.  The  larva  penetrates 
the  skin  in  a  few  hours  and,  by  way  of  the  heart,  lodges  in  the  lungs 
and  bronchi,  whence  it  is  expectorated  or  swallowed;  in  the  latter  case 
the  larva  reaching  the  intestine,  sheds  one  skin  and  acquires  a  buccal 


312  METAZOAN  INFECTIONS 

capsule  by  which  it  adheres  to  the  mucosa;  from  the  mucosa  It  draws 
blood  and  sheds  its  last  skin.  Subjects,  harboring  the  hook-worm, 
void  feces  laden  with  ova  of  the  parasite.  In  localities,  most  severely 
affected,  the  privies  are  commonly  so  exposed  that  swine  or  fowl  scatter 
the  ova  from  the  dejecta  over  the  ground;  even  more  frequently,  out- 
houses are  not  employed,  but  the  infected  persons  defecate  in  the  barn- 
yard, bushes,  garden,  fields  or  in  the  mines.  The  ova  develop  into  larvse 
in  the  moist  ground,  shallow  water  or  the  soil  of  a  mine,  and  attack  those 
running  bare-foot,  enter  the  hands  or  reach  the  mouth. 

The  male  worm  is  8  to  10  and  the  female  10  to  18  mm.  in  length; 
the  mouth  has  hooks  by  which  it  adheres  to  the  mucosa  of  the  duodenum. 
The  ova  measure  30  to  60  micromillimeters;  they  are  oval,  are  covered 
with  a  translucent  shell  and  differ  from  the  flat  oxyuris  ova.  They 
show  1  to  6  yolk  segments  and  may  number  over  4,000,000.  They 
develop  into  the  larvse. 

Symptoms. — Some  subjects  resist  the  parasites  they  carry  and  present 
no  symptoms.  Despite  their  immunity,  these  "carriers"  disseminate 
the  disease.  Mechanisms  of  the  symptoms:  (1)  The  parasites  suck 
blood;  Ernst  and  Treichtenstern  describe  dying  worms  ejecting  blood, 
as  a  locomotive  puffs  smoke.-  (2)  They  also  bore  into  the  intestinal 
mucosa  but  destroy  it  and  the  submucosa  which  Looss  pictures  drawn  into 
their  esophagus  and  even  into  their  intestines.  (3)  Their  bites  become 
infected  (A.  J.  Smith).  (4)  It  is  also  possible  that  they  secrete  a  sub- 
stance which  degenerates  the  bloodvessels,  hinders  hemostasis  or  operates 
as  a  hemolytic.  Types:  (i)  The  symptoms  may  be  only  mild  dyspepsia, 
slight  anemia  (hemoglobin  80  or  more),  dull  headache,  etc.  (ii)  Moderate 
intensity;  with  hemoglobin  60"  to  80  per  cent.,  epigastric  pain,  poor 
development  in  the  case  of  children  and  some  apathy,  (iii)  The  severe 
type,  with  hemoglobin  30  to  60  per  cent.,  great  dyspnea  and  abdominal 
pain,  vomiting,  anasarca  and  other  symptoms  {v.  i.).  (iv)  The  severest 
form,  with  hemoglobin  below  30  per  cent.,  and  all  symptoms  extreme. 

The  ground  itch  represents  the  atrium  in  most  cases  and  a  history  of 
it  is  generally  obtained.  Around  the  toes,  or  less  often  on  the  hands  or 
buttocks,  an  itching,  very  painful  eruption  develops,  first  of  vesicles 
which  loosen  the  skin  and  contain  the  larvse,  then  of  pustules,  oozing 
and  fissures.  In  a  few  days  the  larvse  reach  the  air  passages  (v.  s.)  and 
cause  sore  throat,  bronchitis,  cough  and  expectoration,  which  latter, 
being  swallowed,  allow  the  larvse  to  reach  the  bowel. 

Alimentary  Symptoms. — The  tongue  exhibits  ink-like  patches.  The 
appetite  may  be  increased  in  cases  of  mild  or  moderate  intensity  but  is 
lacking  in  the  severest  types;  it  is  often  perverted  and  resin-chewing, 
eating  of  hair,  earth  (geophagy),  clay  or  pebbles,  inordinate  or  early 
chewing  of  tobacco,  etc.,  are  frequently  observed.  Ashford  and  King 
find  that  epigastric  pain  or  uneasiness  is  the  most  constant,  suggestive 
and  clear  symptom.  Nausea,  vomiting,  diarrhea  alternating  with 
constipation  and  colic  are  common.  Occult  or  obvious  blood  in  the 
stools  is  the  rule.  In  the  Panama  case  which  the  author  saw  in  the 
County  Hospital,  there  was  great  nausea,  pain  and  exquisite  abdominal 
tenderness;  the    stools    contained    blood,    eosinophile    cells,     Charcot- 


DISEASES  CAUSED  BY  NEMATODES  313 

Leyden  crystals  and  ova.  Stiles  suggests  a  ready  test  for  blood,  by  which 
parts  of  the  stool  are  placed  upon  blotting  paper;  after  an  hour  or  so  a 
rusty  stain  develops  about  the  stool.  Children  become  pot-bellied.  In 
the  subjects  coming  to  autopsy,  the  feces  show  Charcot's  crystals,  eosino- 
philes,  much  mucus,  ova,  worms  and  blood.  Reddish  areas  may  be  seen 
through  the  unopened  gut.  The  bowel  may  appear  red  or  chocolate 
color;  Peyer's  patches  and  the  solitary  follicles  are  often  swollen;  ecchy- 
moses,  submucous  cysts  and  erosions  are  common;  and  moist  red  areas 
are  noted,  either  elevated  or  bitten  by  the  worms,  and  eosinophilic  infil- 
tration of  the  mucosa,  submucosa  and  even  the  muscularis.  Most  of 
the  parasites  lodge  in  the  jejunum  but  also  in  the  duodenum  and  upper 
ileum.    Before  the  death  of  their  host,  many  leave  the  body. 

Blood  Findings. — An  anemia  develops  which  is  first  of  the  secondary 
type  and  later  resembles  pernicious  anemia;  it  is  due  to  loss  of  blood 
and  possibly  some  hemolysin  from  the  parasite.  The  hemoglobin 
averages  67  per  cent.  (Dock  and  Bass)  or  42  per  cent.  (Ashford  and 
King);  it  is  more  reduced  than  the  red  cells  (low  color  index).  The 
red  cells  range  between  2|  and  3|  millions;  there  are  polychromatophilia, 
normoblasts  and  microcytes.  The  white  cells  are  usually  not  increased; 
in  advanced  cases  there  is  leukopenia;  the  eosinophiles  average  15  to 
25  per  cent.,  but  may  run  higher  (30  to  72  per  cent.).  The  skin  is  sallow, 
pasty,  even  lemon-color  or  waxy,  and  finally  edematous.  The  bone- 
marrow  is  pale — perhaps  lymphoid,  gelatinous  or  fatty;  nucleated 
cells  indicate  blood  regeneration. 

Many,  perhaps  most,  of  the  other  findings  are  anemic — the  extreme 
dyspnea,  rapid  pulse  (over  100),  pulsating  vessels,  edema  of  the  skin, 
serous  sacs  and  brain;  dulness,  somnolence,  headache,  inertia  (laziness), 
weakness  and  headache  are  common  and  in  severer  infections  the  vertigo 
is  extreme;  pains  develop  in  the  joints  and  sternum;  marked  pares- 
thesia, abolition  of  the  patellars  and  weakness  develop,  to  the  simulation 
of  paralysis;  the  pupils  dilate  and  the  eyes  present  a  fishy  look;  there 
is  retinal  clouding,  anemia  and  hemorrhage;  and  extreme  apathy, 
anxiety  or  melancholia  intervenes.  Cardiac  hypertrophy  and  dilatation 
and  arteriosclerosis  are  frequent.  The  urine  is  copious,  of  low  specific 
gravity,  either  free  of  albumin  or  highly  albuminous  and  contains  no 
casts.  The  heart,  liver  and  kidneys  are  fatty,  degenerated  and  enlarged; 
the  spleen  is  not  usually  enlarged  (save  in  Egyptian  autopsies).  The 
temperature  is  subnormal,  sometimes  with  irregular  runs  of  fever.  Mal- 
nutrition and  maldevelopment  mark  the  pronounced  types.  Children 
grow  poorly  and  reach  puberty  late  and  incompletely.  Men  of  twenty 
may  appear  ten  years  old.  Some  are  dwarfs.  The  pubic  hair  is  scant, 
the  beard  comes  slowly,  the  mammse  are  small,  and  in  males,  impotence, 
and  in  women,  amenorrhea  are  common. 

Diagnosis. — The  diagnosis  is  suggested  by  the  anemia,  dyspnea, 
dilated  heart,  epigastric  pain,  maldevelopment  and  history  of  ground 
itch,  but  is  made  certain  only  by  examination  of  the  stools  for  ova 
or  worms. 

Prognosis. — The  outlook  depends  on  the  stage  of  the  malady.  Uncin- 
ariasis greatly  reduces  the  resistance  to  other  diseases.    The  eosinophilia 


314  METAZOAN  INFECTIONS 

measures  the  degree  of  resisting  power.  The  mortahty  is  10  to  30  per 
cent.    ]\Iuch  depends  on  early  therapy. 

Treatment. — 1 .  Prevention. — Drinking  water  should  be  boiled  and  the 
hands  should  be  cleansed  before  eating.  The  stools  should  be  received 
in  water-tight  closets  and  disinfected;  careless  defecation  in  mines  has 
caused  wide  dissemination  of  the  disease.  Mines  should  be  disinfected 
with  the  milk  of  lime.  Prevention  means  (i)  the  extermination  of  the 
mature  worms  in  man,  particularly  in  "carriers;"  (ii)  preventing  the 
growth  of  ova  into  larvse;  and  (iii)  guarding  against  infection  by  already 
developed  larvse. 

2.  Medication. —  Thymol  is  the  most  efficacious  remedy.  After  a 
preliminary  purge  of  sodium  sulphate,  the  patient  is  kept  abed  and  as 
the  peristalsis  decreases,  gr.  xx  of  thymol  are  given  in  capsules  and  repeated 
twice  at  three-hour  intervals.  The  thymol  is  first  well  triturated  with 
an  equal  amount  of  sugar  of  milk  to  prevent  its  cohering  and  followed 
by  a  saline  purge  two  hours  afterward.  The  first  treatment  evicts  80 
to  90  per  cent,  of  the  parasites,  5  courses  cure  95  per  cent.,  and  persisted 
in,  "it  always  succeeds."  As  toxic  symptoms  (nervous  excitation, 
smoky  urine,  dizziness,  fainting,  abortion  or  death;  11  cases  in  America) 
may  develop,  no  solvents  of  thymol  should  be  given,  as  alcohol,  chloro- 
form, ether  or  castor  oil.  This  treatment  should  be  repeated  once  a 
week,  as  long  as  ova  or  Charcot-Leyden  crystals  appear  in  the  stools. 
Ver}'  edematous  patients  do  not  tolerate  thymol.  Male  fern  is  considered 
the  best  remedy  by  Tenholt  and  other  Westphalian  writers. 

V.  FUaria. — Demarquai  (1863)  first  found  the  embryos  of  the  filaria; 
Wiicherer  (1866)  found  them  in  the  urine  and  Lewis  (1872)  in  the  blood. 

1.  Filaria  Noctuma, — (Bancrofti,  Cobold,  1877).  Its  distribution  is  largely 
tropical  and  subtropical.  It  occurs  in  30  per  cent,  of  the  inhabitants  of 
the  Samoan  and  Friendly  Islands.  In  the  United  States  it  has  been 
found  in  the  South,  New  York,  Illinois  and  Pennsylvania,  (a)  Infec- 
tion of  man  occurs  by  mosquito  bites  or  possibly  by  water,  contaminated 
with  mosquito  eggs.  In  the  mosquito,  the  embryos  change  to  the  young 
adult  form.  (6)  The  next  stage  is  the  presence  of  adult  filaria  in  the 
lymph  channels,  where  they  cause  lymph  stasis  and  lymphangitis.  The 
female  filaria  measures  155  x  0.7  mm.  and  the  male  83  x  0.4  mm.  (c)  The 
embryos  enter  the  blood  current  from  their  birth  place,  the  lymph  channels; 
they  are  very  numerous,  measure  |  inch  in  length  and  the  diameter  of 
a  red  blood  cell.  Under  a  low-power  lens  their  active  movements  are 
easily  seen.  They  appear  in  the  blood  only  at  night,  usually  near  mid- 
night, and  during  the  day  retire  to  internal  organs,  as  the  lungs,  but  if 
the  patient  sleeps  by  day,  they  appear  in  the  daytime  only.  (For  Staubli's 
method  of  detection  see  page  310.) 

Symptoms  are  absent  in  the  majority  of  cases  of  human  and  animal 
infection  and  are  due  to  the  parent  worm,  not  to  the  embryos,  (a) 
Chyluria  or  hematochyluria  is  due  to  plugging  by  the  worm  or  its  ova  of 
the  Ivmphatic  vessels  in  the  peritoneum,  pelvis,  vesical  and  perirenal 
tissues.  Lymph  stasis,  ectasia  and  lymphangitis  result,  with  intermittent 
rupture  into  some  part  of  the  urinary  tract,  and  the  passage  of  milky, 
chylous  urine,  containing  molecular  albumin  and  fat.     The  amount  of 


DISEASES  CAUSED  BY  NEMATODES  315 

the  urine  varies;  it  may  be  normal  or  increased.  There  is  usually  also 
some  blood.  If  the  blood  clots,  vesical  distiu"bance  results.  The  embryos 
are  often  found  in  the  blood  and  sometimes  in  the  urine;  there  is  also 
a  non-filarial  chyluria.  The  affection  may  last  for  years  without  im- 
pairment of  health.  The  very  rare  rupture  into  the  peritoneum  causes 
chylous  ascites,  (b)  The  lymph  scrotum  is  due  to  hTnphatic  obstruction 
by  the  adult  worm.  The  scrotimi  may  weigh  50  to  200  pounds.  Rupture 
into  the  tunica  vaginalis  causes  chylocele.  The  labia  may  be  similarly 
involved.  The  embryos  are  often  missing  from  the  blood,  being  appar- 
ently confined  to  the  local  involvement  by  the  hinphangitic  thickening, 
whence  the  difficulty  in  stating  the  relative  percentage  of  parasitic  and 
non-parasitic  cases  of  lymph  scrotum  and  elephantiasis,  (c)  Elephan- 
tiasis usually  develops  in  the  legs,  scrotum  and  labia,  less  often  in  the 
arms,  breasts  or  trunk.  In  forms  (6)  and  (c)  there  occur  intermittent 
exacerbations  with  fever  and  nervous  disturbance. 

2.  Other  Forms  of  Filaria. — The  exact  status  of  the  Filaria  diurna 
(Man<on,  lS91j  is  not  kno\^m;  F.  perstans  (Manson,  1891),  which  causes 
pustular  eruptions  (craw-craw) ;  F.  loa  (the  adult  stage  of  Filaria  perstans) 
which  inhabits  the  conjunctiva;  F.  lahialis;  and  F.  oris  and  bronchialis 
are  other  forms. 

Treatment.  —  (a)  For  prevention,  mosquitoes  and  infected  water 
should  be  avoided.  (6)  Xo  parasiticide  is  knoT\m.  (c)  Chyluria  is 
treated  by  cinchonization,  salvarsan  and  .r-rays.  (d)  Lymph  scrotum 
and  elephantiasis  may  necessitate  castration  or  amputation. 

VI.  Dracunculus  (Filaria)  Medinensis. — This  is  found  on  the  West 
African  coast,  the  Gold  Coast,  in  Abyssinia  and  South  Egypt;  on  the 
Caspian  Sea  and  Persian  Gulf;  in  the  East  Indies,  parts  of  India  and 
South  America.  Guinea-worm  disease  (drachontiasis)  developed  in 
persons  who  had  always  lived  in  Philadelphia  and  Fortress  ^Monroe. 
'SIslh  is  infected  by  a  small  water  flea  (cyclops)  which  contaminates  the 
water  with  the  larvae  (embryos).  These  embryos,  measuring  0.6  mm., 
enter  the  stomach,  bowel  and  probably  the  mesentery,  where  they 
copulate;  the  male,  of  which  little  is  known,  is  either  discharged  from 
the  bowel  or  dies  in  the  mesentery.  The  female  is  cylindrical  in  form, 
measures  50  to  SO  x  2  mm.,  has  a  triangular  mouth,  eight  papillae  and  a 
blunt  tail;  its  uterus  occupies  almost  its  entire  length.  The  female, 
which  is  usually  solitary,  wanders  downward  in  the  subcutaneous  and 
intermuscular  tissues  to  the  thighs,  legs  and  in  66  per  cent,  of  cases 
reaches  the  feet  where,  near  its  head,  vesicles,  abscesses  and  ulcers 
develop.  Its  downward  course  occupies  a  year,  during  which  it  may  be 
felt  subcutaneously.  ^^^len  the  skin  breaks  the  parasite  discharges  her 
embryos  and  then  leaves  the  body,  to  die. 

Treatment. — Treatment  by  excision,  or  by  1  to  1000  bichloride  injec- 
tions, seems  most  rational.  If  the  worm  is  ruptured  in  efforts  to  extract 
it,  high  temperature,  alarming  nervous  symptoms  and  sepsis  result  from 
migration  of  the  embryos  liberated  in  the  tissues. 

Vn.  The  Trichocephalus  Dispar  or  Whip-worm. — This  nematode  is 
found  most  often  in  southern  Italy  and  France  and  but  seldom  in  this 
country;  one  case  occurred  in  the  Cook  County  Hospital.     It  is  also 


310  METAZOAN  INFECTIONS 

called  trichuris  trichura.  It  requires  no  intermediate  host,  enters  with 
the  food  and  drink  and  is  found  in  the  cecum  and  large  gut.  The  male 
is  slightly  shorter  than  the  female,  which  is  4  or  5  cm.  in  length.  The 
anterior  portion  of  the  worm  is  thin;  the  posterior  two-fifths  is  thick, 
in  the  male  round  and  in  the  female  pointed.  It  bores  into  the  mucosa 
and  is  nourished  by  the  blood  and  not  by  the  alimentary  contents.  The 
eggs  measure  0.05  mm.,  are  oval  and  are  marked  by  a  button-like  pro- 
jection. It  causes  few  symptoms;  occasionally  there  is  severe  abdominal 
pain.  Three  fatal  cases  are  recorded.  Male  fern  and  thymol  internally 
and  benzene  5.1  to  Oij  of  water  as  an  enema  are  recommended. 

Vin.  The  Strongyloides  Intestinalis. — This  includes  a  number  of 
nematodes,  as  the  Anguillula  intestinalis  or  stercoralis,  rhabdonema, 
etc.  They  are  found  in  the  endemic  diarrhea  which  occurs  in  Cochin- 
China.  Strong  reports  cases  from  INIanila  and  W.  F.  Thayer  reported 
3  cases  in  America.  A  few  parasites  cause  no  s^nnptoms.  Thymol  is 
almost  specific. 

Enstrongylus  Gigas. — The  Enstrongylus  gigas  which  occurs  frequently 
in  dogs  and  wolves,  is  very  rare  in  man.  It  is  a  nematode  whose  ova 
appear  in  the  urine..  It  causes  pyelitis,  hematuria,  colic,  tenesmus  and 
sometimes  chyluria. 

DISEASES   CAUSED   BY   TREMATODES    (DISTOMIASIS). 

1.  Bilharzia  disease  (endemic  hematuria)  is  due  to  the  blood  fluke 
(Schistosomum  hematobium).  Bilharz  described  the  disease  in  1851. 
It  is  an  African  and  Japanese  affection;  it  has  prevailed  for  many  cen- 
turies in  Egypt,  where  Bilharz  considered  that  half  of  the  lower  classes 
was  affected.  It  .  is  equally  frequent  in  Uganda.  Importation  has 
occurred  into  India,  the  Mediterranean  islands  and  Am.erica.  Only  12 
cases  have  occurred  in  the  United  States. 

Children  are  more  predisposed  than  adults  to  infection,  which  occurs 
through  the  drinking  water  or  possibly  through  the  skin.  The  embryos 
enter  the  stomach,  penetrate  the  alimentary  mucosa  and  mature  in 
the  veins  of  the  pelvis,  spleen,  mesentery,  liver,  kidney  and  bladder. 
The  male  worm  -measures  4  to  15  x  0.6  mm.,  the  female  15  to  20  x  0.3  mm. 
The  male  is  rolled  up  like  a  leaf,  forming  a  groove  in  which  the  female 
lies  during  copulation.  ]Many  ova  are  found  in  the  urine;  they  are 
oval,  carry  a  spine  and  contain  a  ciliated  embryo.  They  die  in  the  urine 
in  a  day  but  live  for  some  time  in  water,  where  their  life-history  is  still 
imperfectly  understood. 

Hematuria  is  the  most  common  and  often  the  only  symptom;  it 
may  be  macro-  or  microscopic  and  occurs  chiefly  at  the  end  of  urination; 
examination  shows  many  ova  and  eosinophiles.  Cystitis  occurs  in  severe 
infection.  Stones  are  not  uncommon,  particularly  in  Canton,  China. 
Suppuration  may  develop  fistulse.  These  clinical  symptoms  result  from 
massive  accumulation  of  ova  in  the  submucosa,  which  leads  to  papillo- 
matous hyperplasia,  hemorrhage,  suppuration,  necrosis,  salt  deposits 
(calculi)  and  rarely  to  malignant  degeneration.  Similar  changes  in  the 
rectum  cause  pile-like  papillomata,  dysenteric  evacuations  and  tenesmus. 


DISEASES  CAUSED  BY  TREMATODES  317 

As  complications,  pyelitis,  prostatitis,  urinary  fistulee  and  changes  in  the 
liver  (thickening  of  the  periportal  connective  tissue),  uterus,  vagina, 
seminal  vesicles  and  renal  pelvis,  resembling  those  in  the  bladder,  may 
develop.    The  eosinophiles  are  increased  to  10  to  50  per  cent. 

Schistosomum  Jayonicum  (Cattoi).  This  fluke  is  found  in  China,  the 
Philippines  and  Japan.  Its  ova  are  smaller  and  have  no  spine.  Living 
in  the  bloodvessels  of  the  digestive  tract,  it  induces  a  severe  anemia, 
dysentery,  ascites  and  cirrhosis  of  the  liver  and  spleen.  Epilepsy  may 
develop.  In  the  intestines,  other  flukes  may  be  found — the  Gastrodiscus 
(Amphistoma)  hominis  and  Distoma  (Fasciolopsis)  Buskii,  in  India  and 
the  Mesogonimus  heterophyes  in  Egypt  and  Japan. 

Treatment. — Change  of  climate  is  advisable  to  avoid  reinfection.  The 
parasites  usually  die,  though  slowly,  and  as  no  local  or  systemic  remedies 
modify  their  life-history,  treatment  must  be  expectant. 

2.  Lung  flukes  cause  the  endemic  hemoptysis,  observed  by  Balz  chiefly 
in  North  China,  Corea,  Japan,  the  Philippines  and  Formosa.  The 
parasite  is  named  Distoma  pulmonale  (Paragonimus  westermani);  it 
measures  10  x  6  mm.  and  is  found  largely  in  the  lungs,  but  sometimes 
in  the  brain  and  skin.  In  young  males  dyspnea,  anemia,  lung  induration 
and  a  chronic  cough  develop  with  bloody  or  prune-juice  sputum, -in  which 
are  found  blood,  dark  brown  ova  measuring  0.08  to  0.1  x  0.05  mm., 
eosinophile  cells  and  Charcot-Leyden  crystals.  The  hemorrhages,  which 
are  sometimes  profuse,  result  from  small  infarcts  and  cysts  of  ova  in  the 
subpleural  lung  tissue.  Epilepsy  and  hemiplegia  may  result  from  brain 
embolism.  The  course  is  usually  favorable,  though  chronic,  and  is  not 
influenced  by  treatment. 

3.  Liver  flukes  (Fasciola  hepatica,  Opisthorchis  sinensis  and  at  least 
four  other  species)  enter  like  the  above  forms  through  contaminated 
water.  The  fluke  is  found  in  the  upper  small  intestine  and  the  biliary  or 
pancreatic  duct.  It  measures  10  to  20x2  to  5  mm.  and  its  ova  30  x  15ju. 
It  is  found  in  Japan  and  certain  provinces  show  a  mortality  of  20  to 
72  per  cent.  (Balz  and  Inouye).  White  reported  18  cases  in  San  Fran- 
cisco, and  Brayton  and  Darling  cases  in  Panama.  The  liver  is  enlarged 
and  tender;  icterus  results  from  biliary  stasis,  for  the  parasites  lie  in 
the  walls  of  the  biliary  ducts  and  gall-bladder;  diarrhea  develops,  and 
the  dejections  contain  ova  and  blood;  anemia,  ascites,  anasarca,  ady- 
namia and  emaciation  develop  and  death  invariably  results.  There  is 
no  treatment  beyond  the  symptomatic  support  of  the  heart.  Prophyl- 
axis :  avoidance  of  drinking  or  of  swimming  in  canal  water,  and  thorough 
cooking  of  fish  and  mussels  have  stamped  out  the  plague  in  one  Japanese 
province  (Inouye). 


SECTION  11. 

DISEASES  OP  THE  CIRCULATION. 


DISEASES  OF  THE  HEART  MUSCLE. 

INTRODUCTORY   PHYSIOLOGY. 

Although  convention  has  sanctioned  the  classification  of  heart  diseases 
into  those  of  the  myocardium,  endocardium  and  pericardium,  besides 
its  nervous  disturbances,  nearly  all  cardiac  disorders  are  referable — on 
the  last  analysis — to  failure  of  the  heart  muscle.  A  review  of  the  more 
salient  afi^ections  of  the  heart  relegates  many  of  them  to  a  secondary  place. 
Thus,  valvular  diseases  seldom  attract  attention,  until  the  overstrained 
heart  muscle  becomes  more  or  less  "incompetent."  In  pericarditis, 
the  fresh  effusion  presses  on  the  heart  and  embarrasses  its  diastole;  or, 
when  older  adhesions  firmly  anchor  the  organ,  the  heart's  systole  is 
impeded.  The  heart  muscle  and  the  vasomotor  system  sustain  the 
brunt  of  the  acute  infections  and  chronic  intoxications.  Angina  pectoris 
is  a  myocardial  malady,  arising  from  disease  of  the  coronary  vessels, 
which  bathe  the  myocardium  with  fresh  blood.  Arteriosclerosis  works 
its  gravest  injury  on  the  cardiac  musculature.  The  fatty  heart,  chronic 
myocarditis,  the  senile  heart,  heart-block,  and  many  of  the  arrhythmias 
or  "neuroses"  of  the  heart,  are  but  instances  of  failing  competency  in 
some  segment  of  this  hollow  contractile  muscle. 

Until  recently  it  was  maintained  that  the  heart  mechanism  was 
regulated  by  nervous  influences  (the  neurogenic  theory),  but  now  the 
source  of  cardiac  action  is  held  to  reside  in  the  muscle  itself  (the  myo- 
genic theory — which  is  possibly  overstrained  in  our  swing  from  one 
extreme  to  another).  Gaskell  enumerates  the  functions  of  the  myo- 
cardium as  five:  "The  muscular  fibers  of  the  heart  are  capable  of 
rhythmically  creating  a  stimulus  {rhythmicity) ,  of  being  able  to  receive 
a  stimulus  (excitability),  of  responding  to  a  stimulus  by  contracting 
(contractility),  of  conveying  the  stimulus  from  muscle  fiber  to  muscle 
fiber  (conductidty) ,  and  of  maintaining  a  certain  ill-defined  condition 
called  tone  (tonicity)." 

The  normal  (or  sinus)  rhythm  of  the  heart  consists  of  the  successive 
contraction  of  the  sinus,  auricle  and  ventricle.  The  stimulus  to  contrac- 
tion arises  in  the  remains  of  the  sinus  venosus  (the  sino-auricular  node 
of  Keith  and  Flack)  at  the  mouth  of  the  superior  vena  cava;  it  is  called 
the  pace-maker  of  the  heart.    In  the  wall  of  the  right  auricle  near  the 


320  DISEASES  OF   THE  HEART  MUSCLE 

coronary  sinus  is  Tawara's  auriculo ventricular  node,  the  origin  of  the 
auriculoventricular  bundle  of  Kent  and  His,  by  which  impulses  are 
conducted  from  the  auricle  to  the  ventricle.  (In  pathological  rhythm, 
stimuli  may  arise  from  other  points  than  the  sino-auricular  node  and 
initiate  extrasy stoles.)  Contractility  is  so  regulated  that  each  systole 
is  forcible  (to  the  full  capacity  of  the  heart's  muscle);  each  beat  is  fol- 
lowed by  a  period  of  rest — a  refractory  period  in  which  contraction 
cannot  be  elicited.  Tonicity  holds  the  heart  in  "tone,"  keeps  its  volume 
less  than  it  would  be  if  the  myocardium  completely  relaxed,  and  prevents 
dilatation.  Tone  is  increased,  e.  g.,  by  digitalis,  and  lessened  by  severe 
toxemias  and  cardiac  overstrain.  The  vagus  inhibits  or  decreases  the 
rate,  conductivity,  irritability  and  contractility  and  the  sympathetic 
increases  the  rate,  etc.  Throughout  this  section,  repeated  reference  to 
these  functions  will  be  made,  as  the  myocardium  is  the  key  to  cardiac 
conditions. 

In  the  balanced  circulation,  besides  the  heart  and  its  nerves,  the 
bloodvessels  are  important;  without  their  elasticity  and  contractility 
and  their  vasomotor  control,  the  circulation  could  not  be  maintained; 
and  in  vasoparalysis,  we  see  the  circulatory  failure  of  certain  severe 
toxemias.  Respiration  aids  in  charging  the  heart  with  blood  and  the 
coronary  flow  is  directly  stimulating.  We  are  just  gaining,  also,  a  small 
conception  of  the  part  played  by  the  organs  of  internal  secretion,  e.  g., 
the  chemical  action  of  the  secretion  from  the  suprarenal  glands  and  the 
pituitary  body. 

DILATATION  OF  THE  HEART. 

Definition. — Dilatation  means  distention  and  diminished  tonicity  of 
the  chambers  of  the  heart.  Tonicity  is  that  function  of  the  heart  which 
sustains  a  slight  degree  of  contraction  even  during  the  diastole.  Hyper- 
trophy is  thickening  of  the  walls  of  one  or  more  chambers.  The  two 
conditions  are  separate  in  themselves,  though  frequently  combined; 
dilatation  is  the  incentive  to  hypertrophy.  Lancisi  (1706-1728)  described 
hypertrophy  and  dilatation. 

Etiology. — 1.  Mechanical  Causes. — The  normal  heart  may  possibly 
yield  to  increased  blood-pressure  or  a  weak  heart  to  normal  pressure. 
Rarely,  if  ever,  is  dilatation  an  independent  condition,  (a)  Valvular  dis- 
ease, e.  g.,  dilatation  of  the  left  ventricle  in  aortic  insufficiency,  or  of  the  left 
auricle  and  right  ventricle  in  mitral  stenosis.  Hypertrophy  is  inversely 
proportional  to  the  dilatation.  In  combined  aortic  and  mitral  insuffi- 
ciency, the  heart  is  enormous — the  ox  heart,  cor  hovinum,  hucardia. 
(Two  types  of  dilatation  are  recognized :  the  accommodative,  in  which 
it  is  compensatory  and  the  dilatation  of  stasis).  (6)  Causes  raising 
arterial  blood-pressure,  as  stenosis  of  the  aorta,  arteriosclerosis  and 
nephritis  produce  hypertrophy  and  dilatation  of  the  left  ventricle. 
Workers  in  caissons  may  suffer  from  dilatation,  (c)  Causes  raising 
blood  tension  in  the  lesser  circulation,  as  spinal  deformity,  chronic  disease 
of  the  lungs  and  pleura,  which  produce  hypertrophy  of  the  right  ven- 
tricle; of  these  emphysema  is  the  most  important;  abdominal  lesions 
are  thought  to  reflexly  raise  the  pulmonary  blood-pressure.    The  lung's 


DILATATION  OF   THE  HEART  321 

vascular  area  must  be  reduced  to  25  per  cent,  in  order  to  affect  the  right 
heart.  When  there  is  pulmonary  obstruction  the  heart  stands  pneumonia, 
bronchitis  and  other  infections  poorly.  The  size  of  the  heart  varies 
much  physiologically;  during  severe  exercise,  the  systole  is  incomplete 
and  right-heart  dilatation — even  tricuspid  regurgitation  and  marked 
venous  stasis — may  follow.  Physical  training  increases  the  power  and 
reserve  strength  of  the  right  heart,  the  "wind"  and  endurance.  An 
equal  effort  in  an  individual  out  of  training,  or  with  poor  nutrition, 
"breaks  his  wind"  and  produces  cardiac  exhaustion.  Air  embolism 
also  produces  dilatation. 

2.  Nutritive  Disturbances. — Dilatation  may  be  induced  (a)  by 
acute  infections,  leading  to  cardiac  degeneration  or  acute  myocarditis; 
(6)  by  anemia  or  loss  of  fluids;  (c)  by  chronic  myocarditis,  fatty  heart 
or  coronary  atheroma,  possibly  following  sudden  heart  strain;  by  endo- 
or  pericarditis  invading  the  heart  muscle  by  contiguity,  pericardial 
adhesions,  etc.;  {d)  by  poisons,  alcohol  or  tobacco. 

Pathology. — Dilatation  occurs  (a)  with  thinning  of  the  walls,  simple 
dilatation,  or  (6)  with  eccentric  hypertrophy  (g.  v.).  It  is  most  common 
in  the  thin-walled  auricles  and  less  resistant  right  ventricle.  The  muscle 
is  lax  and  the  heart,  when  held  inverted  by  the  basal  vessels,  may  in 
extreme  instances  fall  flabbily  like  a  cap  over  the  hand;  the  endo-  and 
pericardium  may  almost  touch. 

The  papillary  muscles  and  trabeculse  are  flattened  (pressure  atrophy) 
and  frequently  thickened  (pressure  sclerosis).  Microscopically  the 
heart  muscle  may  be  normal,  or  show  fatty  or  cloudy  degeneration  or 
myocarditis.  There  is  much  blood  in  the  heart's  chambers,  cavse  and 
other  veins.  In  dilatation  occurring  during  the  death  agony  from  acute 
lung  disease,  suffocation,  etc.,  the  right  heart  is  chiefly  affected  and 
on  removal  of  the  postmortem  clots  the  chambers  seem  nearly  of  normal 
size. 

Physical  Signs. — 1 .  Dilatation  of  the  Left  Ventricle. — (a)  On  inspec- 
tion, the  apex  beat  is  dislocated  downward,  to  the  left  and  is  diffuse,  undu- 
lating and  weak,  if  not  absent.  (6)  On  palpation,  the  apex  may  not  be 
felt  even  though  visible;  in  other  cases  the  apex  and  heart  shock  are  snappy 
and  feel  strong  to  the  inexperienced  hand,  yet  contrast  sharply  with 
the  weak,  rapid  and  often  irregular  radial  pulse.  (A  palpable  impulse 
may  be  due  to  active  diastole  of  the  auricle,  to  passive  distention  of 
the  ventricle  by  blood  or  to  closure  of  the  auriculoventricular  valves.) 
Albertini  (1761)  distinguished  hypertrophy  and  dilatation  by  palpation. 
(c)  On  auscultation,  the  heart  tones  are  weak,  though  sometimes  snappy. 
The  first  apex  tone  is  more  valvular.  The  second  aortic  sound  is  weak 
because  of  poor  arterial  tension.  In  insufficient  hearts,  the  heart  tones 
sound  alike,  resembling  the  fetal  heart  tones  (embryocardia) .  An  apical 
systolic  murmur  is  sometimes  due  to  relative  insufficiency  of  the  mitral 
valve  whose  normal  circumference  of  three  and  one-half  inches  may  be 
stretched  to  five.  Decreased  tonicity  accounts  for  the  dilatation  and 
murmur  also;  these  signs  may  be  relieved  by  rest  and  digitalis.  Gallop- 
rhythm  consists  of  three  tones  like  the  rhythm  of  the  hoofs  of  a  galloping 
horse;  according  as  the  extra  tone  falls  at  the  end,  beginning  or  middle 
21 


322  DISEASES  OF   THE  HEART  MUSCLE 

of  the  diastole,  we  distinguish  presystoHc,  protodiastohc  or  mesodiastoHc 
gallop-rhythm.  The  presystolic  type  is  heard  in  strongly  beating  hearts, 
being  due  to  strong  auricular  contraction  and  is  likemse  heard  in  weak 
hearts,  being  due  to  the  ventricle  beating  later  after  the  auricle  than 
usual,  from  delayed  conductivity.  The  other  two  types  originate  in  an 
extra  tone  developed  in  the  ventricles,  probably  based  on  decreased 
tonicity.  The  protodiastolic  (third)  sound  is  heard  in  the  majority  of 
normal  young  individuals.  Gallop-rhythm  is  heard  in  the  failing  hyper- 
trophied  hearts  of  nephritics  chiefl}^,  in  valvular  lesions,  atheroma, 
emphysema  and  in  acute  diseases;  it  is  a  sign  of  great  danger. 
id)  On  ijercussion,  the  heart  extends  to  the  left  and  downward,  giving 
a  more  oval  area  of  dulness. 

2.  Dilatation  of  the  Right  Ventricle. — This  is  more  common. 
{a)  On  inspection,  a  diffuse  beat  is  seen  to  the  right  of  the  sternum  or 
in  the  epigastrium;  and  (6)  it  may  be  'palpated,  (c)  Auscultation  shows 
weak  heart  tones,  and  {d)  percussion  outlines  dulness  to  the  right  of 
the  sternum.  Extreme  dilatation  increases  the  tricuspid  orifice  from 
four  and  one-half  to  five  or  six  and  one-half  inches;  causing  relative 
tricuspid  insufficiency. 

3.  Dilatation  of  the  Aueicles. — Because  of  the  deep  location  of 
the  left  auricle  physical  signs  of  dilatation  are  seldom  obtained.  The 
changes  usually  ascribed  to  the  left  auricle  are  due  to  enlargement  of 
the  conus  of  the  right  ventricle.  The  distended  right  auricle  is  recognized 
by  undulation  to  the  right  of  the  sternum,  above  the  right  ventricle, 
by  dulness  and  sometimes  by  a  presystolic  wave. 

Dilatation  of  all  the  chambers  gives  the  heart  a  trapezoid  conforma- 
tion. The  symptoms  and  physical  findings  of  dilatation  may  develop 
gradually  or  abruptly  after  violent  exercise,  especially  when  the  heart's 
nutrition  is  altered. 

Symptoms. — Subjectively,  the  consequences  of  dilatation  are  loss  of 
reserve  power  of  the  heart  (see  Symptoms  of  Valvular  Disease).  Cardiac 
insufficiency  is  evidenced  by  breathlessness  or  dyspnea,  by  cyanosis, 
cough,  syncopal  attacks,  precordial  anxiety,  and,  when  the  systole 
ceases  to  expel  completely  the  blood  from  the  dilated  chambers,  the 
liver  enlarges  and  becomes  tender,  the  lungs  reveal  crepitant  rales  along 
their  bases,  the  legs  swell  and  the  urine,  the  surest  gauge  of  cardiac 
competency,  becomes  less  abundant. 

Diagnosis. — The  diagnosis  depends  on  the  etiological  factors,  the 
loeak  tones,  the  increased  dulness  and  evidences  of  cardiac  failure.  The 
absolute  heart  dulness  in  middle  life  is  bounded  by  the  left  border  of  the 
sternum,  the  fourth  or  fifth  rib  and  the  left  parasternal  line.  Percussion 
should  be  made  lightly,  using  the  finger-to-finger  method  and  applying 
the  passive  finger  firmly  against  the  chest  wall;  observance  of  this  tech- 
nique gives  as  accurate  results  as  does  the  fluoroscope.  According  to 
Moritz,  the  normal  heart  measures  3.5  to  4.5  cm.  to  the  right  of  a  mid- 
sternal  point  and  7.5  to  8.5  cm.  to  the  left.  The  relative  dulness  reaches 
from  the  third  or  fourth  rib  above  to  the  apex  beat  and  to  a  line  drawn 
obliquely  from  the  third  left  costal  cartilage  across  the  sternum  to  the 
fifth  right  costal  articulation.    Percussion  is  difficult  in  distorted,  fatty 


DILATATION  OF   THE  HEART  323 

or  edematous  chests.  Various  functional  tests"^  are  suggested,  yet  none 
is  satisfactory  except  the  test  where  a  given  effort  causes  it  to  decrease 
in  size,  stimulation  inducing  tonicity,  or  to  increase  in  size,  decreased 
tonicity  on  overstraining.  Differentiation  concerns  the  same  conditions 
discussed  under  effusive  pericarditis  (q.  v.).  Rest  and  digitalis  benefit 
dilatation,  but  not  pericardial  eifusion.  Consolidation  of  the  adjacent 
lung  margin  can  be  recognized  by  the  altered  breathing  and  rales. 
Mediastinal  tumor  and  aneurysm  are  suggested  by  pressure  symp- 
toms. If  the  margins  of  the  lung  are  adherent  from  pleural  adhesions 
or  emphysema  obscures  the  outlines  of  the  heart,  dilatation  is  diagnos- 
ticated by  the  relative,  more  than  by  the  absolute,  dulness.  Palpatory 
percussion,  very  lightly  made,  is  most  valuable  and  the  feel  of  the  increased 
dulness  has  greater  diagnostic  value  than  the  sound  elicited.  Encap- 
sulated pleurisy  is  differentiated  by  careful  puncture,  if  other  signs  fail. 
The  fluoroscope  is  frequently  of  aid.  In  short  chests  and  in  12  per  cent, 
of  women,  the  apex  is  seen  normally  at  or  even  beyond  the  nipple.  In 
spinal  curvature  the  topographical  relations  are  disturbed  by  visceral 
luxation,  and  the  irregularity  of  the  sternum  and  ribs  makes  percussion 
uncertain.  In  fat  individuals,  dulness  may  result  from  adipose  deposit 
in  the  mediastinum.  Dilatation  must  not  be  mistaken  for  dislocation 
due  to  distention  of  the  abdomen. 

Prognosis. — ^The  prognosis  largely  depends  on  the  etiology. 

Treatment. — (a)  The  cause  must  be  treated,  (b)  The  dietetic  and 
special  indications  of  valvular  disease  (q.  v.)  must  be  carried  out.  (c) 
OerteVs  treatment  consists  of  (i)  limitation  of  fluid  ingested,  and  stimula- 
tion of  its  excretion  by  sweats  and  deep  inspirations;  beer  must  be 
interdicted.  Many  nervous  subjects  tolerate  limitation  of  water  very 
poorly,  (ii)  Reduction  of  the  body  weight  (see  Obesity),  (iii)  Stimula- 
tion of  the  circulation  by  exercise.  Mountain  climbing  is  said  to  stimulate 
the  heart,  develop  the  respiratory  muscles,  increase  the  lung  capacity 
and  widen  the  vessels.  Reasonable  exercise  may  prove  beneficial,  but 
rest  in  bed  gives  better  results;  exercise  is  injurious  when  the  heart 
muscle  or  coronaries  are  diseased,  or  when  endocarditis,  pericardial 
adhesions  or  Bright' s  disease  exists,  (d)  The  Schott  method  consists  of 
(i)  baths  in  springs  containing  sodium  and  calcium  chloride,  iron  car- 
bonate and  carbon  dioxide.  The  temperature  should  be  a  few  degrees 
below  body  heat,  and  they  should  be  given  once  daily  for  five  to  twenty 
minutes,  for  two  or  three  days,  and  then  intermitted.  They  may  be 
given  artificially,  using  40  gallons  of  water,  with  3  to  10  pounds  of  salt, 

1  In  Schapiro's  test,  the  normal  decline  of  7  to  15  beats  in  the  heart's  rate,  when  the 
patient  lies  down,  is  absent  in  decompensation.  Graupner' s  test:  Normally  the  pulse  and 
blood-pressure  rise  after  exertion,  such  as  running  upstairs,  and  if  the  effort  is  prolonged  and 
arduous,  the  figures  fall  to  normal  or  below  it,  but  the  pulse  rises  and  falls  before  the  blood- 
pressure  begins  to  rise  and  fall ;  in  weak  hearts  the  blood-pressure  rise  is  delayed,  decreased 
or  absent.  In  Hertz's  test,  the  patient  sits  and  very  slowly  flexes  and  extends  the  right 
forearm,  directing  all  his  attention  on  the  act  but  avoiding  any  firm  contraction  of  the 
muscles;  the  physician  supports  the  patient's  elbow  with  his  left  hand  and  directs  the  move- 
ment with  his  right,  but  without  aiding  the  movement;  there  is  no  influence  on  the  pulse 
in  normal  conditions,  while  in  pathological  conditions,  it  is  slowed  5  to  20  beats.  Marey's 
and  Levy's  test  consists  of  digital  compression  of  both  femoral  arteries;  in  normal  conditions, 
within  three  minutes  the  blood-pressure  rises  5  to  15  mm.  Hg. ;  in  hypertrophy,  even  more 
and  in  weak  hearts,  no  rise  (this  test  is  not  valid  in  neurotics) . 


324  DISEASES  OF   THE  HEART  MUSCLE 

10  ounces  of  pure  calcium  chloride  and  carbon  dioxide  generated  in  a 
vessel  from  sodium  bicarbonate  and  hydrochloric  acid.  The  temperature 
is  then  reduced  to  90°,  and  the  amount  of  carbon  dioxide  increased. 
The  bloodvessels  are  contracted  and  later  dilated.  The  pulse  becomes 
slower  and  fuller,  dilatation  decreases,  stasis  is  lessened,  diuresis  is 
increased  and  the  metabolism  of  the  muscles  and  heart  is  improved. 
(ii)  Movements  by  the  patient,  resisted  by  the  operator,  dilate  the  vessels. 
Active  exercise  constricts  the  vessels.  The  Nauheim  treatment  has  been 
unduly  exploited. 

Each  exercise  is  made  against  slight  resistance  applied  by  the  physician. 

1.  The  arms  are  extended  in  front  of  the  body  at  the  level  of  the  shoulder,  with  the 
palms  touching.  The  arms  are  then  moved  slowly  outward  till  they  are  in  a  line  with  each 
other;    they  are  then  brought  back  to  their  original  position. 

2.  The  arm  and  hand  hanging  down  with  the  palm  turned  forward,  the  forearm  is 
flexed  upon  the  arm  (which  is  kept  stUl)  until  the  fingers  touch  the  shoulder.  The  forearm 
is  then  extended  to  its  original  position. 

3.  The  arms,  hanging  down  as  in  No.  2,  are  raised  outward  until  the  thumbs  meet  over 
the  head ;   they  are  then  returned  to  their  original  position. 

4.  With  arms  dependent,  the  fingers,  at  the  first  phalangeal  joints,  are  pressed  together, 
and  the  arms  are  then  raised  until  the  hands  are  above  the  head,  after  which  they  are 
brought  back  to  their  original  position. 

5.  The  arms,  hanging  in  the  position  of  "attention,"  are  advanced  forward  parallel  to 
each  other  until  they  are  elevated  to  a  vertical  position;"  they  are  then  brought  back  to 
where  they  were  before. 

6.  Same  as  No.  1,  but  with  fists  clenched. 

7.  Same  as  No.  2,  but  with  fists  firmly  clenched. 

8.  The  arms,  starting  from  the  position  of  "attention,"  describe  a  circle  by  moving 
forward  and  upward  untU  they  are  raised  vertically;  then  each  palm  is  turned  outward, 
and  the  arms  descend  backward  to  their  former  position. 

9.  The  body  is  bent  forward,  and  then  brought  back  to  the  erect  position. 

10.  The  body  is  rotated,  without  any  movement  of  the  feet,  first  to  the  right  and  then  to 
the  left,  and  then  back  to  its  original  position. 

11.  The  body  is  flexed  laterally,  as  far  as  possible,  first  to  the  one  side  and  then  to  the 
other,  and  afterward  restored  to  its  original  erect  position. 

12.  The  patient,  standing  with  the  feet  side  by  side  and  supporting  himself  by  leaning 
with  one  hand  upon  any  object,  flexes  the  opposite  thigh  as  far  as  it  is  possible,  and  after- 
ward extends  it  until  the  feet  are  again  side  by  side;  then  leaning  on  the  other  hand,  he 
carries  out  a  similar  movement  with  the  other  thigh. 

13.  The  patient,  supporting  himself  by  one  hand,  as  in  12,  and  the  knee  being  kept 
straight,  each  leg  in  turn  is  raised  as  high  as  possible  in  front  of  the  body,  and  then  in  the 
same  way  behind. 

14.  Supporting  himself  by  placing  both  hands  in  front  on  the  back  of  a  chair,  the  patient 
first  flexes  one  leg  and  then  the  other  upon  the  thigh  as  far  as  he  can. 

15.  Each  leg  in  turn  is  abducted  as  far  as  possible,  the  knees  being  kept  straight,  the 
patient  resting  on  one  or  other  hand  the  while. 

16.  The  arms,  held  horizontally  outward,  are  rotated  forward  and  backward  at  the 
shoulder-joint. 

Contra-indications  are  aneurysm,  angina  pectoris,  acute  cardiac  insuffi- 
ciency and  tendency  to  hemorrhage  or  embolism. 


HYPERTROPHY   OF   THE   HEART. 

Etiology. —  Hypertrophy  of  the  left  ventricle  results  from  (a)  valvular 
lesions  wherein  dilatation  precedes  and  incites  hypertrophy;  (6)  renal  dis- 
ease; usually  from  a  chronic  interstitial  nephritis  (mechanical  obstruction 
to  the  flow  of  blood  or  retention  within  the  blood  of  waste  substances 
which  excite  arterial  spasm);    (c)  arteriosclerosis  {q.  v.);    (d)  congenital 


HYPERTROPHY  OF  THE  HEART  325 

narrowness  (Jiypoplasia)  of  the  arterial  system,  or  of  the  aorta  at  the  isth- 
mus; (e)  dilatation  of  the  aorta,  diffuse  or  aneurysmatic;  (/)  pericardial 
adhesions,  {q.  v.);  (g)  myocarditis  (q.  v.);  (h)  pregnancy;  the  placental 
circulation  or  increased  intra-abdominal  pressure  increases  the  heart's 
work.  The  high  diaphragm  also  apposes  the  heart  to  the  chest  wall  and 
tips  the  apex  outward  so  as  to  simulate  hypertrophy;  {i)  overexertion; 
the  "irritable  heart  of  soldiers"  is  caused  by  forced  marches,  cold  and 
mental  excitement;  the  so-called  idiopathic  hypertrophy  occurs  in  hard 
workers,  and  especially  in  Munich  from  excessive  use  of  beer  and  from 
the  resulting  high  blood-pressure;  hypertrophy  results  from  continued 
hard  work,  while  dilatation  follows  sudden  cardiac  strain;  (j)  nervous  or 
toxic  causes,  as  exophthalmic  goitre  and  tobacco,  especially  strong 
Havana  cigars,  which  cause  rapid  irregular  heart  action;  {k)  reflex 
hypertrophy  is  said  to  result  from  abdominal  growi;hs,  brachial  neuritis, 
etc. 

Hypertrophy  of  the  right  ventricle  arises  from  {a)  left-heart  disease, 
from  the  intimate  connection  between  the  muscular  fibers  of  both  sides; 
ih)  right-heart  valvular  lesions  and  congenital  heart  disease;  (c)  increased 
pulmonary  pressure  from  disease  of  the  pulmonary  artery  or  pressure 
upon  it;  {d)  emphysema,  chronic  bronchitis,  spinal  deformity,  pulmonary 
induration,  extensive  pleural  adhesions,  etc. 

Hypertrophy  of  the  auricles  always  coexists  with  dilatation. 

Pathology. — The  muscle  fibers  increase  even  tenfold  in  size  {hyper- 
trophy) and  increase  in  number  {hyperplasia).  Hypertrophy  may  exist 
alone — simple  hypertrophy,  but  more  frequently  mth  dilatation — eccen- 
tric hypertrophy.  Concentric  hypertrophy  is  rarer  and  some  regard  it  as 
a  postmortem  condition;  the  ventricle  may  be  firmly  contracted  in 
death  from  violence,  cholera  or  hemorrhage,  but  it  can  be  distended  by 
the  finger.  The  size  of  the  normal  heart  is  that  of  the  fist  (Laennec), 
and  the  normal  weight  is  300  gm.  The  heart  is  sometimes  increased  in 
weight,  even  1980  gm. — the  cor  hovinum.  The  left  ventricle,  normally 
9  to  10  mm.  in  thickness,  may  be  more  than  doubled  in  hypertrophy;  the 
right  ventricle  measures  3  or  4  mm.;  the  left  auricle  measures  3  and  the 
right  2  mm.  In  the  fetus  the  ventricles  are  equally  thick.  Up  to  the 
eighth  year,  the  left  ventricle  is  relatively  thicker  than  in  adults,  because 
of  narrowing  of  the  aorta  at  its  isthmus. 

Symptoms. — ^Hypertrophy  of  the  left  heart  may  be  symptomless,  or 
there  may  be  palpitation,  cardiac  oppression  or  cerebral  congestion — 
tinnitus,  headache  or  vertigo.  There  is  frequently  a  tendency  to  hemor- 
rhage— epistaxis,  cerebral  hemorrhage,  excessive  menstruation.  Polyuria 
results  from  high  arterial  tension.  The  causal  nephritis,  valvular  disease, 
arteriosclerosis  or  emphysema  presents  its  own  symptoms.  Right-heart 
hypertrophy  is  attended  by  brown  induration  of  the  lungs,  hemoptysis, 
cyanosis  or  bronchial  catarrh. 

Physical  Signs. — Much  confusion  in  the  clinical  description  prevails 
because  the  signs  of  hypertrophy  are  very  often  confounded  with  those 
of  dilatation,  with  which  it  frequently  coexists. 

Hypertrophy  of  the  Left  Ventricle. — 1.  Inspection. — This  dis- 
closes   (a)    a   strong,  sometimes   heaving,  diffuse   apex;   its   dislocation 


326  DISEAS'ES  OF   THE  HEART  MUSCLE 

indicates  dilatation,  because  thickening  of  the  heart  muscle  alone  gives 
no  appreciable  increase  in  the  size  of  the  heart.  Rotatory  retraction  of 
the  apex  beat  is  sometimes  seen,  {h)  Precordial  'prominence;  (c)  forcible 
'pulsation  of  the  vessels. 

2.  Palpation. — Palpation  confirms  (a)  the  strong  apex  heat,  detects 
(6)  the  palpable  second  aortic  tone  due  to  high  tension  or  atheroma,  and 
sometimes  (c)  a  systolic  apical  thrill  (transmission  of  the  strong  first 
tone),  (d)  The  pulse  is  regular,  full  and  hard  in  simple  hypertrophy; 
in  the  eccentric  form  it  is  softer  and  more  rapid;  it  is  sometimes 
weak  or  almost  absent  in  the  arms,  due  to  loss  of  vessel  tonus,  (e) 
Thrills  over  the  peripheral  vessels  from  high  tension  vibration  may  be 
felt. 

3.  Percussion. — Enlargement  means  dilatation  or  an  atheromatous 
relaxed  aorta  which  allows  sinking  of  the  heart. 

4.  Auscultation. — ^This  brings  out  (a)  the  loud  first  tone  over  the  apex 
(but  not  in  aortic  leakage);  (h)  the  accentuated,  even,  metallic,  second 
aortic  tone;  (c)  systolic  arterial  bruits  from  tension  and  vibration  of  the 
walls;  (d)  the  gallop-rhythm  in  failing  hypertrophy,  especially  in  neph- 
ritics;  (e)  a  peculiar  clink,  sometimes  heard  to  the  right  of  the  apex; 
(/)  an  apical  systolic  murmur,  frequently  of  the  cardiopulmonary  type. 
Seitz  and  Gendrin  recorded  murmurs  resembling  the  pericardial  rub, 
due  to  violent  muscular  contraction. 

HYPERTRorHY  OF  THE  RiGHT  VENTRICLE. — (1)  Inspection  shows  a 
strong,  systolic  impulse  under  the  lower  part  of  the  sternum  which  is  (2) 
palpable,  as  is  the  strong  second  pulmonic  tone.  (3)  Auscultation  brings 
out  the  accentuated  second  pulmonic;  and  (4)  percussion  is  negative, 
unless  there  is  coincident  dilatation. 

Diagnosis. — In  left-sided  hypertrophy,  the  cardinal  signs  are  (a)  the 
tense  pulse,  (6)  the  strong  apex  beat  and  (c)  the  accentuated  second 
aortic  tone;  in  right-sided  hypertrophy  they  are  (1)  the  strong  second 
pulmonic  tone  and  (2)  substernal  pulsation. 

In  nervous  overaction  of  the  heart,  the  apex  is  not  heaving.  Retraction 
of  the  left  lung  exposes  more  of  the  left  ventricle,  but  the  heart's  outline 
enlarges  upward  and  to  the  left.  In  narrow  chests  with  poor  lungs,  the 
heart's  dulness  is  wide,  but  hypertrophy  is  lacking.  At  puberty  the  heart 
is  nervously  unstable,  the  chest  is  thin  and  the  heart  normally  wider. 
Abundant  casts  and  blood  in  the  urine  usually  indicate  nephritis,  but, 
if  there  are  other  evidences  of  stasis,  such  as  congested  liver,  they  are 
compatible,  in  the  minds  of  some  clinicians,  with  stasis  alone.  Nephritis 
may  cause  hypertrophy;  nephritis  and  hypertrophy  may  be  due  to  a 
common  cause;  or  a  failing  heart  may  produce  renal  stasis.  (See  Neph- 
ritis, Differential  Table.) 

Prognosis. — The  immediate  outlook  is  good  because  hypertrophy  is 
usually  a  compensatory  process;  the  ultimate  outlook  is  bad,  as  the 
reserve  power  is  exhausted.  Symptoms  appear  gradually  or  suddenly 
from  intercurrent  fevers,  malnutrition  and  mental  or  physical  strain. 
Hypertrophy  caused  by  tobacco  or  athletics  may  regress.  Gallop- 
rhythm  is  ominous,  as  is  the  occurrence  of  the  first  and  second  apical 
tones  close  together. 


FATTY  HEART  327 

Treatment. — The  therapy  is  eminently  causal  and  dietetic;  alcohol,  tea, 
coffee,  tobacco,  cold  baths  and  constipation  are  to  be  avoided.  Treatment 
of  decompensation  is  that  of  valvular  disease  (q.  v.). 

ATROPHY  OF  THE  HEART. 

Atrophy  of  the  heart  is  chiefly  of  pathological  interest. 

Etiology. — The  heart  is  at  times  congenitally  weak  and  small.  It 
may  then  be  associated  with  small  vessels,  chlorosis  (Virchow)  or  with 
hypoplasia  of  the  genitalia  (Rokitansky) .  Pressure  atrophy,  coronary 
sclerosis,  pericarditic  adhesions,  the  senile  involution  and  cachectic 
diseases  are  the  most  frequent  causes.  Anatomically,  the  heart  is  reduced 
in  size  and  weight  (even  to  1^  ounces),  the  subpericardial  fat  disappears, 
the  pericardium  wrinkles,  the  coronary  arteries  are  tortuous  and  the 
heart  muscle  is  pigmented.  The  valves,  especially  the  aortic,  may  waste. 
The  atrophy  may  be  partial,  as  that  of  the  left  ventricle  in  some  cases 
of  mitral  stenosis. 

The  symptoms  are  indeterminate,  and  the  diagnosis  impossible. 

FATTY    HEART. 

Etiology  and  Pathology. — Fatty  heart  is  no  distinct  pathological  or 
clinical  entity.  Two  forms  are  recognized:  (1)  fatty  infiltration  and  (2) 
fatty  degeneration. 

1.  Fatty  Infiltration. — -The  Lipoma  cordis  capsular e,  Virchoiv,  con- 
sists of  invasion  of  the  heart  muscle  by  the  subpericardial  fat,  normally 
found  about  the  heart,  in  its  furrows,  at  the  tips  of  the  ventricles  and 
around  the  basal  vessels.  The  fat  extends  in  parallel  lines  between  the 
muscle  fibers,  which  it  may  wholly  replace.  The  fatty  infiltration  was 
once  considered  primary,  but  it  is  secondary  to  muscle  atrophy  or  some 
nutritive  disturbance.  The  fat  develops  most  in  the  outer  layers  of  the 
myocardium,  but  may  reach  to  the  endocardium.  Fatty  infiltration 
is  most  common  in  obese  males  over  forty  years  of  age.  It  may  occur 
after  the  menopause  or  in  sterile  women.  High  living,  abuse  of  alcohol 
and  heredity  are  factors.  The  heart  is  reduced  25  per  cent,  compared 
with  the  body  weight. 

2.  Fatty  Degeneration. — This  form  is  caused  by  deficient  oxygena- 
tion which  is  either  (a)  general,  resulting  from  acute  infections,  old  age, 
cachexia,  anemia,  poisons,  etc.;  or  (b)  local  or  cardiac,  from  pericarditis; 
coronary  disease,  which  most  frequently  produces  myofibrosis;  and 
from  cardiac  failure  following  hypertrophy.  Most  degeneration  occurs 
in  the  left  heart.  The  fatty  heart  is  flabby  and  yellowish-brown — the 
"faded  leaf"  color  of  Laennec;  the  splashes  and  streaks  of  fatty  degen- 
eration give  the  variegated  "tiger"  or  "tabby-cat"  appearance;  oil 
globules  in  rows  in  the  muscle  fibers  may  replace  them  in  part  or  en- 
tirely. Frequently  the  muscle  fibers  show  albuminoid  degeneration,  the 
first  step  in  fatty  degeneration.  The  striations  of  the  muscle  disappear 
later,  its  consistence  is  decreased  and  its  substance  is  friable. 

Parenchymatous  and  fatty  degeneration  are  observed  in  those  seg- 


328  DISEASES  OF   THE  HEART  MUSCLE 

merits  of  the  heart  where  the  greatest  work  and  the  most  nutrition  are 
demanded,  as  in  the  papillary  muscles  of  the  mitral  valves  and  where 
pressure  is  greatest,  viz.,  the  septum  and  left  conus  arteriosus. 

Symptoms  and  Signs. — Extensive  changes  may  occur  without  clinical 
symptoms;  Leube  details  a  case  of  pernicious  anemia  without  cardiac 
symptoms  in  which  the  apex  was  completely  fatty.  In  some  obese 
subjects,  cardiac  embarrassment  develops  with  dyspnea,  palpitation,  etc. 
The  autopsy  may  reveal  fatty  heart,  but  far  more  frequently  myocarditis, 
hypertrophy  or  coronary  disease  is  found;  i.  e.,  there  is  no  uniformity 
in  the  pathological  findings,  nor  parallelism  between  them  and  the  clinical 
signs.  Though  percussion  of  obese  individuals  is  difficult,  the  heart  is 
found  dilated.  In  fatty  heart,  the  tones  are  weak  and  distant,  the 
apex  beat  is  weak,  diffuse  or  absent,  and  sometimes  an  apical  systolic 
murmur  is  heard,  due  to  irregular  systolic  vibration.  Gallop-rhythm 
indicates  cardiac  fatigue.  The  pulse  may  be  rapid,  small  and  arrhythmic. 
Low  temperature,  sweating  and  bronchitis  are  common.  Much  stress 
was  formerly  laid  on  the  Adams- Stokes's  syndrome  (see  page  342). 

Prognosis. — The  prognosis  is  grave  when  coronary  disease,  angina, 
lung  edema  or  an  irregular  or  very  slow  pulse  intervenes.  Sudden  death 
is  not  uncommon  from  acute  dilatation,  pulmonary  embolism,  cerebral 
hemorrhage,  "heart  block,"  or  rarely  heart  rupture. 

Treatment. — The  treatment  is  that  of  obesity  in  fatty  infiltration, 
but  distinction  must  be  made  between  (a)  obesity  with  anemia,  in  which 
the  subject  is  pale,  with  cold  extremities,  sweating,  scanty  urine,  weak 
muscles  and  dyspnea;  and  (6)  obesity  with  plethora,  in  which  the  color 
is  red,  the  urine  increased  and  uratic,  the  heart  stronger,  the  muscles 
fairly  developed  and  exercise  possible  with  little  dyspnea.  Schott's 
treatment  is  beneficial  in  the  first  type,  and  Oertel's  method  in  the 
latter.  Saline  cathartics,  total  abstinence  from  alcohol  and  the  use  of 
potassium  iodide  are  indicated.  Cardiac  insufficiency  is  treated  as  in 
uncoihpensated  valvular  lesions  and  dilatation.  Morphine  should  be 
used  with  great  circumspection. 


ACUTE   MYOCARDITIS. 

Etiology  and  Pathology. — Acute  myocarditis  is  of  the  greatest  clinical 
and  prognostic  importance. 

Acute  yarenchymatous  myocarditis  corresponds  to  granular  and  fatty 
degeneration  {v.  i.);  the  "mushroom"  heart  of  Stokes,  and  the  "softened 
heart"  of  Laennec  and  Louis. 

Acute  interstitial  myocarditis  has  been  most  studied  of  late  years,  while 
formerly  the  degenerations  attracted  most  attention.  It  was  first  dis- 
covered by  Leyden  in  scarlatina;  it  is  found  in  a  large  percentage  of 
cases  of  diphtheria,  typhoid,  acute  endocarditis  and  rheumatism.  Round 
cells  are  found  in  the  interstitial  tissue,  with  or  without  muscular  altera- 
tion, such  as  vacuolization,  nuclear  multiplication,  pigmentary  deposit, 
blood  extravasation  and  waxy  changes. 

Nodes  {v.  page  284),  inflammatory  thickening  of  the  intima  in  the  cor- 


CHRONIC  MYOCARDITIS  329 

onary  radicles  and  perineuritis  are  also  described.  Probably  inflam- 
mation is  primary  and  degeneration  secondary. 

Symptoms  and  Signs. — During  the  progress  of  an  acute  infection  the 
heart's  strength  decreases;  its  tones,  especially  the  first  mitral,  become 
fainter.  There  is  often  a  marked  presystolic  impulse;  the  less  distinct 
apex  is  dislocated  to  the  left  and  the  pulse  grows  more  weak  and  irregular. 
Vasomotor  relaxation  is  a  very  important  element  in  the  heart  failure. 
Gallop-rhythm  and  embryocardia  develop,  and  there  is  usually  a  rela- 
tive mitral  leakage.  Cardiac  pain  may  be  severe.  These  changes  may 
develop  during  the  typhoid,  scarlatina  or  rheumatism;  or  occur  two  to 
ten  weeks  after  the  infection,  as  in  diphtheria.  Sudden  death  may  occur 
during  convalescence.  Rheumatic  myocarditis  often  leads  to  chronic 
fibrous  myocarditis. 

Diagnosis. — The  etiology  is  important;  acute  myocarditis  is  distin- 
guished with  great  difficulty  from  acute  endocarditis  (g.  v.). 

Treatment. — Prophylaxis. — The  patient  should  have  absolute  rest 
well  into  convalescence,  because  sudden  heart  insufficiency  or  unexpected 
death  may  follow  eftort,  difficult  defecation  or  sexual  intercourse.  Car- 
diants  are  indicated  as  in  valvular  incompetency.  (See  therapy  of 
Typhoid,  Diphtheria  and  Pneumonia.) 

I.  Acute  Circumscript  Myocarditis. — ^This,  the  disease  of  gladiators 
(Galen),  is  a  form  of  sepsis,  and  its  embolic  heart  foci  are  usually  multiple. 
It  is  usually  caused  by  the  pyogenic  organisms.  The  issues  are  (a) 
resorption  with  fibrosis,  (6)  caseation  or  calcification  and  (c)  rupture 
into  the  pericardium  or  into  the  heart  cavity,  thus  producing  "heart 
ulcers,"  embolism,  heart  aneurysm  or  abnormal  communications  between 
the  chambers.  Sudden  valvular  insufficiency  is  sometimes  suggestive, 
though  it  is  usually  impossible  to  make  a  diagnosis.  The  treatment  is 
that  of  the  fundamental  septicopyemia  and  the  resulting  cardiac  insuffi- 
ciency. 

II.  Fragmentation  of  the  Heart  Muscle. — There  are  two  forms  (a) 
segmentation  or  separation  from  each  other  of  the  heart  fibers,  and  (b) 
fragmentation  or  rupture  across  the  normal  or  degenerated  muscle  fibers. 
It  also  has  been  called  segmentary  myocarditis;  it  most  frequently  occurs 
in  death  from  violence,  but  may  have  clinical  significance  in  sudden  or 
gradual  heart  weakness.     (See  Myolysis,  under  Diphtheria.) 

CHRONIC  MYOCARDITIS  (CHRONIC  FIBROUS  OR  INTERSTITIAL 
MYOCARDITIS,  MYOFIBROSIS  CORDIS). 

Etiology  and  Pathology. — Chronic  myocarditis  is  rarely  a  disease 
sui  generis,  but  is  a  sequel  of  some  retrogressive  lesion — a  secondary 
process.  It  .compensates  for  destruction  of  heart  tissue,  is  a  measure  of 
that  loss  and  is  more  often  a  fibrosis  than  an  inflammation.  The  longi- 
tudinal incision  of  the  heart  muscle  discloses  scar-like  tissue  often  unseen 
in  transverse  sections.  This  tissue  is  seen  most  frequently  in  the  lower 
two-thirds  of  the  anterior  wall  of  the  left  ventricle  and  the  upper  two- 
thirds  of  its  posterior  wall  near  the  auricle,  as  glistening  sunken  areas 
under  the  pericardium  or  endocardium.    It  also  occurs  in  the  papillary 


330  DISEASES  OF  THE  HEART  MUSCLE 

muscles  or  septum.  The  scars  appear  as  streaks  or  stellate  plaques,  some- 
times measuring  three  or  four  centimeters.  The  foci  may  be  macro-  or 
microscopic,  circumscribed  or  general.     Gross  changes  in  the  heart  include: 

1.  Hypertrophy. — This  is  vicarious  and  is  inversely  proportional  to 
the  number  of  scars.  The  relation  is  twofold;  (a)  hj-pertrophy  often 
compensates  for  moderate  muscular  destruction;  or  (b)  fibrosis  develops 
in  tired,  hypertrophied  hearts. 

2.  DiL-\TATiox. — This  follows  extensive  fibrosis  and  decreased  tonicity. 
Fibrosis  may  neutralize  dilatation, 

3.  Atrophy  of  the  Myocardium. 

4.  Valvular  Disease. — A  relative  mitral  insufficiency  may  follow 
myocarditis  in  the  mitral  papillary  muscles.  Dittrich  described  a  geuuine 
heart-stenosis,  a  myocarditic  contraction  of  the  left  conus  arteriosus 
in  the  adult,  or  of  the  right  conus  in  the  fetus.  Relative  aortic  insuffi- 
ciency may  follow  dilatation  and  myocarditis  of  the  left  ventricle  (personal 
observations) . 

5.  Heart  Aneurysm  axd  He.art  Rupture. — Partial  heart  aneurysm, 
a  localized  bulging  of  the  heart  wall,  is  seen  largely  near  the  apex  (left 
ventricle,  68  per  cent,  of  cases),  where  acute  myomalacia  cordis  or 
chronic  fibrosis  occurs  most  frequently;  it  is  seen  more  rarely  at  the 
base  or  septum  which  may  bulge  into  the  right  heart;  and  most  infre- 
quently in  the  right  heart.  The  aneurysm  is  usually  small,  but  may 
equal  the  size  of  the  heart;  it  is  usually  single  (though  four  were  found 
by  Thurnam),  and  may  communicate  with  the  heart  cavity  by  a  neck- 
like constriction;  its  walls  consist  of  connective  tissue,  which  is  rarely 
ossified,  as  in  Corvisart's  case.  It  may  rupture  or  detach  a  valve.  During 
twenty  years  ending  in  1903,  D.  G.  Hall  found  112  cases  recorded  (26 
had  aneurysm  in  the  valves,  and  25  in  the  coronary  vessels);  Volker 
alone  made  a  diagnosis.     Rupture  of  the  heart  (r.  page  332). 

Pathogenesis. — The  most  frequent  cause  is  disease  of  the  coronary  arter- 
ies, which  are  end  arteries,  and  anastomose  with  each  other  only  through 
their  capillaries.  The  vessels  of  Thebesius,  entering  the  muscle  from 
the  auricles  and  ventricles  may  carry  on  some  collateral  circulation 
when  the  coronary  arteries  are  occluded.  Coronary  narrowing  may  be 
gradual,  by  obliterative  endarteritis  or  by  the  occlusion  of  the  vessel 
from  an  atheromatous  plaque  in  the  aorta;  or  it  may  be  sudden  and 
fatal  by  embolism  or  thrombosis  in  an  already  narrowed  vessel;  the 
most  common  location  is  in  the  left  ventricle  (anterior  coronary  artery 
which  is  relatively  small)  and  in  the  septum.  In  acute  coronary  obstruc- 
tion, the  heart  muscle  becomes  ischemic  and  opaque  and  the  necrotic 
area  swells  (coagulation  necrosis) ;  a  wedge-shaped  anemic  infarct  is  less 
common.  The  muscle  fibers  become  fragmented,  lose  their  nuclei  and 
disappear;  this  process  may  lead  to  rupture  of  the  heart  or  sudden 
death.  Ziegler  named  it  myomalacia  cordis.  If  the  subject  lives,  scar 
tissue  develops — a  dystrophic  sclerosis.  Huchard  employs  the  terms, 
arteriosclerosis  of  heart  and  arterial  cardiopathy,  to  emphasize  the 
causal  role  of  arterial  disease.  A  less  frequent  cause  is  actual  chronic 
myocarditis  following  acute  myocarditis  or  endarteritis  due  to  rheumatism, 
typhoid  or  diphtheria.    Dehio  holds  that  myofibrosis  is  a  result  of  dilata- 


CHRONIC  MYOCARDITIS  331 

tion,  and  occurs  where  the  muscle  is  destroyed,  as  a  necessary  and  pro- 
tective process,  conforming  with  Thoma's  conception  of  arteriosclerosis 
(q.  v.). 

Symptoms. — (a)  In  the  latent  tyye  there  are  no  symptoms  and  sudden 
apoplectiform  death  occurs  in  apparently  perfect  health,  (h)  Most 
cases  present  chronic  symptoms  of  cardiac  insufficiency.  There  is  venous 
congestion.  The  'pulmonary  circulation  suffers  especially,  as  is  shown 
by  cyanosis,  large  infarcts,  hydrothorax,  edema  of  the  lungs,  bronchitis 
and  dyspnea.  The  cardiac  symptoms  are  precordial  oppression,  pal- 
pitation, cardiac  asthma  or  angina  pectoris.  Examination  of  the  heart 
sometimes  gives  negative  results,  but  dilatation  and  hypertrophy  are 
usually  present  (cardiomegalia) .  The  heart  tones,  at  first  often  clear, 
become  jaint  and  irregular,  so  that  in  the  resulting  delirium  cordis,  the 
tones  are  disorderly  and  the  phase  of  the  murmur,  due  to  relative  mus- 
cular insufficiency  or  to  arteriosclerotic  dilatation,  cannot  be  distinguished. 
The  second  pulmonic  sound  is  accentuated  or  split  and  the  second  aortic 
tone  is  weak,  because  the  arterial  tension  is  low.  The  pulse  is  usually 
irregular;  paroxysms  of  arrhythmia  may  indicate  an  extension  of  the 
sclerosis.  Irregularity  usually  antedates  cardiac  insufficiency.  A  regu- 
lar pulse  may  be  present  throughout,  or  a  number  of  regular  strong 
beats  is  followed  by  a  wave  of  rapid,  tumbling  heart  action.  The  pulse- 
rate,  often  slow  at  first,  increases  to  90  or  100,  with  ominous  crises  of 
tachycardia.  In  some  instances  the  pulse  is  persistently  slow  and  asso- 
ciated with  syncope  {v.  i.  Bkadycardia)  . 

Edema  is,  as  a  rule,  less  common  and  intense  than  in  valvular  disease. 
Embolism  may  occur.  Digestive  disturbances  are  constant.  Alimentary 
autotoxemia,  from  carelessness  in  diet,  may  cause  paroxysmal  cardiac 
symptoms.  Potain  and  Barie  hold  that  digestive  disorders  induce  a 
reflex  contraction  of  the  lung  vessels  and  thus  lead  to  dyspnea.  The 
urine  is  that  of  stasis  in  the  later  stages,  but  early  in  the  disease  poly- 
uria may  prevail  from  high  blood-pressure. 

Diagnosis. — ^There  are  five  cardinal  points:  (a)  In  the  majority  of 
cases  arteriosclerosis  is  most  important;  it  is  usually  diffuse,  but  may 
exist  in  the  heart  and  not  in  the  radial  arteries,  and  conversely.  (6) 
The  heart  is  usually  dilated  and  hypertrophied.  (c)  No  valvular  murmur 
exists  in  uncomplicated  cases.  The  systolic  apical  murmur  of  arterio- 
sclerotic dilatation  may  be  heard  or  the  soft,  variable  bruit  of  relative 
mitral  leakage,  {d)  The  pulse  is  fast  and  irregular.  A  regular  pulse  does 
not  absolutely  exclude  myocarditis,  (e)  Dyspnea  and  pulmonary  stasis 
are  suggestive. 

Myofibrosis  may  be  overshadowed  by  the  more  frank  yet  wholly  iden- 
tical fibrosis  of  the  vessels,  kidneys,  liver  and  perhaps  meninges  or 
adrenals  (poly visceral  scleroses),  until  one  of  the  great  trio  of  risks  of 
diffuse  degeneration  intervenes — cerebral  accidents,  renal  suppression 
or  cardiac  agony  (angina  with  pain  or  angina  with  precipitate  coronary 
death) . 

Differentiation  is  often  so  difficult  that  many  clinicians  limit  the 
diagnosis  to  muscular  insufficiency;  fatty  heart,  hypertrophy  and  dilata- 
tion, or  pericardial  adhesions  may  be  found  at  autopsy  instead  of  the 


332  DISEASES  OF  THE  HEART  MUSCLE 

anticipated  myocarditis.  Sometimes  when  myocarditis  is  suspected,  the 
heart  shows  nothing  microscopically  or  macroscopically  (the  causes  of 
heart  failure  are  often  beyond  detection  by  the  microscope) .  A  diagnosis 
is  made  by  exclusion,  and  then  is  only  a  "probability  diagnosis."  In 
differentiation  from  the  "heart  of  renal  disease,"  long  observation,  the 
gallop-rhythm  (more  common  in  the  cor  renale)  and  uremic  manifesta- 
tions are  helpful;  myocarditis  and  renal  disease  are  frequently  asso- 
ciated. From  mitral  stenosis:  both  lesions  cause  irregularity  and  a  weak 
radial  pulse  and  apex  beat;  when  the  presystolic  stenotic  murmur  is 
absent,  the  loud  second  pulmonic  sound,  the  loud  snapping  apical  tone 
and  the  wide  right  heart  are  most  suggestive  of  mitral  stenosis.  "  Cardiac 
apoplexy"  may  be  mistaken  for  cerebral  apoplexy  or  embolism;  the 
autopsy  in  cases  of  sudden  death  often  discloses  coronary  closure  with 
myomalacia  cordis  or  fibrous  myocarditis. 

Prognosis. — Since  digitalis  is  often  ineffectual  and  angina  pectoris, 
heart  rupture  or  coronary  closure  may  occur,  the  outlook  is  most  un- 
promising. Some  patients,  especially  elderly  subjects,  may  live  a  decade 
or  more,  until  intercurrent  pneumonia  or  another  secondary  affection 
causes  their  death.  Early  digestive  symptoms  are  less  favorable  than 
early  edema  or  congested  liver. 

Treatment. — ^The  therapy  is  (a)  that  of  the  causal  factor ,  arteriosclerosis 
(g.  n.)  being  the  most  common  cause.  Potassium  iodide  should  be  given, 
freely  diluted  in  milk  or  water — 

I^ — Potassii  iodidi Siiss 

Syr.  sarsaparillse  co giv 

M.  et  S. — One  teaspoonfu)  in  a  glass  of  water  after  meals. 

(6)  Dietetic,  stimulants  should  be  used  carefully  and  overexertion 
and  excitement  avoided,  (c)  The  Schott  treatment  (v.  s.).  (d)  Cardiants. 
Digitalis  is  beneficial  in  the  early  stages— less  so  in  advanced  cases,  or 
when  the  pulse  is  slow.  Strychnine  is  frequently  valuable.  For  anginal 
seizures  or  hard  vessels,  nitroglycerin  is  given.  Caffeine,  camphor,  and 
morphine  should  be  administered  for  cardiac  asthma.  (See  Therapy 
OF  Valvular  Disease.) 

RUPTURE    OF    THE   HEART. 

Etiology.^— i^wp/wre  through  the  altered  heart  muscle  occurs  in  myocar- 
ditis; heart  aneurysm,  in  which  it  may  even  perforate  the  chest  wall; 
myomalacia  cordis;  coronary  aneurysm;  fatty  heart,  abscess,  gumma 
or  neoplasm  of  the  heart,  ulcerative  endocarditis,  obstructive  valvular 
disease  and  stenosis  of  the  isthmus  of  the  aorta.  It  occurs  largely  in 
men  over  sixty  years  of  age.  It  may  occur  during  sleep  or  may  be  caused 
by  trauma,  vomiting,  great  effort,  excitement,  delivery^  coitus,  or  by  the 
abuse  of  digitalis.    Kroll  collected  332  cases. 

Pathology  and  Symptoms. — (a)  Rupture  of  a  valve  induces  sudden  val- 
vular insufficiency.  (5)  Total  rupture  is  usually  single,  though  five  rents 
are  recorded,  and  takes  place  in  the  left  ventricle  (80  per  cent.)  where  the 
pathological  factors  come  most  into  play.     Sudden  death  may  occur,  or 


ANGINA   PECTORIS  333 

death  may  result  after  a  few  hoiirs  to  eleven  to  seventeen  days.  The 
symptoms  are  a  sense  of  something  giving  way  in  the  chest,  great  precor- 
dial pain,  incoercible  vomiting  or  diarrhea,  irritation  of  the  vagus  from 
hemopericardium,  collapse  and  death  from  pressure  of  the  blood  on  the 
heart  or  vense  cava?.  Hemopericardium  (g.  v.)  may  be  suspected  because 
of  greatly  increased  triangular  dulness,  faint  heart  tones  and  absent  or 
weak  apex  beat  within  the  left  border  of  the  dulness. 

Diagnosis  and  Treatment. — The  diagnosis  is  rarely  made.  It  depends 
on  the  etiology,  increased  dulness,  cardiac  insufficiency  and  symptoms 
of  internal  hemorrhage.  The  outlook  is  bad  and  the  treatment  wholly 
symptomatic;    absolute  rest  should  be  enforced. 

ANGINA   PECTORIS. 

This  affection  is  usually  described  under  cardiac  neuroses  but  it  is 
a  coronary  cardiopathy  and  its  effects  relate  to  the  myocardium.  Angina 
pectoris  (stenocardia,  breast-pang)  was  first  described  by  Heberden  and 
then  by  Hunter.  Edward  Jenner  first  recognized  the  connection  between 
angina  pectoris  and  coronary  disease.  By  far  the  best  treatises  are  Osier's 
classic  on  Angina  Pectoris  and  Allied  States,  and  Neusser's  Ausgewdhlte 
Kajntel  der  klinischen  Symptomatologie,  Heft  2. 

Definition. — An  arteriosclerotic  cardiopathy,  characterized  by  (a) 
paroxysms  of  excruciating  cardiac  pain,  (b)  mental  anguish,  a  sense  of 
dying  and  (c)  frequently  by  sudden  death. 

Etiology  and  Pathology. — The  chief  and  practically  constant  patho- 
logical finding  is  arteriosclerosis  involving  the  heart  muscle  directly 
by  coronary  atheroma,  or  indirectly  by  plaques  in  the  aorta  at  the 
coronary  orifices.  The  aorta  is  often  atheromatous  without  coronary 
involvement  and  coronary  sclerosis  is  frequent  without  much  change  in 
the  aorta.  It  is  notable  that  atheroma  is  frequent  and  angina  pectoris 
is  rare.  The  etiology  is  that  of  arteriosclerosis  (q.  v.) — syphilis  (aortitis), 
gout,  alcohol,  contracted  kidneys,  sometimes  infections  such  as  rheu- 
matism or  influenza.  A  history  of  its  occurrence  through  several  gen- 
erations is  sometimes  elicited.  It  occurs  chiefly  in  men  (90  per  cent.), 
usually  after  the  fortieth  year  (although  cases  in  the  second  decennium 
are  reported)  and  in  the  well-to-do  classes,  professional  men,  hard  workers 
and  luxurious  livers.  Angina  is  far  more  common  in  private  than  in 
hospital  practice. 

Symptoms. — ^Mode  of  Onset. — (a)  In  some  cases  the  oiiset  is  gradual, 
and  is  preceded  by  dyspnea,  especially  when  dressing  or  undressing, 
lacing  the  shoes,  emptying  the  bowels,  sitting  up  or  beginning  to  exer- 
cise; by  short,  deep  respiration,  precordial  oppression,  pulmonary  edema, 
bronchial  catarrh,  strong  beating  in  the  second  or  third  left  interspace, 
and  difficulty  in  moving  the  left  arm.  This  "cardiac  asthma"  is  followed 
by  genuine  angina;  both  are  secondary  to  coronary  disease.  (6)  In  other 
cases  angina  is  the  first  im'portant  symptom  of  cardiac  disease.  It  is 
excited  by  muscular  effort,  as  walking  up  hill;  mental  excitement,  as 
anger  or  coitus;  chilling  or  bathing;  flatulent  dyspepsia  or  overloading 
the  stomach,  which  by  way  of  the  vagus,  may  induce  the  attack  when 


334  DISEASES  OF   THE  HEART  MUSCLE 

the  patient  is  quiet  or  just  going  to  sleep,     (c)    Death  may  be  the  first 
symptom. 

Paroxysm. — The  attack  itself  consists  of  (1)  sudden  agonizing  pain, 
which  is  lancinating  and  feels  like  an  iron  hand  squeezing  the  heart. 
The  pain  emanates  from  the  cardiac  plexus  lying  behind  the  aorta, 
and  in  the  nerve  branches  from  it  to  the  coronary  arteries,  whence  its 
reflection  to  other  parts,  mentioned  later.  During  the  seizure  the  heart 
muscle  is  ischemic  from  coronary  obstruction  or  possibly  from  superin- 
duced spasm  of  the  vessel  (Allan  Biu-ns,  Potain).  In  man  and  in  the 
horse,  atheroma  or  thrombosis  of  the  abdominal  aorta  or  its  branches  to 
the  legs,  shuts  off  the  blood  necessary  diu-ing  exertion;  with  moderate 
exercise  the  collateral  circulation  is  sufficient,  but  prolonged  exertion 
produces  tingling,  cramps  and  transient  paraplegia  ("intermittent 
claudication").  The  heart-pang  is  caused  by  an  analogous  cardiac 
ischemia  when  unusual  stress  is  thrown  on  the  diseased  coronaries  and 
the  myocardium  becomes  exhausted  (impaired  contractility).  The 
author  obserA'ed  thoracic  and  abdominal  angina  followed  by  claudica- 
tion. The  "unutterable"  pain  is  usually  substernal  and  radiates  to  the 
left  shoulder,  neck  and  arm  (to  the  chin,  ear,  jaw,  occiput,  larynx,  even 
to  the  gall-bladder  and  renal  region,  spine,  stomach,  left  leg  and  testis). 
Pain  along  the  ulnar  nerve  to  the  fingers  may  precede  the  angina,  or  perhaps 
is  associated  with  motor  weakness  or  ulnar  atrophy  fin  primitive  verte- 
brates, the  nerves  involved  Avould  have  been  over  the  heart).  Hyper- 
esthesia of  the  arm,  chest  or  mammary  regions  is  frequent,  and  may  per- 
sist, due  to  reflex  cord  irritation.  The  pain  produces  vasomotor  symp- 
toms, such  as  great  pallor,  low  temperature  and  profuse  sweating.  The 
patient  may  fall,  perhaps  in  a  fatal  syncope,  or  more  often  may  support 
himself  for  a  few  seconds  or  minutes  until  the  paroxysm  has  passed. 

(2)  The  mental  anguish,  the  angor  animi  (Latham)  is  the  second  com- 
ponent of  the  seizure  and  consists  of  a  sense  of  dying,  with  great  anxiety, 
complete  consciousness,  immobile  attitude  with  head  and  trunk  extended, 
and  perhaps  inability  to  articulate. 

(3)  The  danger  of  sudden  death  is  the  third  element.  Death  may  come 
without  pain  (syncope  anginosa)  in  the  first  seizure;  often  in  the  second 
or  third  attack;  years  after  the  initial  paroxysm;  or  after  repeated 
attacks,  maybe  twenty  a  day  (the  etat  angineuse).  O.sler  has  called  the 
anterior  branch  of  the  coronary  artery  the  "artery  of  sudden  death." 

Other  Sigxs  axd  Symptoms. — The  heart  is  variable,  sometimes  nor- 
mal in  rate  and  strength,  and  again  tense  or  weak,  slow  or  rapid  or 
irregular.  The  left  radial  pulse  may  be  smaller  than  the  right.  Dunin 
found  the  arterial  pressure  low  in  45  per  cent,  and  high  in  20  per  cent,  of 
his  cases.  Delirium  cordis,  partial  heart-block,  gallop-rhythm,  extra- 
systoles,  pulsus  alternans  and  shortening  of  the  long  pause  are  but 
signs  of  cardiac  fatigue. 

The  second  aortic  tone  is  often  loud  and  metallic;  a  rough  or  blowing 
systolic  (and  sometimes  a  diastolic)  murmur  is  heard  over  the  aorta, 
which  is  sometimes  dilated;  and  the  left  ventricle  may  be  dilated; 
the  relative  mitral  leakage  relieves  the  high  blood-pressure  inducing 
the  angina  and  exhausting  the  left  heart.     These  incidents  are  simply 


ANGINA   PECTORIS  335 

arteriosclerosis  and  its  sequences.  Constitutional  disturbance  is  very  fre- 
quent, as  loss  of  weight,  color  and  endurance.  Dyspnea  is  not  a  part 
of  angina  pectoris,  but  of  heart  insufficiency.  The  urine  is  often  pale 
and  abundant  after  the  seizure.  Dysphagia,  singultus,  air-swallowing  or 
gastric  symptoms  are  due  to  sympathetic,  phrenic  and  pneumogastric 
participation. 

Diagnosis. — When  the  attack  is  typical  and  severe,  there  is  little 
difficulty  in  diagnosis.  Mild  or  early  attacks  may  be  confused  with  car- 
diac asthma.  Angina  involving  the  abdomen  (angina  abdominis)  or  legs 
(angina  cruris)  is  easily  mistaken  and  may  appear  first  or  alternate  with 
the  more  usual  angina  pectoris  (see  Arteriosclerosis).  The  classical 
picture,  together  with  hardness  of  the  arteries  and  atheroma  of  the 
aorta,  makes  the  diagnosis  practically  certain.  When  the  heart  seems 
normal,  severe  precordial  pain  means  angina. 

Pseudo-angina  (Latham  and  Walshe)  is  the  most  frequent  cause  of 
diagnostic  error.  Its  varieties  are  (a)  nervous  pseudo-angina.  (James 
Mackenzie  regards  all  angina  as  of  the  genuine  type;  the  anginal  pain 
arising,  e.  g.,  in  worn-out  women,  is  due  to  exhaustion  of  the  heart  as 
well  as  of  the  nervous  system.)  Huchard's  widely  quoted  table  is  substan- 
tially as  follows: 

True  Angina vs. Pseudo-angina. 

Most  common  in  middle-aged  men.  Commonest  in  women,  at  any  age. 

Paroxysms  induced  by  exertion,  etc.;    diur-  Spontaneous;    often  nocturnal  and  periodic; 

nal;  few  in  number.  frequent. 

Pain  intense,  of  short  duration,  precordial.  Less  severe,  lasting  hours;    epigastric;    agi- 

inarticulate;     immobile  attitude;     sensa-  tation,  activity;    sensation  of  distention. 

tion  of  cardiac  compression. 

No  nervous  symptoms.  Neurasthenic  or  hysterical  stigmata. 

Vasomotor  form  rare.  Common. 

Prognosis  grave  or  fatal.  Never  fatal. 

Lesions:  from  coronary  sclerosis.  From  neuralgia. 

Arterial  medication.  Neuralgic  medication  successful. 

(6)  Vasomotor  angina  is  attended  by  vasomotor  spasm,  coldness  and 
numbness  in  the  extremities,  faintness  and  great  pain  in  the  heart  (Noth- 
nagel).    It  may  be  reflex  in  origin. 

(c)  Toxic  pseudo-angina  is  due  to  coffee,  etc.,  but  especially  tobacco. 
Vasomotor  symptoms,  amaurosis,  dyspepsia,  weak,  rapid  or  irregular 
heart  action,  palpitation  and  anginal  pain  are  common.  Functional 
tobacco  angina  from  coronary  spasm  heals  when  tobacco  is  withheld; 
but  actual  coronary  disease,  due  to  tobacco  and  other  heart  poisons,  is 
not  curable,  (d)  The  crises  of  tabes  and  precordial  pain  due  to  brachial 
or  vagus  neuritis,  gout,  etc.,  may  be  difficult  to  diagnosticate. 

Prognosis. — The  prognosis  must  be  given  with  great  caution;  one 
patient  lived  for  forty  years.    Few  recoveries  are  reported. 

Treatment.^ — The  treatment  concerns  (a)  the  etiology — arteriosclerosis. 
Gout  and  diabetes  necessitate  appropriate  diet  and  therapy.  Attention 
must  be  directed  to  the  question  of  stimulants.  The  possibility  of 
syphilis  should  always  be  considered;  aside  from  syphilis,  the  iodides 
are  valuable,  given  two-thirds  of  the  time,  for  months  and  years.  Small 
amoimts  are  tolerated  not  as  well  as  10-  or  20-grain  doses.  Care  in  their 
use  is  necessary  in  nephritis  and  even  then  well-diluted,  gastric  disorder 


336  DISEASES  OF   THE  HEART  MUSCLE 

may  result;  Spts.  glycerylis  nitratis  is  indicated  in  the  intervals,  in 
doses  of  Tllij,  four  or  more  times  daily;  its  effects  last  less  than  an  hour. 
It  may  cause  headache,  flushing  or  (in  larger  doses)  cyanosis  or  pallor, 
muscular  relaxation,  dyspnea  and  irregular  pulse;  erythrol  tetranitrate 
in  doses  of  gr.  ss.  t.  i.  d.  has  a  more  lasting  effect.  (See  Arteriosclerosis.) 
(6)  The  causes  precipitating  paroxysms.  Prophylaxis  concerns  exertion, 
excitement,  coitus,  chilling,  constipation  and  dyspepsia;  foods  favoring 
flatulency  should  be  avoided,  and  a  light  evening  meal  should  be  taken. 
Rest  is  imperative,  as  whatever  exhausts  the  heart,  precipitates  the 
paroxysm.  Bromides  and  chloral  may  avert  nocturnal  attacks.  The 
patient  should  be  provided  with  aromatics  to  dispel  flatulency: 

1} — Spiritus  ammonise  aromatici 5ss 

Spiritus  chloroformi gss 

Spiritus  glycerylis  nitratis gtt.  j 

Spiritus  setheris  compositi 3ss 

M.  et  S.— To  be  taken  in  hot  water  (as  a  single  dose). 

(c)  The  paroxysm.  Amyl  nitrite  was  advised  by  Brunton  (1867)  as 
an  analgesic  and  vasodilator;  the  pearls  contain  three  minims  of  the 
remedy.  They  often  operate  powerfully  and  instantaneously,  even 
when  the  blood-pressure  is  normal;  sometimes  they  are  useless.  It  is 
better  to  have  the  patient  carry  the  spts.  glycerylis  nitratis  or  amyl 
nitrite  with  him,  for  the  physician  rarely  sees  the  attack.  Some  member 
of  the  family  should  be  taught  to  give  a  hypodermic  of  morphine  and 
atropine.  Morphine,  and  chloroform  by  inhalation  are  dreaded  when 
brain  trouble  exists,  but  they  must  be  used;  large  doses  of  morphine  are 
required  and  tolerated.  A  full  drink  of  whisky,  is  excellent,  as  first  aid. 
{d)  Cardiac  weakness  is  treated  by  ammonia,  camphor,  strychnine  and 
digitalis;    morphine  is  carried  in  one  hand  and  stimulants  in  the  other. 

I^ — Tr.  digitalis 5iv 

Tr.  strophanthi 5ij 

Tr.  Valerianae q.  s.  ad.  Biv 

M.  et  S. — One  teaspoonful  after  meals. 

Coffee  dilates  the  coronaries  and  prevents  cardiac  weakness  and  the 
paroxysms.  Pseudo-angina  is  treated  according  to  the  type.  Electricity 
and  arsenic  are  valuable. 


TUMORS    OF   THE   HEART. 

The  heart  is  rather  insusceptible  even  to  neoplasms  in  its  immediate 
vicinity.  Link  collected  91  cases  (1909).  Carcinoma  and  sarcoma  are 
the  most  frequent,  and  lipoma,  myxoma,  fibroma  and  myoma  infrequent. 
They  are  usually  secondary.  Cardiac  insufficiency,  valvular  compression, 
anginal  symptoms  or  embolism  sometimes  develop. 

Parasites  are  most  often  accidental  postmortem  findings.  Echinococcus 
occurs  twice  as  often  in  the  right  ventricle  as  in  the  left;  55  cases  are 
reported.  Cardiac  rupture,  sudden  death  from  occlusion  of  the  pul- 
monary trunks,  relative  pulmonary  insufficiency  or  cardiac  incompetence 
may  occur.  The  cysticercus,  the  pentastomum  and  trichina  are  of  purely 
anatomical  interest. 


NEUROSES  OF   THE  HEART  337 

CARDIAC    THROMBOSIS— THROMBOSIS    CORDIS. 

This  usually  occurs  at  the  time  of,  or  after,  death. 

Symptoms. — (a)  Entire  latency,  (fe)  Thrombosis  sometimes  develops 
during  life  and  leads  to  pulmonary  or  arterial  embolism,  (c)  Sudden 
cardiac  weakness,  (d)  Sudden  valvidar  stenosis,  a  ball  thrombus  forming 
in  the  auricle,  and  occluding,  e.  g.,  the  mitral  orifice;  it  is  beyond  clinical 
recognition,  although  frequently  associated  with  gangrene  of  the  lower 
extremities  or  ascites. 


NEUROSES    OF    THE   HEART. 

This  topic  is  closely  related  to  affections  of  the  myocardium,  especially 
the  arrhythmias  and  heart-block. 

Palpitation  of  the  Heart. — Palpitation  (cardiopalmus,  cardiogmus  or 
h,yperkinesis  cordis)  is  purely  a  symptom,  the  patient  experiencing  a 
fluttering  sensation;  in  health  the  patient  is  not  conscious  of  his  heart 
action;  extreme  irregularity,  or  the  pounding  action  in  aortic  insufficiency, 
may  escape  the  patient's  notice,  while  the  normal  heart  may  palpitate 
after  overwork  or  abuse  of  coffee.  It  is  closely  related  to  the  hyperdiastole 
caused  by  vagus  stimulation.   . 

Etiology. — 1.  Nervous  Causes  (Hyperesthesia  of  the  centripetal 
heart  fibers). — Nervous  excitability  is  common  especially  in  medical 
students,  whose  hearts  must  be  examined  when  they  first  study  physiology 
or  physical  diagnosis.  Peter  Frank  feared  aneurysm  while  writing  his 
Diseases  of  the  Heart.  It  is  common  in  school  children,  from  nervous 
tension,  fear  of  examinations  and  public  exercises;  it  is  more  frequent 
in  females  at  puberty,  climacteric  or  menstruation.  It  occurs  constantly 
in  exophthalmic  goitre  and  in  50  per  cent,  of  neurasthenics;  neurasthenia 
cordis  is  attended  by  turgid  face,  red  eyes,  contracted  temporal  arteries 
and  angioneurotic  edema.  Exhaustion,  anemias,  acute  infections,  lacta- 
tion, poor  hygiene,  incipient  tuberculosis  and  sexual  excess  may  produce 
palpitation.  The  "irritable"  heart  of  soldiers,  observed  by  Da  Costa  in 
our  Civil  War,  associated  with  arrhythmia,  diarrhea,  emotional  causes 
and  physical  strain  and  often  placed  under  this  head,  is  better  classified 
as  muscular  insufficiency. 

2.  Reflex  CAUSES.^The  products  of  indigestion  and  mechanical 
gastric  distention,  constipation,  intestinal  parasites,  gall-stones,  renal 
calculi,  prostatic,  uterine  or  ovarian  disease  and  floating  kidney  are 
possible  causes. 

3.  Toxic  Causes. — Palpitation  may  result  from  the  use  of  cofi'ee, 
tea,  alcohol,  tobacco,  narcotics  and  from  gout. 

4.  Cardiac  Causes. — Palpitation  may  occur  in  organically  incom- 
petent hearts,  viz.,  valvular  disease,  acute  or  chronic  myocarditis. 

Symptoms. — The  patient  complains  of  "feeling  the  heart  beat,"  "gone- 
ness," "fluttering,"  forcible  or  intermittent  action  of  the  heart,  dyspnea 
and  anxiety.  Intermittent  epigastric  throbbing  and  vasomotor  symp- 
toms, as  flushing  of  the  face,  pale  urine,  etc.,  are  not  uncommon.  Phreno- 
cardia,  described  by  Herz  (1909),  is  a  syndrome  composed  of  pain  below 
22 


338  DISEASES  OF   THE  HEART  MUSCLE 

the  nipple,  palpitation  and  difficulty  in  breathing,  and  ascribed  to  sexual 
repression. 

Physical  Examination. — Sometimes  the  heart  is  absolutely  normal. 
Some  authors  describe  palpitation  under  tachycardia.  The  heart's  rate  is 
often  increased  after  exertion  or  fright  to  100  to  150,  with  violent  arterial 
throbbing  due  perhaps  to  stimulation  of  the  accelerator  nerves.  The 
heart  is  rarely  slowed.  A  series  of  rapid  beats  followed  by  a  series  of 
slower  beats  is  somewhat  characteristic.  If  the  pulse  is  irregular  when 
the  patient  is  quiet  it  sometimes  becomes  regular  after  exertion.  The 
first  apex  tone  is  often  accentuated,  is  even  metallic  or  may  be  heard  by 
the  physician  at  some  distance  from  the  patient's  chest.  The  systole  may 
sound  short.  The  second  tone  at  the  base  is  more  often  strong  than 
weak.    A  murmur  at  the  base  is  usually  functional. 

Diagnosis. — (a)  The  etiology,  (b)  Negative  results  of  examination  of  the 
heart  during  the  attacks,  but  particularly  in  the  intervals.  Coronary 
disease,  arteriosclerosis,  myocarditis,  etc.,  are  usually  excluded  with 
ease,  but  may  coexist  with  palpitation.  Palpitation  is  held  by  some 
to  lead  to  dilatation  or  hypertrophy,  but  this  is  confusion  of  cause 
and  effect,  (c)  If  pain  be  present  in  nervous  palpitation,  it  is  more  often 
lower  (an  "  ejngastric  cramj)")  than  the  pain  of  organic  lesions  which 
radiates  to  the  shoulder  or  arms. 

Prognosis. — The  outlook  is  generally  favorable.  The  old  belief  that 
fright  could  cause  death  is  as  unfounded  as  most  popular  conceptions, 
and  few  such  instances  are  recorded  (Bollinger,  Laache). 

Treatment. — (a)  If  the  cause  is  nervous,  suggestion  is  valuable  and 
repeated  examinations  assure  the  patient  and  avoid  error.  Regulated 
exercise,  tepid  baths  with  active  friction,  light  meals,  regular  habits 
and  possibly  the  rest  cure  are  indicated.  It  seems  from  personal  experi- 
ence that  isolation  often  increases  introspection.  In  anemic  cases  iron, 
arsenic  and  strychnine  should  be  given. 

I^ — Ferri  valeratis, 

Quininse  valeratis, 

Ammon.  valeratis aa     gr.  xx 

M.  et  ft.  in  pil.  xx. 

S. — One  pill  after  meals. 

A  few  doses  of  veratrum  and  belladonna  often  quiet  the  violent  throbbing 
and  general  nervousness,  probably  affecting  the  peripheral  fibers  of  the 
vagus.    Sexual  hygiene  must  be  strictly  observed. 

^ — Fluidextr.  veratri gtt.  x 

Fluidextr.  belladonnee gtt.  xv 

AquEe q.  s.  ad.  o  i 

M.  et  S. — One  teaspoonful  every  half -hour  for  two  or  three  doses. 

(6)  When  the  cause  is  reflex,  flatulency  and  constipation  must  be  treated, 
with  bromides,  given  well  diluted. 

I^ — Sodii  bromidi 5J 

Spts.  ammon.  aromat Sss 

Syr.  zingiberis 5iij 

Aquae q.  s.  ad.  gij 

M.  et  S. — One  teaspoonful  in  hot  water  every  half-hour  for  four  doses. 


NEUROSES  OF  THE  HEART  339 

A  light  evening  meal  of  non-nitrogenous  food  is  beneficial  in  children 
afflicted  with  night  terrors  or  palpitation,  (c)  The  toxic  type,  (d)  hi 
vahulnr  disease  (q.  v.),  belladonna  and  the  ice-bag  are  indicated.  Digitalis 
is  of  little  use  in  the  nervous  type. 

Arrhythmia. — There  are  five  major  varieties:  (1)  Sinus  arrhythmia; 
(2)  extra-systole;  (3)  heart-block;  (4)  auricular  fibrillation;  (5)  the 
pulsus  alternans. 

1.  The  juvenile,  sinn^  or  respiratory  form  is  found  in  all  children  at 
some  time.  The  normal  (fundamental  or  sinus)  rhythm  or  contraction 
of  the  heart  is  initiated  at  the  mouths  of  the  great  veins  in  the  right 
auricle;  this  arrhythmia  is  a  sinus  irregularity  and  the  chief  ^'a^iation 
is  changing  of  the  pulse-rate  with  respiration  and,  if  the  heart  is  rapid, 
shortening  of  the  diastole.  The  heart  function  concerned  in  this  type 
of  arrhythmia  is  the  stimulus  production,  and  the  vagus  is  largely  con- 
cerned also  (whence  atropine  often  controls  it  temporarily).  Hygienic 
measures  are  usually  efficacious. 

2.  Extra-systole  is  the  most  frequent  irregularity,  and  the  usual  cause 
of  intermittent  pulse.  Its  causation  is  increased  irritability  of  the  myo- 
cardium which  answers  to  some  abnormal  stimulus  and  initiates  a  "pre- 
mature," "abortive,"  "futile"  contraction  during  the  diastole.  The 
source  of  the  contraction  is  at  the  auriculoventricular  node,  or  perhaps 
in  the  auricle  or  ventricle,  or  some  point  between  them.  In  one  group 
of  cases,  there  is  no  heart  disease  and  the  extra-systole  is  physiological, 
as  in  young  people,  women  at  puberty  or  menopause,  or  mental  or  physical 
fatigue;  in  a  second  group,  the  cause  lies  in  poisoning  (tobacco,  alcohol, 
coffee,  digitalis),  in  reflex  alimentary  origin  or  sometimes  in  infections 
where  it  is  ominous;  in  the  third  group,  there  is  organic  heart  dis- 
ease, or  increased  arterial  tension  from  atheroma  or  nephritis.  If  the 
extra-systole  occurs  early  in  the  diastole,  no  change  in  the  pulse  is 
noticed,  as  the  aortic  valves  are  not  opened  and  a  muflSed  third  sound 
is  heard;  if  it  falls  later  in  the  systole,  the  aortic  valves  are  opened, 
two  sharp  sounds  are  heard  and  the  pulse  shows  the  extra  beat  (pulsus 
bigeminus,  trigeminus,  polygeminus).  There  is  always  a  systolic  tone. 
The  compensatory  (diastolic)  pause  is  lengthened  after  each  systole, 
because  of  exhaustion  of  the  left  ventricle,  which  becomes  "refractory" 
to  stimuli,  and  the  next  beat  becomes  delayed.  The  time  occupied  by 
the  normal  systole  plus  the  extra-systole  plus  the  compensatory  pause 
equals  the  time  occupied  by  two  complete  normal. cardiac  cycles.  In  many 
cases,  the  extra-systole  is  described  by  the  patient  as  a  thump,  fluttering 
or  stopping  of  the  heart.  What  appears  simple  extra-systole  may  turn 
out  after  years  to  be  arteriosclerosis  with  high  blood-pressure.  Com- 
pensation may  remain  normal  or  may  break,  depending  on  the  specific 
cause  {v.  s.),  upon  which  also  hangs  the  prognosis  and  therapy.  In 
decompensation  digitalis  often  helps  (though  it  is  an  occasional  cause 
of  this  arrhythmia). 

3.  Heart-block  (v.  i.  Bradycardia). 

4.  Auricular  fibrillation  is  also  called  perpetual  arrhythmia,  absolute 
irregularity  or  nodal  rhythm.  All  rhythm  is  lost  and  the  condition  is 
associated  with  loss  of  tonicity,  occurring  in  severe,  specially  rheumatic 


340  DISEASES  OF   THE  HEART  MUSCLE 

heart  disease  with  dilatation,  particularly  in  mitral  stenosis  and  also  in 
the  last  stages  of  exophthalmic  goitre  and  in  myofibrosis;  its  cause 
apparently  is  always  intracardial,  but  rarely  coming  from  the  acute 
infections  or  the  use  of  digitalis.  The  auricle  contracts  or  flutters  with 
extreme  rapidity  but  ineffectually  and  the  bundle  of  His  is  overwhelmed 
with  impulses  attempting  to  pass  to  the  ventricle;  consequently  the 
ventricle  beats  as  it  lists,  irregularly  as  to  sequence,  force,  equality  or 
rate;  these  changes  show  disturbance  in  conductivity  also.  The  normal 
auricular  wave  in  the  jugular  tracing,  representing  auricular  systole,  dis- 
appears, as  the  auricle  weakens  and  the  curve  shows  400  to  900  fine  undu- 
lations from  auricular  fluttering  (fibrillation).  This  gives  the  delirium 
cordis  (permanent  rapidity),  temporary  rapidity  like  paroxysmal  tachy- 
cardia, and  rarely  a  slow  rate  of  action.  A  positive  venous  pulse  appears 
in  the  jugulars.  Mackenzie  described  its  sudden  onset  in  mitral  stenosis 
and  Lewis  demonstrated  that  auricular  fibrillation  was  the  cause;  these 
authors  estimate  that  it  is  the  cause  of  50  to  70  per  cent,  of  irregularities 
of  the  heart.  Symptoms  may  be  absent  and  the  patient  goes  on  unaware 
of  the  change;  again  there  is  breathlessness  and  signs  of  a  weak  right 
heart;  in  mitral  stenosis  the  presystolic  murmur  disappears  and  a 
positive  venous  jugular  pulse  is  detected.  Rest  may  eliminate  the 
trouble  and  here,  more  than  in  any  other  condition,  digitalis  works  its 
marvellous  effects,  increasing  tonicit}^  and  blocking  the  abortive  impulses 
sent  through  the  bundle  of  His  by  the  excited  auricle.  Atropine  may  be 
used  with  benefit  in  certain  cases. 

5.  The  pulsus  alternans  is  a  disturbance  not  of  the  rate  but  of  the 
size  of  the  heart  beats;  it  shows  in  the  sphygmogram  as  alternating 
high  and  small  waves.  It  indicates  lasting  depression  of  contractility 
and  is  always  serious,  occurring  in  mitral  lesions,  angina,  advanced 
arteriosclerosis,  old  rheumatic  hearts,  high  blood-pressure  and  irremedi- 
able cardiac  fatigue,  with  death  in  tw^o  or  three  years.  In  pulsus  alter- 
nans, we  may  hear  strong  tones  alternating  with  weaker  ones.  It  is 
to  be  distinguished  from  the  p.  bigeminus,  in  which  the  second  beat  is 
due  to  an  extra-systole  and  is  followed  by  a  longer  pause. 

Tachycardia. — Definition. — Tachycardia  is  the  usual  term  for  rapid 
heart  action,  although  polycardia  and  pyknocardia  are  better  etymo- 
logically,  for  tachycardia  implies  quick  (not  rapid)  heart  action  like 
the  pidsus  celer.  Tachycardia  is  only  a  symptom.  Some  hearts  normally 
beat  90  to  100  (120  in  the  case  of  Congreve). 

Etiology. — (a)  Heart  and  vascidar  disease;  coronary,  valvular  or  myo- 
cardial aft'ections.  (6)  Nervous  affections;  brain  and  cord  disease,  as  of 
the  medulla  (vagus  centre),  tumors,  hemorrhage,  bulbar  paralysis,  etc.; 
vagus  neuritis,  compression  of  its  trunk  by  tumors,  irritation  of  the 
accelerator  nerve,  exophthalmic  goitre,  neuroses  as  emotional  tachy- 
cardia and  reflex  tachycardia  from  uterine  or  ovarian  conditions,  (c) 
General  diseases  as  fevers,  chronic  troubles  (tuberculosis,  cancer),  and 
convalescence,  exhaustion  or  excesses,  (d)  Toxic  causes;  tea,  coffee,  alcohol, 
lead,  digitalis,  atropine,  amyl  nitrite,  etc.  Some  individuals  by  volun- 
tarily moving  the  ear  or  skin  muscles  of  the  neck  can  raise  the  heart's 
rate,  through  the  spinal  accessory  nerve  and  the  vagus  (Tarchanoff). 


NEUROSES  OF  THE  HEART  341 

A  special  variety  is  the  tachycardia  paro.rysmalis  described  by  Probsting 
and  defined  by  Nothnagel  as  a  slumbering  of  the  vagus  centre.  Paroxysms 
of  rapid  heart  action  occur  abruptly,  last  from  a  few  seconds  or  minutes 
to  days  or  even  weeks,  and  usually  end  abruptly.  It  is  seen  mostly  in 
strong,  hard-working  men  who  indulge  in  excesses  in  alcohol,  tobacco,  etc. 

The  pulse  becomes  smaller  and  weaker,  and  its  rate  reaches  150  or 
even  280.  It  is  usually  regular,  though  arrhythmia  may  mark  the 
beginning  and  end  of  the  seizure.  There  are  three  types:  In  one  the 
auricular  beat  precedes  the  ventricular,  as  normally;  in  a  second,  more 
frequent  form,  the  auricles  and  ventricles  beat  synchronously  (see 
nodal  rhythm);  in  the  third  type,  the  ventricle  beats  independently  of 
the  auricle;  the  irritation  is  in  the  auricle,  auriculoventricular  bundle 
or  in  the  ventricle,  respectively.  The  heart  often  dilates.  The  pause  of 
the  heart  is  lessened,  the  systole  incomplete  and  the  diastole  shortened. 
The  systolic  tone  is  often  clicking.  The  vessels  pulsate  violently  and  the 
patient  is  anxious,  depressed  and  late  in  the  course,  shows  signs  of  venous 
stasis.  The  urine  is  of  low  specific  gravity.  An  acute  distention  of  the 
lungs  like  that  observed  in  valvular  disease,  may  be  caused  by  vagus 
or  phrenic  irritation  or  tonic  contraction  of  the  diaphragm. 

Diagnosis. — Permanent  tachycardia  suggests  organic  disease  in  the 
medulla  or  nerve  trunks.  The  physiology  of  the  vagus  and  accelerator 
nerves  is  still  obscure  from  the  clinical  stand-point.  It  has  been  held  that 
(a)  increase  in  the  pulse  up  to  120  indicates  sympathetic  irritation 
(accelerator  stimulation),  which  is  relieved  by  morphine;  (6)  increase 
from  120  to  180  indicates  paralysis  of  the  vagus,  which  is  relieved  by  press- 
ure on  the  vagus  trunk;  (c)  increase  over  180  is  indicative  of  sympathetic 
irritation  in  addition  to  paralysis  of  the  vagus.  Sympathetic  symptoms 
may  prevail,  as  exophthalmos,  wide  pupils  and  interpalpebral  increase. 
Evidences  of  centric  vagus  involvement  may  exist,  such  as  respiratory, 
laryngeal  or  gastric  crises,  polyuria,  etc.;  sudden  onset  and  cessation 
suggest  a  bulbar  origin. 

Prognosis, — The  permanent  is  less  favorable  than  the  paroxysmal 
form.  Bouveret  holds  that  permanent  cure  is  rare  and  reported  4  cases 
of  sudden  death.  The  infrequent  autopsies  (only  16  out  of  135  cases 
collected  by  Hoffmann  in  1900)  show  degeneration  of  the  heart  muscle. 

Treatment. — Stimulation  of  the  vagus  is  effected  by  faradization  of 
the  neck,  holding  of  the  breath,  by  Valsalva's  experiment,  by  firm  ban- 
daging of  the  abdomen,  pressure  on  the  right  vagus,  the  use  of  the  ice-bag, 
swallowing  ice,  induction  of  vomiting  by  apomorphine  and  inverting  the 
patient.  Morphine,  asafetida,  valerian  and  bromides  are  frequently  of 
value.     The  causal  factors  require  consideration. 

Bradycardia. — Definition. — Bradycardia,  spanocardia  and  brachycardia 
are  the  usual  terms  for  slow  heart  but  oligocardia  is  a  better  desig- 
nation. A  yulsus  tardus  is  normal  to  some  individuals  and  certain 
families  in  successive  generations.  It  is  often  accommodative,  as  in 
aortic  stenosis.  The  apparent  pulse-rate  must  be  verified  by  cardiac 
auscultation.  Paroxysmal  bradycardia  may  occur  with  weak  heart, 
l)a]pitation,  difficulty  in  breathing  or  gastric  distress. 

Mackenzie   distinguishes:      (1)    normal    bradycardia,    where    all    the 


342  DISEASES  OF  THE  HEART  MtJSCLE 

heart's  chambers  beat  slowly;  (2)  slow  heart  due  to  missed  beats;  (3) 
nodal  rhythm  (v.  i.),  where  the  auricle  ceases  to  beat  or  beats  synchron- 
ously with  the  ventricle;  (4)  heart-block;  and  (5)  vagus  slowing  of 
the  heart — stand-still  of  the  whole  heart. 

Etiology. — The  etiological  factors  are:  (a)  Acute  injections;  brady- 
cardia is  very  common  during  or  after  typhoid,  pneumonia,  diphtheria 
and  rheumatism,  probably  caused  by  acute  myocarditis  (lessened  con- 
ductivity or  heart-block)  or  by  a  vagus  neuritis.  (6)  Digestive  disorders; 
jaundice,  constipation,  gastric  cancer,  ulcer,  distention  or  vomiting  and 
gall-stones  are  the  most  frequent  causes,  (c)  Respiratory  disease  is  a 
less  frequent  cause;  emphysema  occurs  frequently  with  a  slow,  strong 
pulse,  (d)  Circulatory  disease,  such  as  aortic  stenosis,  fatty  heart,  coro- 
nary atheroma  or  chronic  myocarditis,  lessens  conductivity  and  con- 
tractility. Dehio  uses  atropine  to  distinguish  between  (i)  disease  of 
the  heart  muscle,  upon  which  the  drug  has  but  little  effect,  and  (ii)  slow 
heart  due  to  inhibition  of  the  vagus,  in  which  it  brings  the  heart  to,  or 
above,  the  normal  rate,  (e)  Toxic  conditions  such  as  poisoning  from  lead, 
alcohol,  tobacco,  digitalis  and  other  drugs;  in  cholemia  and  in  uremia  it 
is  unfavorable.  (/)  General  troubles,  such  as  diabetes,  cachexia,  anemia 
or  exhaustion,  lessen  the  irritability  of  the  heart  muscle,  (g)  Nervous 
conditions,  apoplexy,  meningitis,  disease  of  the  medulla  or  cervical  cord, 
vagus  stimulation  by  tumors,  compression  of  the  vagus  trunk,  are  factors 
in  its  development.  Jacob  describes  an  angiospastic  form  (bradycardia 
with  chills,  wide  pupils,  cold  skin,  loud,  second  aortic  tone,  etc.). 

Heart-block. — The  Adams-Stokes  syndrome  was  first  described  by 
Morgagni  (1761)  and  Spens  (1792).  but  more  fully  by  Adams  (1827)  and 
Stokes  (1846).  It  is  due  to  disturbed  conductivity  through  the  bundle  of 
His,  who  in  1893  found  a  band-like  muscular  bundle  connecting  the  right 
auricle  and  the  ventricles.  It  measures  18  millimeters  in  length,  2.5 
millimeters  in  width  and  1.5  millimeters  in  thickness,  and  courses  poste- 
riorly in  the  septum  ventriculorum,  whence  it  reaches  the  right  and  left 
ventricles  and  their  valves.  J.  G.  Wilson  considers  that  the  bundle  is 
an  intricate  nerve  pathway.  According  to  Gaskell  (1883),  and  especially 
Erlanger  (1906),  slight  compression  of  His's  bundle  increases  the  inter- 
ventricular pause;  marked  compression  causes  intermittency  in  the 
ventricular  contractions;  complete  compression  results  in  independent 
contraction  of  the  auricles  and  ventricles,  known  as  "heart-block." 
Its  causes  are  various;  mild,  transient  or  incomplete  heart-block  may 
occur  after  infections,  as  typhoid,  diphtheria,  etc.,  in  old  rheumatic 
hearts,  arteriosclerosis,  from  the  use  of  digitalis  or  strophanthus,  or 
possibly  from  nervous  causes,  e.  g.,  by  the  vagus.  In  the  more  severe 
and  permanent  cases,  organic  changes  are  discovered  in  Flis's  bundle,  as 
gummata,  an  endocarditic  patch  in  Stengel's  case,  postdiphtheritic  myo- 
carditis (A.  S.  Dunn),  acute  myomalacia  cordis,  tumors  and  changes  in 
the  medulla. 

Symptoms. — The  complete  syndrome  consists  of  (1)  bradycardia;  (2) 
pulsation  of  the  cervical  veins,  exceeding  in  rate  the  arterial  pulsation; 
(3)  cerebral  disturbances,  as  syncope  and  convulsive  seizures;  and  (4) 
accessory  symptoms.    The  normal  rhythm  and  stimulus  to  contraction 


EMDOCARDIfrS  843 

begin  in  the  right  auricle  and  pass  over  the  bridge  or  bundle  of  His  to 
the  ventricles.  Disturbance  in  conduction  leads  either  to  delayed  con- 
traction of  the  ventricles  or  to  complete  "blocking"  of  the  stimulus,  when 
the  ventricles  beat  independently  of  the  auricles  (ventricular  rhythm). 

1.  Bradycardia. — With  the  normal  pulse  of  70,  one-fifth  of  a  second 
intervenes  between  the  auricular  and  ventricular  systoles;  if  this  interval 
is  much  increased,  there  is  disturbance  of  conduction  and  the  trans- 
mission of  the  contraction  wave  from  the  auricle  to  the  ventricle  is 
"blocked";  the  auricular  movements  may  be  seen  in  the  pulsating  cervi- 
cal veins,  the  fluoroscope  or  in  polygraph  tracings.  When  the  ventricular 
contractions  exceed  36  a  minute,  there  is  a  definite  relation  between  the 
ventricular  beat  and  the  auricular  waves  (seen  in  the  pulsating  jugulars), 
as  1  ventricular  to  2,  3,  or  4  jugular  beats;  if  the  ventricular  rate  is  30 
or  less,  there  is  no  definite  ratio.  An  interval  of  one  or  two  minutes  may 
intervene  between  the  ventricular  contractions  (or  radial  pulse  beats). 
During  the  ventricular  systole,  a  muffled  sound,  due  to  auricular  contrac- 
tion, may  be  heard  and  identified  with  it  as  one  watches  the  pulsating 
jugulars.    The  pulse  may  fall  to  6  beats. 

2.  Jugular  ■pulsations  are  synchronous  with  the  auricular  contractions 
(y.  s.)  and  the  radial  pulse  with  the  ventricular. 

3.  Cerebral  disturbances  are  not  necessarily  connected  with  dissociated 
action  of  the  auricles  and  ventricles.  Attacks  resembling  apoplexy  are 
marked  by  coma,  pallid  or  congested  face,  stertorous  breathing,  aphasia, 
etc.,  and  are  probably  due  to  venous  stasis  in  the  brain.  In  other  instances 
there  is  vertigo  or  epileptiform  attacks  ensue,  from  arterial  anemia.  In  a 
personal  observation  the  convulsive  attacks  came  on  with  the  eyes 
open,  so  that  an  incorrect  diagnosis  of  hysteria  had  been  made. 

4.  Accessory  manifestations  embrace  angina,  Cheyne-Stokes's  respira- 
tion, cardiac  asthma,  etc. 

Prognosis. — The  constant  is  less  favorable  than  the  paroxysmal  type. 

Treatment. — The  causal  therapy  alone  is  of  value.  Morphine  must 
be  given  with  care  where  there  is  disease  of  the  central  nervous  system. 
Strong  cardiants  are  usually  contra-indicated  and  in  the  Adams-Stokes's 
syndrome  are  actually  dangerous  (see  digitalis,  page  374).  Alcohol  is 
injurious.  Mercury  and  iodides  help,  maybe  cure,  syphilitic  disease 
in  His's  bundle,  unless  the  gummata  are  sclerosed.  Atropine  may, be  of 
service  in  partial  heart-block. 


DISEASES  OF  THE  ENDOCARDIUM. 

ENDOCARDITIS. 

Definition. — Inflammation  of  the  endocardium.  Its  clinical  importance 
attaches  to  the  fact  that  chiefly  the  valves  are  involved.  Two  varieties 
are  distinguished,  the  acute  and  the  chronic.  Bouillaud,  in  1840,  first 
placed  the  disease  on  a  scientific  basis. 


344  DISEASES  OF  THE  ENDOCARDIUM 

I.  Acute  Endocarditis. — This  is  a  secondary,  general  and  mycotic  disease. 
Its  clinical  varieties — (a)  malignant  or  ulcerative  endocarditis,  and  (b) 
benign  or  verrucose  endocarditis — differ  only  in  degree;  the  term  benign 
is  relative,  as  most  endocarditides  entail  serious  sequels.  Litten  divides 
endocarditis  into  (a)  the  benign  forms  produced  by  rheumatism,  chorea, 
etc.;  and  (6)  malignant,  (i)  non-suppurative  and  (ii)  suppurative  or 
septicopyemic. 

(A)  Malignant  (Ulcerative  or  Septic)  Endocarditis.  —  Etiology.  —  The 
heart  lesion  is  either  (1)  secondary  to  some  clearly  causal  infection, 
or  (2)  cryptogenetic,  when  the  causal  infection  is  not  apparent;  care 
in  examination  and  at  autopsy  usually  reveals  the  cause.  The  atrium, 
bacteriology,  mode  of  extension  and  symptoms  are  described  under  Septic 
Infections. 

The  disease  is  more  frequent  in  women  than  in  men,  even  excluding 
puerperal  infections,  and  between  the  years  of  twenty  and  forty.  Its 
frequency  is  2  per  1000  patients.  Seventy-five  j)er  cent,  of  cases  develop 
upon  an  old  valvular  lesion  by  which  the  local  physiological  resistance  is 
lessened.  The  literature  contains  11  cases  developing  at  a  patent  ductus 
Botalh  (Hart,  1904). 

Pathology. — Malignant  endocarditis  in  86  per  cent,  involves  the  left 
heart  which  is  far  more  frequently  the  seat  of  previous  lesions  and  its 
arterial  blood  favors  the  growth  of  microorganisms;  the  right  heart  is 
involved  more  frequently  (12  per  cent.)  than  it  is  in  other  types  of 
endocarditis;  both  sides  are  diseased  in  2  per  cent. 

The  process  may  involve  the  walls  (parietal  or  mural  endocarditis), 
or  more  frequently  attacks  the  valves  (valvular  endocarditis),  which  are 
often  already  indurated  by  previous  simple  endocarditis  and  are  subject 
to  greater  mechanical  activity.  The  valvular  localization  is  embolic. 
The  endocardium  becomes  opaque,  and  irregular  deficits  occur  on  the 
undersurface  of  the  aortic  or  the  auricular  surface  of  the  mitral  valves; 
later  there  is  injection  of  the  endothelial  coat  and  a  grayish  deposit. 
Exudation  is  more  abundant  on  the  mitral  than  on  the  aortic  or  pulmo- 
nary valves.  Thrombi  and  excrescences  develop  on  the  erosions,  whose 
removal  discloses  subjacent  ulceration.  The  thrombi,  especially  in 
pneumococcic  and  gonococcic  infections,  consist  of  lamellated  fibrin  and 
bacteria.  The  vegetations  may  attain  the  size  of  a  walnut  and  often 
extend  from  one  valve  to  another  by  contact  infection;  some  thrombi  are 
purely  mechanical  deposits  of  fibrin,  but  endocarditis  is  always  mycotic. 
Heiberg  first  found  microorganisms  (1869)  and  Weichselbaum  first 
obtained  pure  cultures.  The  following  bacteria  have  been  found :  strep- 
tococcus, staphylococcus,  pneumococcus,  less  frequently  the  gonococcus, 
colon,  diphtheria,  influenza,  tubercle  and  typhoid  bacillus,  meningococ- 
cus and,  very  exceptionally,  other  bacteria.  The  same  organism  may 
produce  either  the  benign  or  malignant  form.  Experimental  endocarditis 
has  been  produced  by  inoculations  of  various  organisms,  usually  after 
wounding  the  valves  by  a  sound  introduced  through  the  cervical  vessels, 
but  also  without  trauma.  The  pyogenic  organisms  are  said  to  attack 
more  frequently  the  mitral,  and  the  pneumococcus  rather  elects  the 
aortic  valves.    The  mitral  valves  are  more  often  involved  than  are  the 


ENDOCARDITIS  345 

aortic.  The  process  may  invade  the  aorta  or  the  pulmonary  artery. 
Destructive  ulceration  through  one  leaf  of  the  valve  may  produce  acute 
vahular  aneurysm,  which,  when  aortic,  projects  toward  the  ventricle,  and 
when  mitral,  projects  toward  the  auricle.  If  the  necrosis  destroys  both 
lamellae  of  the  valve,  the  perforation  leads  to  valvular  insufficiency. 
Ulceration  of  the  chordae  tendinese  or  papillary  muscles  also  produces 
valvular  insufficiency;  necrosis  of  the  parietes  results  in  a  "heart  ulcer," 
which  sometimes  leads  to  communication  between  the  ventricles  or  to 
rupture  of  the  heart.  Dislodgement  of  tissue  particles,  thrombi  or  bacteria 
occurs  frequently,  usually  in  the  arterial  circuit.  The  effects  vary  with 
the  location  of  the  infarct  (see  Symptomatology)  and  with  the  character 
of  the  microbes;  i.  e.,  emboh  act  mechanically,  infectively  or  in  both  ways. 
Streptococci  are  said  to  produce  anemic  infarcts,  while  staphylococci 
result  in  suppuration.  Loehlein  described  typical  glomerular  lesions  due 
to  the  Streptococcus  viridans;  their  epithelia  swell,  proliferate  and 
desquamate;  necrosis  sets  in,  with  ultimate  organization.  Pathological 
changes  in  other  organs  are  those  of  (a)  general  sepsis,  such  as  parenchy- 
matous degeneration  or  splenic  tumor,  (h)  embolism,  (c)  stasis  when  the 
heart  fails,  and  (d)  the  primary  disease. 

Symptoms. — The  clinical  features  vary  greatly,  according  to  the 
basic  disease,  embolic  involvement  and  virulence  of  the  microorganisms. 
The  onset  may  be  violent  or  most  insidious.  In  the  majority  of  cases 
the  septic  element  prevails.  The  various  types,  artificial,  though  con- 
venient for  description,  are: 

1.  The  Typhoid  Form. — The  toxemic  symptoms,  such  as  apathy, 
delirium,  dry  tongue,  distended  abdomen,  diarrhea  and  splenic  tumor 
are  suggestive  of  typhoid.  The  resemblance  may  be  heightened  by 
hemorrhage  of  the  bowels,  rose-like  spots  and  the  diazo  reaction.  Dila- 
tation of  the  right  heart  and  cardiac  murmurs,  so  important  in  endo- 
carditis, are  not  uncommon  in  typhoid.  But  at  this  point  certain  varia- 
tions arouse  doubt;  there  is  no  Widal  and  no  typhoid  bacillemia  and 
certain  septic  symptoms  or  cardiac  signs  come  to  the  front.  In  the  skin 
or  upper  air  passages,  emboli  appear  as  spots  with  white  or  yellow 
centres  and  hemorrhagic  peripheries,  or  as  pemphigus,  gangrene  or  sup- 
purative foci.  Infarcts  sometimes  occur  in  the  conjunctiva,  and  in  the 
retina,  simple  hemorrhage  or  actual  infarcts  with  yellow  centres  are 
frequently  detected.  The  entire  eye-ball  may  suppurate.  The  frequent 
splenic  infarction  is  characterized  by  sudden  pain,  tenderness,  enlarge- 
ment and  sometimes  perisplenitic  friction.  Embolism  is  often  accom- 
panied by  fever,  chill  and  vomiting.  Renal  infarction  is  very  frequent,  is 
attended  by  pain  in  the  loins,  hematuria,  albuminuria  and  sometimes 
anuria  or  dysuria.  Severe  nephritis  is  common.  Cerebral  embolism. 
usually  occurs  in  the  left  Sylvian  artery  and  results  in  the  usual  stroke 
and  hemiplegia  with  aphasia.  Pulmonary  infarcts  are  caused  by  lesions 
of  the  right  heart  or  by  auricular  thrombi,  and  occasion  sudden  pleuritic 
pain,  dyspnea,  hemoptoe,  temperature  and  possibly  a  small  area  of 
crepitant  rales,  pleural  friction  or  consolidation.  Embolism  also  occurs 
in  the  liver,  in  the  mesenteric  artery  (with  enterorrhagia  and  peritonitic 
symptoms),  in  the  muscles  and  joints,  testes  and  parotid;    in  the  heart 


DISEASES  OF  THE  ENDOCARDltiM 

and  various  mucosae;  in  the  meninges,  pleurae,  pericardium,  peritoneum 
and  in  the  peripheral  arteries,  sometimes  causing  gangrene  or  embolic 
aneurysm,    Tlie  pneumococcus  is  often  the  cause  of  this  type. 

The  course  may  be  peracute,  acute  or  chronic.  Death  occurs  from 
sepsis,  embolism  or  cardiac  failure. 

2.  The  Septic  or  Intermittent  Type. — This  form  runs  an  irregular  fever- 
curve,  with  chills,  drenching  sweats  and  enlarged  spleen.  Heart  symp- 
toms may  be  absent  or  the  relaxation  of  the  right  heart  and  the  murmur 
are  called  functional.  The  paroxysms  are  more  irregular  than  in  malaria 
and  no  response  to  quinine  is  obtained.  Sepsis  is  suspected  but  the 
localization  is  not  immediately  determined.  The  streptococcus  is  often 
causal.  Cardiac  findings,  embolism  or  clearly  septic  manifestations  may 
establish  the  diagnosis.  The  course  is  usually  several  weeks  but  may 
cover  several  months  to  over  a  year, 

3,  The  Visceral  Forms. — In  these  cases  one  organ  is  especially  involved. 
In  the  cardiac  form,  the  heart  murmur  seems  hemic,  until  a  typical 
valvular  lesion  develops,  or,  if  one  already  be  present  from  older  valvular 
disease,  until  another  appears,  as  a  diastolic  following  a  systolic  murmur. 
In  the  cerebral  form,  meningitis,  apoplexy,  coma  or  psychoses  may 
dominate  the  clinical  picture.  The  symptoms  referable  to  any  organ 
which  is  the  seat  of  embolism  may  seem  to  indicate  a  primary  disease; 
thus  acute  yellow  atrophy,  pernicious  anemia,  Banti's  disease,  tubercu- 
losis, nephritis,  rheumatism,  etc.,  have  been  incorrectly  diagnosticated. 

Special  Symptoms, — (1)  All  types  of  fever,  from  intermittent  to 
continuous,  are  noted,  although  it  may  be  absent  for  long  intervals, 
(2)  The  heart  is  always  somewhat  disturbed.  Its  action  is  more  frequent 
and  variable,  now  being  rapid,  again  slow  and  often  irregular.  The 
heart  seems  to  beat  harder  and  the  pulse  may  throb,  although  the  irritable 
overaction  is  attended  by  low  arterial  tension.  Palpitation  is  frequent. 
Cyanosis  is  not  common.  (3)  Respiration  is  always  increased,  from 
toxemic  centric  stimulation,  pain  or  complications  as  septic  pneumonia, 
infarcts,  pleurisy,  etc.  (4)  The  digestive  tract  may  be  affected,  as  nausea, 
vomiting  and  diarrhea  from  the  general  sepsis.  Embolism  has  been 
mentioned.  The  liver  is  enlarged,  perhaps  tender  or  the  seat  of  friction. 
Icterus  is  ominous  and  referable  to  duodenal  catarrh  or  oversecretion 
of  bile  (polycholia).  (5)  the  spleen  is  almost  always  palpably  enlarged 
from  sepsis  or  embolism.  (6)  The  urine  shows  evidences  of  the  sepsis  or 
stasis  by  albuminuria,  with  or  without  cylindruria,  and  of  the  "blood 
dissolution"  and  embolism  by  hematuria.  The  course  may  resemble 
that  of  subacute  nephritis,  present  in  33  per  cent,  of  cases.  (7)  The 
nervous  system  is  irritated  or  dulled  by  the  sepsis  toxins;  or  embolic  men- 
ingitis or  encephalitis  may  intervene.  (8)  The  muscles  are  frequently 
tender  and  inflamed  and  may  undergo  suppuration.  The  bones  are  often 
tender,  particularly  the  sternum,  and  the  joints  tender  or  sioollen,  although 
the  swelling  is  more  frequently  periarticular  than  intra-articular;  bac- 
teria are  seldom  found,  whence  the  occasional  resemblance  to  rheumatism. 
(9)  The  skin  may  be  the  seat  of  embolism  {v.  s.)  or  of  toxic  sudamina,  ery- 
thema, purjmra  or  polymorphous  septic  rashes.  Bulla?,  gangrene,  phleg- 
mons or  bed-sores  are  also  observed.     (10)  Optic  neuritis  is  frequent. 


Endocarditis  347 

(11)  The  blood  exhibits  marked  anemia;  without  heart  findings,  the 
anemia  and  splenic  tumor  have  been  confused  with  pseudoleukemia. 
The  leukocytes  are  not  often  increased.  Bacteria  may  be  cultivated  from 
the  blood  {v.  pages  19  and  20). 

Bacteriological  Forms. — (a)  Streptococcic  Endocarditis. — The  strep- 
tococcus is  the  usual  cause  of  rapidly  fatal  ulcerative  endocarditis,  with 
severe  repeated  chills  and  high,  irregular  fever;  chronic  infective  endo- 
carditis is  almost  invariably  streptococcic,  especially  the  S.  viridans  of 
Jochmann  and  Schottmiiller  (see  page  21);  this  type  is  often  latent, 
chronic  and  is  attended  by  slight  if  any  leukocytosis,  great  frequency  of 
positive  blood  cultures  (Libman  and  Jochmann,  95  per  cent.)  and  the 
absence  of  suppuration;  Schottmiiller  designates  this  type  endocarditis 
lenta.  (6)  Staphylococcic  endocarditis  is  less  frequent.  The  course  is 
acute  and  attended  by  high  fever,  pustules  in  the  skin,  disseminated 
hemorrhages  and  septic  infarcts,  especially  in  the  kidneys,  (c)  Pneumo- 
coccic  endocarditis  is  usually  acute  but  may  last  over  one  year;  frequently 
follows  pneumonia  {q.  v.),  less  often  cholecystitis;  begins  with  gradual 
fever  rise  associated  with  chills;  and  is  often  attended  by  suppurative 
meningitis,  id)  Gonococcic  endocarditis  (Ricord,  1S47)  may  result  from 
Neisser's  coccus  or  from  mixed  infection.    Cases  of  recovery  are  instanced. 

Dlvgxosis. — Bamberger's  remark  still  holds:  "The  diagnosis  of  acute 
endocarditis  is  seldom  easy,  usually  difiicult  and  often  impossible." 
^Yithout  physical  changes  in  the  heart,  the  diagnosis  is  only  presumptive. 
A  proper  etiology,  malaise,  weakness  or  emaciation,  the  presence  of  an 
old  valvular  lesion,  fever  or  other  e\ddences  of  sepsis,  signs  of  cardiac 
insufficiency,  such  as  irregular,  weak  pulse  with  apparently  strong  cardiac 
shock,  and  dilatation  are  strongly  suggestive  and  may  be  confirmed  by 
continued  observation,  embolism,  change  in  the  vah'ular  murmur  and 
positive  blood  cultures.  The  difference  between  malignant  and  benign 
endocarditis  is  that  the  former  is  septicemic  (bacillemic)  or  pyemic. 
Actual  hypertrophy  of  the  heart  not  only  requires  time  for  development 
l)ut  adequate  nutrition,  of  which  the  acuity  of  the  disease  seldom  admits. 
The  misleading  visceral  forms  have  been  discussed  {v.  s.).  In  37  per  cent, 
of  cases,  the  heart  is  negative,  in  44  per  cent,  the  murmur  is  systolic 
and  in  5  per  cent,  diastolic.  Absolute  certainty  rests  upon  our  ability 
to  diagnosticate  by  physical  signs,  the  presence  of  a  mitral  regurgitation 
(q.  V.)  which  is  the  most  frequent  form,  or  of  an  aortic  regurgitation  (q.  v.), 
plus  the  signs  of  sepsis  of  which  the  disease  is  a  part  ("arterial  pyemia"). 
The  valvular  murmur  may  disappear  after  embolism.  (See  Typhoid, 
differential  table.) 

Diastolic  murmurs  are  very  rarely  functional  and  their  appearance 
is  therefore  especially  suggestive.  Acute  myocarditis  may  produce  a 
systolic  murmur,  but  is  usually  attended  by  marked  early  muscular 
insufficiency,  weak  heart  shock  and  irregular  pulse,  weak  systolic  mur- 
mur and  a  moderately  accentuated  second  pulmonary  tone;  fatty  and 
cloudy  degeneration  of  the  myocardium  is  the  rule  in  acute  endocarditis, 
besides  which  the  muscle  may  sufier  from  coronary  closure  or  embolism, 
stasis  and  direct  involvement,  by  contiguity,  through  inflammation 
or  ulceration. 


348  DISEASES  OF  THE  ENDOCARDIUM 

Prognosis. — Satterthwaite's  figures  show  5  per  cent,  of  recoveries.  It 
depends  on  the  bacteriology,  the  number  of  infarcts  and  their  location, 
the  variability  of  the  heart  murmurs  (which  may  indicate  danger  of 
embolism),  and  the  intensity  of  the  sepsis.  Recovery  from  the  gonor- 
rheal form  is  relatively  frequent.  Musical  murmurs  with  fever  are 
usually  ominous.  Apparently  mild  endocarditis  may  become  severe. 
The  course  may  be  rapid  or  severe,  of  a  few  davs'  duration,  or  a  slower 
evolution  of  over  a  year. 

Treatment. — (See  Benign  Endocarditis  and  Septic  Infections.) 

(B)  Acute  Verrucose  or  Benign  Endocarditis. — This  variety  is  more 
frequent,  constituting  1.5  per  cent,  of  clinical  cases,  and  is  always 
secondary.  It  differs  from  the  malignant  type  in  degree  of  virulence 
only. 

Etiology.- — (a)  Rheumatism  {q.  i\),  its  most  frequent  cause,  accounts 
for  60  to  85  per  cent,  of  the  cases.  Over  20  per  cent,  of  rheumatic  patients 
develop  endocarditis;  in  children  it  is  very  frequent,  for  in  them  the 
heart  "resembles  an  articulation."  Muscular  rheumatism,  angina  or 
erythema  nodosum  may  occasion  endocarditis,  (h)  Chorea:  30  per  cent, 
of  clinical  and  82  per  cent,  of  fatal  cases  are  complicated  by  endo- 
carditis, (c)  Of  other  specific  infections,  scarlatina  ranks  first,  causing 
10  per  cent,  of  endocarditides,  and  active  or  latent  foci  in  the  tonsils,  or 
elsewhere,  rank  not  far  behind.  Endocarditis  is  far  more  uncommon  after 
typhoid,  diphtheria,  measles,  erysipelas,  gonorrhea,  variola,  syphilis, 
grippe,  tuberculosis,  etc.  (d)  Occasionally  it  is  associated  with  trauma, 
burns,  cancer,  Bright's  disease,  gout  or  diabetes,  (e)  It  is  most  common 
in  males  between  the  years  of  twenty  and  thirty. 

Pathology. — The  vegetations  are  verrucose,  wart-like,  papular  or 
even  pedunculated,  are  usually  small  and  occur  at  or  above  the  lines  of 
closure  of  the  valves,  whereby  their  function  is  impaired  and  valvular 
insufficiency  or  stenosis  results.  At  times  the  vegetations  are  cauliflower- 
like or  condylomatous.  They  are  grayish,  gelatinous  and  transparent; 
they  become  whiter  and  firmer  with  age  and  consist  of  two  strata,  the 
deeper  being  granulating  endocardium  and  subendocardial  tissue  and  the 
superficial  layer  consisting  of  thrombi  from  the  coagulable  elements  of 
the  blood.  The  signs  of  active  inflammation,  such  as  redness  or  swelling, 
are  usually  lacking,  redness  being  sometimes  confused  with  postmortem 
imbibition  of  hemoglobin  from  the  blood.  Vegetations  must  not  be  con- 
fused with  Albini's  nodes,  seen  in  infants  and  children.  The  vegetations 
are  at  an  early  stage,  cellular  from  leukocytic  exudation  and  tissue  pro- 
liferation and  usually  contain  bacteria  (see  Ulcerative  Type);  the 
inflammation  is  probably  primarily  embolic  in  the  myocardium,  and 
affects  the  valves  secondarily.  The  outgrowths  becoming  detached, 
emboli  are  released  and  produce  mechanical  hemorrhages  or  anemic 
.infarcts,  not  suppurative  infarcts  as  in  the  ulcerative  type.  The  fate 
of  the  vegetations  is  (a)  embolism;  (b)  organization  with  bare  possi- 
bility of  restoration  to  normal;  (c)  more  often,  organization  with  valvular 
lesions  resulting  from  retraction,  induration  and  calcification;  (r/)  being 
a  locus  resistentioB  minoris,  endocarditis  may  be  recurrent;  (e)  the  inflam- 
mation mav  lead  to  malignant  endocarditis. 


ENDOCARDITIS  349 

Localization. — The  vegetations  are  largely  on  the  same  surface  of  the 
same  valves  as  in  the  first  type,  and  in  the  left  heart;  conditions  in  fetal 
life  predispose  to  endocarditis  on  the  valves  of  the  right  heart,  or  on 
fetal  openings  or  defects.  The  mitral  valves  are  most  affected  (50  per 
cent,  of  the  cases  alone  or  80  per  cent,  when  combined  with  other  lesions), 
next  the  aortic  (13  per  cent,  alone  or  40  per  cent,  when  combined  with 
other  lesions),  and  far  less  frequently,  the  tricuspid  and  pulmonary  valves 
and  the  walls,  chordae  or  parietes. 

Symptoms. — The  symptoms  are  not  characteristic  unless  the  valves 
are  considerably  involved.  Simple  endocarditis  therefore  is  found  far 
more  frequently  at  autopsy  than  at  the  bedside;  i.  e.,  it  is  very  often 
latent.  An  increased  pulse  may  indicate  palpitation,  a  valvular  lesion  or 
a  myocarditis,  though  the  latter  is  the  more  likely  cause.  Daily  examina- 
tion of  the  heart  in  such  diseases  as  rheumatism  may  reveal  a  gradual 
involvement  of  the  endocardium,  with  moderate  fever,  cardiac  unrest, 
oppression,  palpitation  or  insufficiency.  Pain  is  generally  pleuritic  or 
pericarditic.  A  valvular  bruit  often  follows  muffling  or  irregularity  of 
the  cardiac  sounds,  and  is  still  later  followed  by  the  signs  of  mitral  or 
aortic  insufficiency  (q.  v.).  In  marantic  causation,  as  cancer  and  tuber- 
culosis, murmurs  are  generally  absent.  The  infrequent  diastolic  mur- 
murs are  more  distinctive  than  the  systolic,  for  they  are  rarely  functional. 
Embolism  is  very  important,  as  in  the  first  type,  but  mechanically  rather 
than  bacteriologically. 

Diagnosis. — Conservatism  in  diagnosis  is  necessary  and  acute  benign 
endocarditis  is  much  too  often  diagnosticated.  The  most  conspicuous 
symptom  is  fever,  though  it  is  not  characteristic  and  may  blend  with 
that  of  the  causal  disease;  the  most  important  findings,  objectively,  are 
the  signs  of  valvular  heart  disease;  for  these  findings  one  must  often 
wait,  because  in  many  cases  the  evolution  alone  is  final.  More  stress 
should  be  placed  upon  the  results  of  percussion  than  on  the  murmur  itself. 
The  murmurs  are  mistaken  for  functional  murmurs  accompanying  febrile 
relaxation  of  the  heart  chambers  or  myocarditis,  which  also  always 
accompanies  endocarditis. 

Recurrent  endocarditis  shows  not  only  the  fever  and  other  symp- 
toms caused  by  the  fresh  lesions,  but  also  the  hypertrophy  of  the  older 
valvular  lesion.  An  aortic  diastolic  or  a  mitral  presystolic  murmur 
is  more  likely  to  indicate  an  old  lesion.  With  repeated  examinations, 
fresh  murmurs  may  be  heard  in  addition  to  the  old  ones.  (See  Mitral 
Insufficiency  and  Ulcerative  Endocarditis.) 

Prognosis. — (a)  As  to  life,  the  outlook  is  generally  good,  unless  (i) 
emboli  lodge  in  important  structures,  such  as  the  basilar  or  coronary 
arteries,  or  (ii)  the  process  becomes  malignant,  (b)  As  to  complete  recovery, 
(i)  valvular  lesions  are  usual  which  are  anything  but  "benign";  (ii) 
fresh  recurrent  endocarditis  is  very  common ;  and  (iii)  complete  recovery 
is  uncommon,  though  not  unknown. 

Treatment. — The  treatment  of  the  two  forms  of  endocarditis  is 
considered  together,  (a)  Prophylaxis  resolves  itself  into  the  treatment 
of  the  causal  acute  infection,  such  as  rheumatism  or  sepsis.  The  admin- 
istration of  salicylates  in  rheumatism  shortens  the  rheumatic  attack. 


350  DISEASES  OF  THE  ENDOCARDIUM 

(6)  Rest  sjjares  the  heart  and  probably  lessens  the  percentage  of  cases 
involved.  Psychical,  physical  and  cardiac  rest  is  the  prime  essential, 
and  requires  that  the  patient  lie,  not  sit,  in  bed  for  many  weeks  after 
temperature  and  cardiac  weakness  have  wholly  disappeared.  Should 
relative  recovery  occur,  the  general  care  of  the  heart's  strength  must  be 
insisted  upon  as  in  chronic  valvular  disease  and,  with  intercurrent 
affections  or  with  the  appearance  of  temperature,  the  patient  must  be 
confined  to  bed.  Senac  (1749-1783)  recognized  the  causal  importance 
of  inflammation  in  heart  disease,  the  necessity  of  avoiding  strain  and  of 
regulating  the  amount  of  fluid  and  food  ingested,  the  relations  of  liver 
and  stomach  disturbance  and  the  advantages  of  mental  quietude,  (c) 
The  sepsis  is  treated  by  moderate  doses  of  quinine,  with  three  ounces  of 
red  wine  every  four  hours;  bichloride  of  mercury  and  other  antiseptics 
are  futile;  there  may  be  some  virtue  in  hexamethylenamine.  (d)  The 
irritahle  heart  may  be  quieted  by  the  ice-bag.  Sinapisms  sometimes  act 
favorably  but  blisters  are  to  be  avoided.  Cardiac  stimulants  should 
be  employed  with  caution;  digitalis  is  only  indicated  when  tumultuous 
heart  action  threatens  to  induce  embolism,  (e)  Symptomatic  treatment: 
For  nervous  symptoms,  sodium  bromide  is  indicated.  Sulphonal  and 
trional  are  to  be  avoided  when  the  heart  weakens.  Hydrotherapy, 
aside  from  simple  sponging,  is  inadvisable,  for  the  joints  and  muscles  are 
very  tender  and  movement  may  provoke  embolism.  Diarrhea  of  septic 
origin  should  not  be  checked  at  once,  because  it  is  nature's  effort  at 
elimination.  A  light  diet  should  be  given  because  of  the  fever.  Potassium 
iodide  is  often  administered  as  a  resolvent  after  the  acute  stage  has 
passed.     (/)  Vaccines  and  serums  injure  more  often  than  they  help. 

II.  Chronic  Endocarditis.  Chronic  Valvular  Disease. — Etiology. — Val- 
vular disease  constitutes  5  per  cent,  of  all  diseases.  It  most  often  develops 
from  (a)  acute  verrucose  endocarditis  and  in  60  per  cent,  the  cause  is 
rheumatism.  One-half  the  cases  of  valvular  disease  are  in  children  and 
over  one-third  occur  between  20  and  30  years  of  age.  Some  apparently 
primary  cases  are  seen  mostly  in  young  or  adolescent  subjects  and  in 
women,  but  doubtless  some  minor  or  forgotten  infection  explains  this 
group,  ih)  Atheroma  is  an  important  cause;  it  is  promoted  by  over- 
exertion, as  in  the  working  classes,  by  advanced  years  or  by  chronic 
nephritis,  gout,  diabetes,  syphilis,  alcoholism  and  lead  poisoning.  It  is 
more  common  in  males.  Chronic  valvular  disease  may  develop  from 
other  causes  than  actual  endocarditis,  e.  g.,  from  (c)  rupture  of  the 
valves;  this  occurs  most  often  in  the  aortic  valves  during  supreme  physical 
efforts  and  is  favored  by  previous  valvular  lesions,  although  sometimes 
observed  in  normal  valves.  Healing  is  rare,  (d)  In  relative  valvular 
insufficiency  the  normal  valves  are  unable  to  close  their  orifices  because 
the  heart  is  dilated;  it  is  most  commonly  tricuspid  and  mitral,  and  more 
rarely  aortic  and  pulmonary.  Relative  stenosis  is  not  clearly  established, 
(e)  Other  rarer  causes  are  aortic  aneurysms,  neoplasms,  valvular  aneurysms 
and  cardiac  thrombi. 

Pathology. — Small  grayish-red  swellings  are  sometimes  seen  in  the  early 
stages.  Foci  of  endocardial  thickening  and  retraction  {endocarditis 
retrahens)  develop,  in  which  calcification,  and  even  ossification,  of  the 


ENDOCARDITIS  351 

\'alves  may  be  present.  The  valves  become  opaque,  rigid,  unable  to  unfolds 
adherent  to  each  other  or  distorted  by  their  own  thickening  and  retraction 
or  that  of  the  chordse  or  papillary  muscles.  Acute  exacerbations  may 
occur  and  then  the  ordinary  vegetations  appear.  Embolism  occurs  in 
30  per  cent,  of  cases.  The  myocardial  changes  are  hypertrophy,  dilata- 
tion and  myocarditis.  The  valves  most  often  involved  are  the  mitral 
(78  per  cent.),  especially  in  adolescence,  then  the  aortic  (20  per  cent.), 
especially  in  syphilis  and  arteriosclerosis,  and  finally  the  tricuspid  (1 
per  cent.)  and  the  pulmonary  valves.  Combined  valvular  lesions  occur 
in  33  per  cent,  of  cases.  The  process  often  extends  by  continuity  of  sur- 
face from  the  mitral  to  the  aortic  valves.  When  one  valve  is  but  moder- 
ately involved,  the  others  of  the  same  valvular  orifice  may  compensate 
by  stretching  to  cover  the  defect,  especially  in  aortic  disease.  In  fetal 
cases  the  right  heart  is  more  frequently  involved. 

Valvular  insufficiency  is  caused  by  (a)  thickening  and  retraction  or 
even  calcification  of  the  valves  or  the  chordse  tendinese  and  papillary 
muscles;  (h)  massive  vegetations;  (c)  growing  together  of  the  valves,  or 
of  the  valves  with  the  wall  of  the  heart  or  aorta;  or  adhesions  between 
the  papillary  muscles  and  tendons;  (d)  valvular  aneurysm,  perforation, 
rupture  or  tearing  of  the  tendons  or  muscles.  Valvular  stenosis  (stenosis 
of  the  orifice)  results  from  (a)  adhesions  between  the  valves,  (b)  retraction, 
calcification,  fibrosis  of  valves  or  ring  of  insertion  and  (c)  vegetations. 
Combined  valvular  insufiiciency  and  stenosis  are  very  common. 

Symptoms. — The  symptoms  of  valvular  disease  are  (a)  the  cardiac 
findings  peculiar  to  each  lesion,  which  will  be  first  considered,  and 
(h)  the  general  symptoms  more  or  less  common  to  all  forms  of  cardiac 
insufficiency,  the  description  of  which  will  follow  the  individual  lesions. 

Aortic  InsufPiciency  (Corrigan's  Disease). — Aortic  regurgitation  was 
described  by  Cowper  (1705),  Vieussens  (1715)  and  Hodgkin  (1829),  but 
the  first  full  description  was  Corrigan's  (1832). 

Etiology. — 1.  The  endocarditic  form  explains  27  per  cent,  of  cases. 
The  sinuses  of  the  valves  may  fuse,  vegetations  are  present,  or  the  valves 
grow  together  at  their  margins  and  shrink;  this  is  more  frequent  than 
valvular  perforation  or  ulceration,  which  is  rapidly  fatal.  If  calcifica- 
tion develops  there  may  be  coincident  stenosis  of  the  aortic  orifice. 
The  endocarditic  form  usually  follows  a  previous  mitral  lesion,  occurs  at 
an  earlier  age  and  is  not  attended  by  the  arteriosclerotic  changes  in  the 
aorta  and  coronary  arteries  which  characterize  the  atheromatous  form. 

2.  The  atheromatous  form  accounts  for  44  per  cent,  of  leakage.  Ather- 
oma may  be  slight  in  the  aorta  and  located  mostly  on  the  valves.  It 
is  a  slow,  degenerative  process  with  marginal  valvular  retraction  (see 
Arteriosclerosis);  it  is  caused  by  excessive  use  of  alcohol,  by  con- 
tinued hard  work  or  athletics.  It  is  often,  therefore,  seen  in  middle-aged 
men.  The  valves  may  adhere  to  the  aorta.  Their  edges  are  rounded 
and  present  no  endocarditic  masses.  The  atheromatous  process  may 
overlie  or  actually  invade  the  coronary  orifices;  this  is  obviously 
dangerous.     Coincident  stenosis  is  uncommon. 

3.  The  syphilitic  form  explains  29  per  cent.  In  half  the  cases  of  pure 
aortic  leakage,  the  aorta  shows  a  luetic  mesa-ortitis  and  about  three- 


352  DISEASES  OF   THE  ENDOCARDIUM 

quarters  show  the  Wassermann  test  (pages  208  and  219).  The  following 
forms  are  infrequent: 

4.  Relative  insufficiency  occurs  mostly  in  cases  of  aortitis,  aneurysm 
and  arteriosclerotic  dilatation  of  the  root  of  the  aorta;  the  aorta  relaxes 
one  centimeter  in  circumference  after  the  fortieth  year.  It  may  also 
occur  in  cases  of  dilatation  of  the  left  ventricle,  resulting  from  hypertrophy, 
myocarditis  or  renal  disease. 

5.  Congenital  Defects. — These  are  rare;  absence  of  a  valve  may  be  in 
part  compensated  for  by  the  others,  though  anatomical  anomalies  pre- 
dispose to  sclerosing  endocarditis. 

6.  Trauma. — Only  46  aortic  cases  are  recorded  in  a  total  of  72. 
Mechanism. — From  aortic  incompetence,  a  diastolic  regurgitation  of 

blood  into  the  left  ventricle  takes  place  from  gravity  and  contraction 
of  the  aorta.  Blood  currents  are  caused  by  the  blood  flowing  (normally 
from  the  left  auricle  and  pathologically  from  the  aorta)  into  the  left 
ventricle,  thereby  producing  the  diastolic  murmur.  The  left  ventricle 
becomes  dilated  to  accommodate  its  added  volume  and  hyyertroiihied  to 
propel  the  normal  plus  the  regurgitated  blood;  the  heart  may  weigh 
50  ounces  ("ox-heart" — cor  hovinum).  The  hypertrophied  left  ventricle 
suddenly  forces  a  large  amount  of  blood  into  the  arteries,  and  thus 
causes  the  many  arterial  phenomena  (Stewart  believes  that  the  amount 
of  regurgitated  blood  is  small). 

Physical  Signs. — 1.  Inspection. — (a)  Precordial  'prominence  is  ob- 
served chiefly  in  plastic  chests  and  in  the  endocarditic  type  and  therefore 
mostly  in  women  and  children.  Mensuration  confirms  the  prominence 
(the  right  chest  normally  measures  nearly  an  inch  more  than  the  left). 
(6)  The  heart  shock  is  powerful  and  diffuse,  (c)  The  apex  heat  is  dislocated 
dowmvard  (6th,  7th,  8th  interspace)  and  outward,  beyond  the  nipple  or 
anterior  axillary  line.  It  is  heaving,  pulsating  and  superficial.  The  lung 
is  pushed  back  and  slight  rots.tory  systolic  retraction  of  the  chest  wall  is 
seen.  These  findings  are  referable  to  the  dilated  and  hypertrophied  left 
heart.  If  the  leak  is  slight,  there  may  be  little  or  no  dilatation  or  hyper- 
trophy, clinically.  The  apex  also  lies  low  in  arteriosclerotics,  from  relaxa- 
tion of  the  aorta,  (d)  Pulsation  in  the  first  and  second  right  intercostal 
spaces  is  usually  dynamic,  because  the  blood  expelled  with  extra  force 
causes  dilatation  of  the  aortic  arch,  (e)  The  peripheral  vessels  pulsate 
with  unusual  violence;  pulsation  in  the  jugular  fossa  or  abdominal  aorta 
may  simulate  aneurysm,  and  the  temporals,  carotids  and  radials  attract 
attention  before  the  patient  undresses.  The  crossed  leg  may  pulsate  and 
the  head  may  throb  (Musset's  nodding).  These  are  all  caused  by  ventri- 
cular hypertrophy,  the  extra  volume  of  blood  thrown  into  the  vessels  or  an 
accommodative  dilatation  of  the  peripheral  vessels.  Pulsation  may 
also  be  seen  in  the  retina  spontaneously  or  by  pressure  on  the  eye-ball, 
as  occurs  also  in  Basedow's  disease.  The  liver  may  pulsate,  though  this  is 
rare  because  a  strong  heart  action  with  stasis  is  necessary.  (The  liver 
also  pulsates  in  tricuspid  incompetency  from- venous  filling  of  the  organ.) 
Pulsation  also  may  occur  in  the  spleen,  tongue,  palate  and  penis;  the 
pupils  may  contract  and  dilate  rhythmically.  (/)  The  capillary  (Quincke  s) 
pulse  occurs  in  over  80  per  cent,  of  cases;   it  is  also  seen  in  health,  fevers 


EXDOCARDITIS 


353 


or  anemias.  It  is  a  symptom  of  overfilling  of  the  arteries  and  capillary 
dilatation  and  is  best  observed  when  the  hypertrophy  exceeds  the  dila- 
tation; it  disappears  when  the  heart  weakens.  It  is  elicited  by  exerting 
slight  pressure  on  the  tips  of  the  finger  nails,  on  the  lips  by  a  glass  slide 
or  by  rubbing  the  forehead  until  it  is  red ;  there  is  a  systolic  reddening  and 
a  diastolic  paling  in  these  parts.  It  is  sometimes  found  in  the  retina, 
palate  or  in  complicating  erysipelas,  (g)  The  passing  over  of  the  blood 
from  the  arterioles  into  the  veins  may  produce  the  centripetal  venous 
pulse — most  obviously  in  the  forearm,  and  caused  by  relaxation  of  the 
vessels,  as  in  fevers,  nervous  lesions  and  chlorosis;  by  delicate  skin;  and 
full  heart  action.  (/?)  The  arteries  are  actually  lengthened,  (i)  Patients 
often  assume  the  dorsal  decubitus,  for  gravity  increases  the  leakage;  sub- 
jects with  mitral  insufficiency  usually  sit.  The  findings  by  inspection  are 
practically  pathognomonic. 

2.  Palpation. — (a)  The  hand  corroborates  the  results  of  inspection — ■ 
as  the  heaving,  throhhing  apex  and  the  diastolic  impulse,  (b)  A  diastolic 
thrill  over  the  base  is  infrequent,  occurring  mostly  in  cases  of  endocarditic 
origin,  (c)  In  the  jugulum,  especially  in  arteriosclerotics,  the  widened  aorta 


Fig.  21. — Sphygmogram  of  case  of  uncomplicated  aortic  leakage. 


can  be  felt,  (d)  The  2>uhe  findings  may  seem  paradoxical;  the  arteries 
are  filled  violently  (the  pulsus  durus),  though  the  tone  of  the  vessels  is 
less  than  normal.  Oppolzer  is  reputed  to  have  secured  his  professorship 
in  Vienna  by  his  diagnosis  of  aortic  leakage  from  placing  his  hand  on  a 
patient's  foot. 

The  radial  artery  is  suddenly  filled,  the  "pistol  pulse"  or  pulsus  celer, 
due  to  hypertrophy  of  the  left  ventricle.  The  heart  action  is  c^uicker, 
at  the  expense  of  the  diastole,  shortening  of  which  is  favorable,  since 
less  time  is  allowed  for  the  leakage.  The  condition  of  the  heart  muscle 
and  pulse  depends  on  the  etiology  of  the  case;  hypertrophy  is  marked  in 
the  endocarditic  form,  but  in  the  atheromatous  type,  coronary  atheroma 
and  fibrous  myocarditis  lessen  the  myocardial  activity,  render  the  pulse 
atypical  and  make  the  prognosis  less  favorable.  The  sphygmographic 
tracing  shows  the  high  up-stroke  with  an  acute  apex  (the  pulsus  alius). 
The  dicrotic  wave  is  ill-marked  arid  the  pulse  rapidly  recedes  (the  "col- 
lapsing pulse''),  due  to  the  inability  of  the  aortic  valves  to  hold  the 
receding  blood.  (Stewart's  explanation  is:  a  reflex  dilatation  of  the 
peripheral  vessels  and  heart  stimulation  by  the  increased  pressure  within 
the  left  ventricle.)    The  collapse  of  the  pulse  is  sometimes  increased  by 


354  DISEASES  OF   THE  ENDOCARDIUM 

lifting  the  arm.  This  piilse  is  strongly  suggestive  but  also  occurs  in 
fevers  or  anemias.  The  typical  findings  are  altered  by  atheroma;  other 
valvular  lesions  (aortic  stenosis  or  mitral  regurgitation) ;  or  by  heart  weak- 
ness. When  the  pulse  findings  precede  the  murmur,  it  is  claimed  that 
the  lesion  is  due  to  disease  of  the  aorta.  Thrills  may  be  felt  over  the 
peripheral  vessels.  The  peripheral  pulse  is  delayed  in  half  of  the  cases, 
because  the  regurgitation  continues  into  the  first  part  of  the  systole. 
The  systolic  blood-pressure  is  higher,  and  the  diastolic  is  lower,  than 
normal . 

3.  Percussion. — (a)  The  heart  area  is  increased  downward  and  to  the  left; 
the  a'-ray  shows  the  heart  rather  horizontal,  "recumbent"  or  of  an 
"egg  form."  Dulness  reaches  the  second  or  third  rib  to  the  left  of  the 
sternum  (see  Plate  X,  Fig.  C).  The  dulness  extends  slightly  beyond  the 
apex  and  is  due  to  dilatation  of  the  left  ventricle;  the  right  heart  may  be 
crowded  somewhat  to  the  right,  although  dulness  to  the  right  of  the 
sternum  is  infrequent.  The  papillary  muscles  are  found  flattened  and 
thickened  at  autopsy,  from  the  pressure  of  the  regurgitant  blood.  (6) 
A  small  area  of  dulness  in  the  first  and  second  right  interspaces  denotes 
mechanical  dilatation  of  the  arch,  from  the  cardiac  hypertrophy. 

4.  Auscultation. — (a)  A  diastolic  murmur  is  heard  over  or  to  the  left 
of  the  sternum  at  the  level  of  the  second  or  third  rib,  and  increased 
downward  along  the  sternum,  for  the  regurgitant  column  follows  this 
direction  (Plate  X,  Fig.  C).  It  has  a  blowing,  deep  and  less  often  sawing, 
musical  or  whistling  sound  (which  latter  suggests  a  relative  aortic  leakage) . 
When  slight,  it  may  easily  escape  recognition;  when  well  developed  it  is 
very  characteristic,  sounding  like  the  word  "loho."  It  may  best  be  heard 
with  the  bare  ear  against  the  chest.  It  sometimes  disappears  before 
death  when  the  heart  is  weak  and  the  lesion  great,  but  generally  corre- 
sponds to  the  degree  of  leakage.  It  rarely  reaches  the  neck,  abdomen  or 
axilla.  Valvular  rupture  may  produce  a  murmur  which  can  be  heard 
at  a  distance.  (6)  A  slight  systolic  murmur  over  the  aorta  is  common, 
but  the  too  frequent  diagnosis  of  aortic  stenosis  (g.  v.)  is  not  justified. 
It  is  soft  in  the  atheromatous  and  often  harsh  in  the  endocarditic  type. 
Its  various  explanations  are:  rough  aorta  or  valves;  physiological  stenosis 
(the  rigid  valves  lying  between  a  wide  aorta  and  a  dilated  ventricle); 
\ibration  of  the  aorta;  or  leakage  continuing  into  the  beginning  of  the 
systole,  (c)  Weakness  or  absence  of  the  second  aortic  tone  is  explained  by 
imperfect  closure  of  the  valves.  As  the  second  tone  is  normally  heard 
over  the  carotid  artery,  it  should  be  listened  for  there,  because  it  is 
removed  from  the  murmur  and  the  second  pulmonic  tone.  If  it  is  pres- 
ent, one  or  more  valves  are  closing,  though  probably  imperfectly.  By  lift- 
ing the  stethoscope  a  little  from  the  skin  over  the  aortic  region,  the  second 
sound,  previously  obscured  by  the  bruit,  may  be  heard,  (d)  The  first 
mitral  tone  is  often  weak  or  lost,  because  the  papillary  muscles  are  flattened 
and  indurated  by  the  regurgitant  column,  or  a  mitral  systolic  murmur 
may  replace  the  first  tone,  {e)  An  apical  presystolic  (Flint's)  murmur  is 
due  to  aortic  leakage  continued  in  the  systole,  or  to  pressm-e  on  the 
mitral  valves,  which  hinders  the  flow  of  blood  from  the  left  auricle  into 
the  left  ventricle  (Flint,  1862).    Thayer  found  it  in  60  per  cent,  of  74 


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ENDOCARDITIS  355 

cases,  and  in  less  than  one-quarter  of  these  was  there  coincident  mitral 
stenosis.  (/)  Arterial  tones  and  murmurs  result  from  vibration  of  the 
vessel  wall;  the  tones  may  become  murmurs,  when  there  is  great  differ- 
ence in  tension.  The  systolic  vessel  tone  is  increased  by  the  larger 
volume  of  blood  and  increased  ventricular  action,  and  is  most  plain 
when  the  vessels  are  not  sclerotic.  The  femoral  systolic  tone  is  convertible 
into  a  murmur  on  pressure.  Trauhe's  double  femoral  sounds  consist  of  two 
spontaneous  tones  (produced  without  pressure),  most  satisfactorily 
explained  by  sudden  change  in  tension.  They  are  heard  best  when  the 
heart  is  strong  and  the  vessels  soft.  They  may  be  confused  with  the 
double  venous  (Friedreich's)  tones,  heard  over  the  vein  in  tricuspid 
leakage.  Duroziez's  double  murmur  consists  of  two  murmurs,  elicited  by 
slight  pressure  and  due  to  the  progress  and  recession  of  blood  in  the 
artery.     These  phenomena  also  occur  in  other  conditions. 

Diagnosis. — Physical  examination  by  inspection,  palpation,  percus- 
sion and  auscultation,  in  the  order  named,  prevents  error  in  the  inter- 
pretation of  murmurs.  The  cardinal  findings  are:  (a)  dilatation  and 
hypertrophy  of  the  left  ventricle;  (b)  the  pulsus  celer  and  alius;  (c)  the 
arterial  phenomena;  and  (d)  the  diastolic  murmur. 

Comparing  the  types,  endocarditic  aortic  insufficiency  is  generally 
rheumatic  and  occurs  in  younger  subjects;  precordial  prominence  and 
diastolic  thrill  are  more  common;  the  heart  muscle  hypertrophies  and 
the  pulsating  vessels  are  more  conspicuous;  the  pulse  is  more  typically 
"pistol-like"  and  collapsing,  as  the  vessels  are  not  sclerosed;  the  capillary 
pulse  and  vessel  tones  are  more  frequent;  on  auscultation  the  diastolic 
murrhur  is  rather  harsher  and  nearer  the  valves,  Flint's  murmur  is  more 
common  and  if  a  systolic  aortic  bruit  is  heard,  it  is  often  harsher  and 
coincident  aortic  stenosis  is  more  frequent. 

In  the  atheromatous  form,  sexual  excesses,  manual  work  and  alco- 
holism are  more  evident.  Syphilis  is  declared  by  the  immobile  pupil, 
lightning  pains  of  tabes  or  Wassermann  reaction.  As  arteriosclerosis 
readily  involves  the  heart,  anginal  pains,  myocarditis  or  dyspnea  may 
stand  forth.  The  dilated  aorta  is  more  frequently  palpable  in  the  jugulum 
and  allows  the  heart  to  sag  lower  in  the  chest.  The  diastolic  murmur 
is  more  characteristically  deep  and  blowing  and  the  vascular  phenomena 
are  considerably  modified  by  the  rigid  arteries. 

Relative  aortic  regurgitation  is  difficult  to  differentiate  from  the  val- 
vular; the  murmur  is  a  short,  presystolic  or  postdiastolic,  almost  pathog- 
nomonic "huff"  after  the  second  aortic  tone.  The  pulse  is  frequently 
small,  tardy  and  tense,  but  not  quick.  The  murmur  varies  from  time 
to  time,  sometimes  short,  then  longer,  sometimes  blowing,  and  again 
coarse. 

Diastolic  murmurs  are  rarely  anemic  {cardiopulmonary  or  junctional) ; 
such  bruits  exist,  however,  in  the  cava  and  other  veins;  they  are  uneven 
and  stronger  in  the  beginning  of  the  diastole.  Aortic  aneurysm  (q.  v.) 
may  cause  confusion.  In  mitral  lesions,  the  capillaries  are  poorly  filled 
and  the  skin  is  cyanotic;  in  aortic  regurgitation  the  arterioles  are  over- 
filled and  the  skin  is  pale,  perhaps  red.  In  mitral  disease,  congestion  of 
the  lungs,  brown  induration  and  dilatation  of  the  right  heart  obtain; 


356  -         DISEASES  OF   THE  ENDOCARDIUM 

these  are  absent  in  aortic  leakage;  a  hemorrhagic  nephritis  may  take 
the  place  of  the  analogous  brown  induration  of  the  lungs  of  mitral  lesions. 

Relative  heaJincj  by  vicarious  stretching  of  sound  valves,  by  increasing 
stenosis  and  by  calcification  is  possible  but  infrequent. 

Aortic  Stenosis.^ — Stenosis  of  the  aortic  orifice,  a  better  term  than  aortic 
stenosis,  is  the  rarest  of  left-heart  lesions;  its  frequency  as  a  solitary 
lesion  is  2.5  per  cent.  It  may  occur  congenitally  from  constriction  of  the 
conus  arteriosus  (Dittrich's  genuine  heart  stenosis).  It  occurs,  however, 
largely  in  the  aged;  the  valves  become  interadherent  or  fibrously  thick- 
ened from  atheroma  or  chronic  endocarditic  calcification,  or  retraction 
at  the  valvular  insertion  obstructs  the  orifice.  Acute  endocarditis,  with 
massive  vegetations,  may  produce  some  stenosis.  It  is  usually  associated 
with  aortic  incompetency. 

Mechanism. — ^The  rigid  valves  narrow  the  orifice  and  at  the  obstruc- 
tion a  systolic  murmur  originates.  The  resistance  to  the  onward  flow 
of  blood  from  the  left  ventricle  leads  to  its  hypertrophy.  The  pulse 
becomes  small  and  slow  because  of  obstruction. 

Physical  Signs. — 1.  Insyection. — Some  precordial  prominence  may 
be  seen  in  yielding  chests.  The  apex  beat  is  sometimes  strong  and 
dislocated  to  the  left,  but  often  no  apex  is  seen  on  account  of  diminution 
of  the  heart's  recoil. 


Fig.  22. — Pulse  tracing  in  stenosis  of  the  aortic  orifice. 

2.  Palpation. — (a)  A  i^rorwunced  systolic  thrill  is  often  felt  over  the 
second  right  interspace,  sometimes  over  the  heart  and  cervical  vessels. 
(h)  The  pulse  is  infrequent  {pulsus  rams),  because  the  systole  is  prolonged 
and  the  coronary  arteries  are  poorly  filled;  small  {p.  parvus)  from  ob- 
struction to  its  flow;  tense  {p.  durus)  from  hypertrophy  of  the  left 
ventricle;  and  slow  {-p.  tardus)  with  tardy  up-and-down  stroke  and  some 
retardation. 

3.  Percussion. — Concentric  hypertrophy  (with  the  left  ventricle  smaller 
than  normal),  and  simple  hypertrophy,  which  are  the  more  common  as 
the  stenosis  is  purer,  give  no  change  on  percussion.  Slight  dilatation  to 
the  left  is  sometimes  present,  especially  with  aortic  regurgitation,  nephritis 
or  atheroma. 

4.  Auscultation. — (a)  The  systolic  murmur  over  the  aortic  area  is 
generally  long,  sawing,  whistling  or  musical  and  is  transmitted  with  the 
blood  current  into  the  arch,  the  descending  aorta  in  the  back,  its  vessels 
(Plate  X,  Fig.  A),  or  over  the  entire  heart  or  even  at  some  distance  from 
the  chest.  It  is  not  proportionate  to  the  intensity  of  the  lesion  and 
disappears  with  broken  compensation.  (6)  The  second  aortic  sound  is 
weak,  from  poor  filling  of  the  aorta  and  weak  closure  of  the  altered  valves, 
or  absent  in  coincident  aortic  regurgitation;  (c)  when  the  second  aortic 
sound  is  absent,  the  second  mitral  tone,  or  indeed  all  the  heart  tones,  are 
weak  or  absent,  (d)  The  systolic  tone  over  the  aorta  is  scarcely  to  be 
heard. 


ENDOCARDITIS  357 

Diagnosis. — The  lesion  may  be  favorable — a  healing  of  an  aortic 
regurgitation.  Aortic  stenosis  is  a  frequent  surprise  at  autopsy,  having 
run  a  latent  course.  Diagnosis  should  be  reserved,  without  these  cardinal 
sig7is:  (a)  systolic  murmur  with  propagation  into  the  large  vessels  or 
over  the  entire  heart;  (6)  a  systolic  fremissement  over  the  aortic  area; 
(c)  the  small,  tense,  tardy,  slotv  pulse,  in  contrast  to  the  strong  apex  beat. 
As  the  lesion  is  uncommon,  its  frequent  diagnosis  implies  confusion 
with  (i)  accidental  murmurs  which  are  variable,  (ii)  Acute  endocarditic 
vegetations,  give  a  soft  murmur  which  becomes  harsher  if  actual  stenosis 
ensues,  (iii)  Atheroma  of  the  aorta,  or  acute  aortitis,  where  the  murmur 
is  more  localized  over  the  aorta,  the  second  aortic  tone  is  metallic  and  the 
pulse  proportionate  to  the  apex  beat.  Atheroma,  the  most  frequent 
cause  of  diagnostic  error,  is  very  common,  while  experienced  clinicians 
see  few  cases  of  pure  aortic  stenosis,  (iv)  Aneurysm  (q.  v.),  which  is  often 
distinguishable  by  its  pressure  symptoms. 

Mitral  Insufficiency. — Mitral  insufficiency  (incompetency,  regurgita- 
tion) is  the  most  frequent  valvular  lesion  and  more  often  endocarditic 
than  atheromatous.  It  is  (a)  valvular,  from  adhesions  between  the  valves 
or  chordae  and  ventricular  wall,  from  vegetations,  from  thickening  with 
retraction,  from  valvular  aneurysm  or  perforation,  or  from  shrinkage  or 
rupture  of  the  papillary  muscles  or  chordae;  (b)  muscular,  from  relative 
insufficiency  due  to  such  ventricular  relaxation  that  the  valves  do  not 
cover  the  orifice;  this,  form  is  common  in  hypertrophy  with  dilatation, 
resulting  from  hard  work,  nephritis,  syphilis,  alcoholism,  myocarditis 
and  adherent  pericardium;  (c)  rupture  of  the  mitral  cusps  is  very  un- 
common. Barie  collected  35  cases  of  valvular  rupture,  of  which  45.7 
per  cent,  were  aortic,  45.7  per  cent,  mitral  and  8.6  per  cent,  tricuspid. 

Mechanism. — During  the  systole,  a  backward  flow  occurs  through 
the  incompetent  valves  into  the  left  auricle,  which,  as  it  also  receives 
blood  from  the  lung  veins,  first  dilates  and  later  hypertrophies  as  far  as 
its  thin  musculature  admits.  The  left  ventricle  dilates  because  it  receives 
in  the  diastole  the  usual  inflow  of  blood  plus  the  regurgitated  blood 
and,  responsive  to  the  dilatation,  it  hypertrophies  because  its  work  is 
increased.  In  aortic  lesions,  the  first  and  greatest  strain  is  felt  in  the 
left  ventricle,  but  mitral  lesions,  by  congesting  the  lungs,  throw  most 
work  on  the  right  heart.  The  stasis  in  the  left  auricle  is  transmitted  to 
the  pulmonary  veins,  capillaries  and  arteries,  thus  leading  to  increased 
blood-pressure  in  the  pulmonary  circuit,  because  (a)  of  this  backward 
pressure,  and  (b)  of  the  onward  pressure  from  the  right  ventricle,  which 
dilates  and  then  hypertrophies.  The  lungs  are  enlarged,  their  vessels 
dilate  and  may  become  atheromatous,  possibly  causing  infarcts  in  the 
lungs  and  fibrosis  (brown  induration).  When  the  final  atonicity  of  the 
right  ventricle,  i.  e.,  broken  compensation,  occurs,  relative  tricuspid 
leakage  from  dilatation,  cyanotic  induration  of  the  liver  and  kidneys, 
edema,  etc.,  result. 

Physical  Signs. — 1.  Inspection. — (a)  The  apex  may  be  normally 
located  or  displaced  to  the  left — even  into  the  axilla,  when  the  heart  lies 
lower  than  normal,  A  normally  strong  apex  beat  in  mitral  insufficiency 
is  evidence  of  hypertrophy,     (b)  Systolic  pulsation  in  the  second,  left  inter- 


358  DISEASES  OF   THE  ENDOCARDIUM 

space  indicates  a  wide  pulmonary  artery  from  stasis,  and  (c)  a  diastolic 
shock  there  is  due  to  closure  of  its  valves;  {d)  precordial  prominence 
occurs  in  yielding  chests  from  dilatation;  (e)  pulsation,  either  epigastric 
or  to  the  right  of  the  sternum,  results  from  dilatation  and  hypertrophy 
of  the  right  ventricle.  (/)  The  enlarged  veins  pulsate  during  the  diastole 
from  stasis,  and  sometimes  during  the  systole  from  tricuspid  incom- 
petency. 

2.  Palpation. — (a)  The  apex  is  dislocated  to  the  left;  (b)  the  pulmonary 
artery  pulsation  and  (c)  the  diastolic  shock  of  the  forcibly  closing  pulmonary 
valves  are  very  often  palpable;  by  placing  one  finger  over  the  valves  and 
another  over  the  apex  the  two  shocks  alternate;  (d)  pulsation  is  felt  to 
the  right  of  the  sternum  from  right  ventricle  dilatation;  (e)  a  systolic 
apical  thrill  is  often  palpable  but  not  pathognomonic.  (/)  In  pure  cases 
the  pulse  is  about  normal  in  tension,  or  weakens  with  decompensation. 
Irregularity  is  not  common. 

3.  Percussion. — (a)  Dilatation  of  the  right  ventricle  is  commonly  fol- 
lowed by  hypertrophy,  in  compensated  cases,  as  the  right  heart  bears  the 
stress  of  this  lesion.  Dilatation  causes  dulness  and  palpatory  resistance 
to  the  right  of  the  sternum  (see  Plate  X,  Fig.  B).  The  .r-rays  show  the 
typical  round  heart.  Hypertrophy  without  dilatation  is  usually  found 
in  the  early  and  well-compensated  lesions.  (6)  The  left  ventricle  usually 
dilates  to  respond  to  the  increased  amount  of  blood,  and  hypertrophies 
because  of  increased  work  or  the  raising  of  arterial  pressure  by  carbon 
dioxide. 

4.  Auscultation. — (a)  The  systolic  murmur  is  due  to  abnormal  eddies 
in  the  left  auricle  or  to  the  vibrations  caused  by  them  in  the  mitral  valves; 
it  most  often  gives  a  blowing  sound,  best  heard  over  the  apex,  which  is 
less  covered  by  the  lung,  but  at  times  is  localized  over  the  left  auricle, 
where  it  originates  and  is  heard  especially  in  early  lesions.  It  is  transmitted 
chiefly  to  the  left  toward  the  left  interscapular  region,  and  more  rarely  to 
the  aorta,  carotids  and  abdomen  (see  Plate  X,  Fig.  B) ;  at  times  it  is 
heard  intermittently,  in  certain  postures  only,  and  it  may  disappear 
with  weakening  of  the  heart.  In  very  rare  cases  it  is  entirely  absent. 
(6)  ThQ  first  mitral  tone  is  usually  absent  because  the  valves  cannot  vibrate; 
if  present  it  is  referable  to  conduction  from  the  tricuspid  valve  or  to 
contraction  of  the  ventricle.  When  obscured  by  the  murmur,  it  may 
sometimes  be  heard  by  lifting  the  stethoscope  a  little  from  the  chest 
wall.  In  extreme  leakage,  the  murmur  replaces  all  tones,  (c)  The 
second  pidmonic  sound  is  accentuated,  "hammer -like,"  and  is  a  measure 
and  result  of  the  right  ventricular  hypertrophy  (Skoda).  It  sometimes 
reaches  the  vessels  of  the  neck.  When  the  tricuspid  valves  become 
relatively  insufficient,  it  usually  weakens.  The  second  tone  is  sometimes 
split,  {d)  A  systolic  murmur  over  the  pulmonary  area  is  propagated  from 
the  apex  or  is  due  to  vibrations  in  the  distended  pulmonary  artery. 

Diagnosis. — ^The  cardinal  features  are  (a)  the  systolic  murmur,  (6) 
accentuated  second  pulmonic  tone  and  (c)  right-heart  changes. 

Excepting  the  etiological  diagnosis  and  the  clinical  evolution,  there 
are  no  positive  criteria  by  which  we  can  differentiate  a  muscular  {relative) 
from  a  valvular  insufficiency,  though  in  the  former  the.  murmur  is  more 


ENDOCARDITIS  359 

variable,  lessens  with  digitalis  and  is  not  associated  with  a  diastolic 
stenotic  murmur,  since  pure  valvular  insufficiency  is  exceptional,  and 
there  is  usually,  anatomically  at  least,  some  mitral  stenosis.  An  organic 
valvular  defect  is  probable  when  the  apex,  dislocated  to  the  left,  is 
forcible. 

From  the  functional  (accidental,  hemic  or  cardiopulmonary)  mur- 
mur, the  diagnosis  is  usually  easy.  The  murmur  is  inconstant,  usually 
systolic,  often  basal,  often  depends  on  posture,  is  circumscribed,  is  not 
typically  transmitted,  follows  fever,  anemia  and  emphysema,  is  often 
associated  with  the  venous  hum  in  the  neck,  but  is  never  associated  with 
typical  mitral  changes  in  the  heart  tones  and  right  ventricle.  The 
intensity,  timbre  or  fremissement  of  the  murmur  must  not  alone  be 
depended  upon. 

In  chlorosis,  we  may  obtain  a  hemic  murmur,  apparently  large  heart 
(because  the  lungs  are  poorly  expanded),  and  a  displaced  apex  (high 
diaphragm) ;   deep  breathing  decreases  the  heart's  dulness. 

Pericardial  friction  {q.  v.)  may  simulate  endocardial  murmurs. 

Frantzel's  rules  aid  in  accuracy:  (1)  Never  make  a  diagnosis  just 
before  death.  (2)  Remember  the  great  infrequency  of  right-heart  lesions. 
(3)  Avoid  complicated  diagnoses.  (4)  Subordinate  the  murmurs  to 
other  physical  findings. 

Mitral  Stenosis. — Anatomically  pure  stenosis  of  the  mitral  orifice, 
without  associated  mitral  leakage,  is  rare.  In  one  group,  especially 
in  young  girls,  the  stenosis  is  clearly  endocarditic  and  the  valves  are 
irregular,  calcareous  and  deformed.  In  another  group,  in  old  subjects 
of  both  sexes,  the  sclerosing  process  is  probably  endocarditic;  and  in  the 
last  group,  almost  exclusively  observed  in  women,  the  nature  of  the 
lesion  is  uncertain;  some  rare  cases  are  associated  with  congenital 
defects.  The  mitral  valves  are  grown  together  or  the  ring  constricted — 
Corrigan's  "button-hole  contraction";  the  orifice  in  extreme  cases  is 
funnel-shaped. 

Mechanism. — ^The  stenosis  obstructs  the  diastolic  discharge  of  blood 
from  the  left  auricle,  which  consequently  dilates  and  later  hypertrophies. 
The  enlarged  auricle  or  pulmonary  artery  may  compress  the  adjacent 
bronchus  or  recurrent  laryngeal  nerve.  The  stasis  is  propagated  back- 
ward through  the  lungs  to  the  right  ventricle,  whose  dilatation  and 
hypertrophy  cause  the  large  right  heart  and  the  increased  pressure 
in  the  lesser  circulation.  The  effects  on  the  right  heart  and  lungs  are 
more  severe  than  in  mitral  insufficiency.  The  right  auricle  also  dilates 
when  the  later  venous  stasis  follows.  Thrombi  in  either  auricle  may  dis- 
lodge and  produce  pulmonary  or  arterial  infarction.  The  arterial  system 
is  poorly  filled. 

Physical  Signs. — 1.  Inspection. — This  reveals  (a)  i^recordial  dis- 
tention, (b)  epigastric  pulsation  and  (c)  a  diffuse  cardiac  shock;  (d)  the 
ajjex  beat  may  in  comparison  be  small,  and  (e)  two  impulses  may  be  seen 
in  the  second  left  interspace;  one  is  systolic,  from  systolic  filling  of  the 
pulmonary  artery,  and  the  other  is  diastolic,  from  pulmonary  valve  closure 
under  high  tension.  All  these  findings  depend  on  the  riglit-heart  hyper- 
trophy and  dilatation. 


360  '  DISEASES  OF   THE  ENDOCARDIUM 

2.  Palpation. — Palpation  confirms  the  above,  especially  (a)  the  apex 
beat,  which  is  often  weak  in  comparison  with  the  diffuse  heart  impulse, 
(6)  the  snap  of  the  second  pulmonic  sound,  (c)  the  pulsating  right  heart, 
and  also  (d)  a  presystolic  (more  rarely  diastolic)  thrill,  jremissement 
cataire,  which  is  usually  limited  to  the  apex,  ends  with  the  snappy  first 
apex  tone,  and  is  felt  sometimes  only  in  the  left  lateral  posture  or  after 
exertion.  Its  mechanism  is  identical  with  that  of  the  murmur  (g.  v.). 
(e)  The  pulse  is  often  irregular  in  pure  stenosis,  because  dilatation  inter- 
feres with  cardiac  conductivity  and  is  usually  small  and  of  low  tension, 
because  the  aorta  is  poorly  filled;  its  weakness  contrasts  conspicuously 
with  the  active  heart  impulse.  It  may  seem  hard.  The  pulse  ajid  sphyg- 
mogram  are  not  pathognomonic. 

3.  Percussion. — (a)  The  right  ventricle  in  the  earlier  stages  may  be 
only  hypertrophied,  which  does  not  show  on  percussion.  Dilatation 
without  hypertrophy  exists  in  few  cases  fortunately,  for  the  prognosis 
is  then  poor.  Most  commonly  hypertrophy  and  dilatation  coexist,  the 
latter  giving  increased  dulness  to  the  right,  as  in  mitral  insufficiency. 
(h)  The  left  ventricle  in  many  cases  of  dominant  stenosis  shows  concentric 
atrophy,  so  that  at  autopsy  it  looks  like  a  mere  appendage  to  the  huge 
right  heart,  as  shown  also  in  the  .I'-ray  examination.  It  is  sometimes 
both  hypertrophied  and  dilated,  because  of  stasis  with  increase  in  the 
blood  of  carbon  dioxide,  which  raises  the  blood-pressure;  or  because  of 
other  lesions,  as  mitral  leakage,  (c)  The  auricles  are  distended,  much  of 
the  dulness  under  or  to  the  right  of  the  sternum  being  due  to  the  dilated 
right  auricle  and  that  above  and  to  the  left,  to  the  left  ventricle  and 
widened  right  conus  arteriosus.  Increased  dulness,  due  apparently  to 
dilatation  of  the  various  chambers  is  often  caused  by  their  disloca- 
tion by  the  wide  right  ventricle.  The  left  auricle  is  best  determined  by 
radiography. 

4.  Auscultation. — (a)  An  apical  presystolic  murmur  occurs  at  the 
end  of  the  diastole  with  the  systole  of  the  hypertrophied  auricle  which 
forces  the  blood  through  the  narrowed  ring;  corresponding  with  its 
energy,  it  is  loudest  at  the  incipiency  and  ending  of  the  auricular  systole 
(crescendo  murmur).  It  so  closely  precedes  the  ventricular  systole 
that  it  is  almost  invariably  called  systolic  by  students.  It  is  usually 
rolling,  sounding  like  r-r-r-,  after  tvhich  comes  the  loud  first  tone, 
sounding  like  p  (r-r-r-p).  It  is  poorly  propagated  as  a  rule,  corre- 
sponding to  the  localized  thrill,  but  may  in  exceptional  cases  be  heard  in 
the  axilla  or  back.  It  is  often  absent  even  with  great  stenosis,  when  the 
auricle  and  ventricle  contract  together  and  when  the  heart  weakens. 
It  is  rarely  diastolic  (diminuendo  murmur).  (6)  Marked  accentuation 
of  the  second  pulmonic  sound  is  the  proof  and  measure  of  hypertrophy 
of  the  right  ventricle  from  pulmonary  congestion.  Its  absence  is  a  poor 
prognostic;  it  usually  weakens  when  relative  tricuspid  leakage  lessens 
the  tension  in  the  lungs,  (c)  Splitting  or  reduplication  of  the  second 
pulmonic  sound  is  due  to  difference  in  tension  in  the  two  arterial  trunks, 
the  aortic  valves  closing  first  and  more  weakly ;  it  is  best  heard  at  the  base 
and  is  often  propagated  into  the  neck  or  axilla,  (d)  The  loud  first  mitral 
tone  is  explained  in  various  ways;  viz.,  by  difference  in  tension  of  the 


ENDOCARDITIS 


361 


valves  during  the  systole  and  diastole  or  by  a  vigorous  contraction  of 
the  left  ventricle  upon  little  blood.  It  is  sometimes  heard  at  a  distance 
of  several  feet,  (e)  The  second  mitral  tone  r  weak  because  of  poor  filling 
of  the  aorta  or  because  the  right  heart  pushes  forward;  it  may  be  split 
at  the  apex  (the  "postman's  knock") ;  the  cause  is  disputed. 

Diagnosis. — ^The  cardial  signs  are  («)  the  presystolic  thrill  and  bruit; 
(6)  the  involvement  of  the  right  heart;  (c)  the  accentuated  second 
pulmonic  sound;  and  (d)  loud  first  apical  tone. 

The  thrill  and  bruit  are  also  found  in  aortic  insufficiency,  in  which 
the  vascular  phenomena  and  the  involvement  of  the  left  heart  are  suffi- 
ciently distinctive,  though  one  out  of  ever}^  three  cases  of  aortic  leakage 
is  complicated  by  mitral  stenosis.  The  bruit  is  also  heard  in  lesions 
leading  to  dilatation  of  the  left  ventricle,  such  as  adherent  pericardium, 
and  in  auricular  contractions. 

Piu-e  mitral  stenosis  is  often  overlooked  in  asthenic  women,  because 
the  lesion  is  so  benign;  characteristic  are  the  positive  findings — loud 
apical  tone,  murmur  and  a  third  tone — and  the  negative  findings — 
absence  of  hypertrophy,  dilatation  and  systolic  bruit. 

An  absence  of  the  murmur  indicates  a  slight  lesion;  a  presystolic 
murmur  argues  for  a  strong  left  auricle;  a  diastolic  murmur  indicates  a 
severe  stenosis;  when  tricuspid  leakage  intervenes,  the  murmur  of 
mitral  stenosis  is  either  absent  or  diastolic,  -because  both  auricles  are 
atonic.  Absent  murmur  with  irregularity  is  indicative  of  the  most 
serious  lesion.  When  the  left  auricle  is  strong,  it  may  suppress  the 
systolic  murmur  of  a  coincident  mitral  leakage;  when  the  auricle  weakens, 
the  systolic  murmur  appears.  Auricular  fibrillation  (page  339)  indicates 
severe  disturbance  in  cardiac  function. 


DIFFERENTIAL   TABLE   OF   THE   COMMON   CHRONIC   VALVULAR   LESIONS. 


Aortic 

Mitral 

insuiEciency. 

Aortic  stenosis. 

insufficiency.               Mitral  stenosis. 

- 

Etiology. 

Arteriosclerosis 

Often      arterio- 

Endocarditis 

Endocarditis. 

chiefly. 

sclerosis. 

chiefly. 

Pni^E. 

Pulsus    celer. 

Pulse    small,    slow , 

No       characteristic 

Small  and  often  irreg- 

Water-hammer, 

tense. 

alteration — often 

ular. 

collapsing. 

normal. 

Left  Ventricle. 

Hypertrophied    and 

Hypertrophy 

Some     hypertrophy 

No  essential  or  regu- 

dilated       greatly; 

usually,  concentric. 

and  dilatation. 

lar  change;  may  be 

heaving  apex. 

small. 

Right 

No  change. 

No  change. 

Hypertrophy    and     iBoth  marked,  also  in 

Ventricle. 

dilatation  marked,  j  auricles. 

MCRMUR. 

Diastolic;     blowing 

Harsh  systolic  mur- 

SystoUc    at     apex,  ;  Presystolic      (oftener 

over  sternum  near 

mur     over     aortic 

blowing,         trans-  !  than            diastolic). 

second    rib;     pro- 

area with  systolic 

mitted     into     left  j   apical,   accompanied 

pagated        toward 

thrill;    propagated 

axilla  and   behind  >  by   presystolic  thrill, 

apex. 

into  neck. 

scapula.                         fairly  localized. 

First  Mitr.\l 

Usually  weak. 

Strong  usually. 

Usually present.per-   Loud       and       sharp. 

Tone. 

haps    covered    by 
murmur. 

clearly  palpable  and 
folloT\ing      murmur. 

Second  Aortic 

Weak  or  absent. 

Weak  only. 

Somewhat  weak. 

Somewhat  weak. 

Tone. 

Second      Pulmo- 

Not accentuated. 

Not  accentuated. 

Loudly  accentuated  Accentuated          and 

nary  Tone. 

and  often  palpable. 

often  split. 

Peripheral 

Violent      pulsation; 

Absent. 

Absent. 

Absent. 

Vessels. 

capillary         pulse; 
arterial  tones;  skin 
red. 

Skin  cyanotic. 

Skin  cyanotic. 

In  conjunction  with  this  table,  Plate  X  should  be  consulted. 


362  DISEASES  OF  THE  ENDOCARDIUM 

Pulmonary  Insufficiency. — The  rare  pulmonary  insufficiency  of  which 
Barie  has  collected  58  cases,  is  often  combined  with  pulmonary  stenosis 
or  other  rare  right-heart  anomalies.  It  is  (a)  congenital,  resulting  from 
fetal  endocarditis  or  from  supernumerary  or  rudimentary  valves;  (6) 
acquired,  from  atheroma,  rheumatism  or  septic  ulceration;  or  very 
rarely  (c)  relative  from  extreme  intrapulmonary  blood-pressure  or  from 
embolism  of  the  pulmonary  trunk. 

Mechanism. — The  mechanism  is  analogous  to  that  of  aortic  insuffi- 
ciency except  that  the  right  heart  suffers  instead  of  the  left  and  the 
arterial  phenomena  are  manifest  in  the  area  of  the  pulmonary  artery. 

Physical  Signs. — 1.  Inspectioii. — The  dilated  and  hypertrophied  right 
heart  pulsates  to  the  right  of  the  sternum.  A  systolic,  dynamic  pulsation 
may  be  seen  over  the  dilated  pulmonary  trunk. 

2.  Palpation. — This  determines  the  diffuse  right-heart  impulse  and  a 
diastolic  thrill  over  the  pulmonic  area;  the  apex  and  radial  pulse  are 
normal  or  weak. 

3.  Percussion. — The  right  ventricle  is  dilated  because  of  the  regur- 
gitant column  of  blood  and  hypertrophied  to  maintain  the  onward  flow 
under  this  burden  (Plate  X,  Fig.  E). 

4.  Auscidtation. — A  diastolic  murmur  is  propagated  down  the  sternum 
over  the  right  ventricle,  and  may  be  confused  with  aortic  leakage,  aneurysm, 
functional  venous  murmurs,  congenital  anomalies  of  the  vessels  or  patent 
foramen  ovale.  The  second  pulmonic  and  the  second  tricuspid  tones 
are  weak  or  replaced  by  the  murmur.  The  bruit  is  but  rarely  heard  in 
the  neck  and  the  normal  second  arterial  tone  is  heard  over  the  carotids. 
A  systolic  murmur  is  heard  in  25  per  cent,  of  cases  over  the  pulmonary' 
trunk,  due  to  vibrations  in  its  walls  or  to  coincident  stenosis  of  the 
pulmonary  ring.  A  double  tone  has  been  heard  over  the  lung,  as  well 
as  variation  in  the  respiration  during  the  systole — a  capillary  pulse 
in  the  pulmonary  vessels. 

Pulmonary  Stenosis. — The  etiology  will  be  considered  under  diagnosis 
and  under  congenital  heart  lesions. 

Mechanism  AND  Physical  Signs. — 1.  Inspection. — There  is  precordial 
bulging,  a  diffuse  heart  shock  from  hypertrophy  and  dilatation  of  the 
right  heart,  and  a  weak  or  absent  apex  beat. 

2.  Palpation. — Palpation  confirms  the  above  and  reveals  a  systolic 
thrill  in  the  left  second  interspace.    The  pulse  is  weak. 

3.  Percussion. — Percussion  shows  an  area  of  increased  didness  over 
the  right  heart  from  dilatation. 

4.  Auscultation. — On  auscultation,  a  loud  and  whistling  or  musical 
systolic  murmur,  caused  by  the  stenosis,  is  often  heard,  and  the  first 
and  second  pulmonic  tones,  hence  also  the  second  tricuspid,  are  weak 
or  absent  from  poor  filling  of  the  pulmonary  artery  and  from  valve 
alteration.    (See  Plate  X,  Fig.  E.) 

Diagnosis. — The  more  frequent  form  is  {a)  the  congenital,  due  to 
malformation,  myocarditis  or  endocarditis,  and  usually  assiociated  with 
open  ductus  Botalli  or  foramen  ovale.  The  obstruction  may  be  below 
the  valves,  from  myocarditic  scars  narrowing  the  conus  arteriosus,  in 
which  case  the  second  pulmonic  sound  is  accentuated;  or  it  may  be  at 


ENDOCARDITIS  363 

the  valves  or  in  the  trunk  of  the  artery.  Congenital  cyanosis  and 
acquired  pulmonary  tuberculosis  are  common.  (6)  The  acquired  valvular 
form  is  rare.  Atheroma  or  gummata  may  be  causal.  The  thrill  is 
far  less  frequently  felt  in  acccidental  murmurs,  which  are  most  com- 
mon over  this  area  because  the  thin  Avails  of  the  artery  vibrate  easily. 
These  "functional"  murmius  are  so  common  as  to  justify  extreme  caution 
in  the  diagnosis  of  right-heart  lesions  in  the  adult.  Functional  murmurs 
may  occur  in  health,  fevers,  anemia  or  as  the  cardiopulmonary  murmur. 
The  organic  murmur  rarely  reaches  the  jugular  or  cervical  vessels.  The 
left  heart  is  frequently  atrophic.  When  the  acquired  stenosis  is  beyond 
the  valve  in  the  pulmonary  trunk  or  lungs,  the  murmur  is  best  heard 
along  the  right  border  of  the  sternum  or  in  the  back,  and  the  second 
pulmonic  sound  is  loudly  accentuated,  from  which  points  a  diagnosis 
occasionally  may  be  made.  In  atresia  of  the  orifice  80  per  cent,  of  the 
subjects  die  in  the  first  year. 

Tricuspid  Insufficiency. — Etiology. — (a)  The  congenital  form  occurs  in 
0.8  per  cent,  of  valvular  cases.  The  venosity  of  the  blood  in  the  right 
heart  tends  to  prevent  endocarditis,  except  in  fetal  life  when  the  blood 
is  arterial.  Myocarditis  or  ulcerative  endocarditis  may  exceptionally 
occur.  (6)  Of  acquired  forms,  the  relative  insufficiency  is  very  common, 
resulting  from  (i)  valvular  lesions  of  the  left  heart,  especially  mitral 
stenosis;  (ii)  obstructive  lung  lesions,  as  induration  or  emphysema; 
(iii)  and  in  severe  anemias,  in  which,  however,  cyanosis  and  dyspnea 
are  absent. 

Mechanism. — The  high  pressure  in  the  lesser  circulation  leads  to  dilata- 
tion and  h}T)ertrophy  of  the  right  ventricle.  Extreme  dilatation  stretches 
the  tricuspid  orifice  so  that  the  valves  cannot  cover  it,  and  relative 
leakage  occurs.  The  leak  into  the  right  auricle  produces  its  dilatation 
and  hypertrophy,  a  systolic  murmur  and  a  systolic  pulse  in  the  veins 
of  the  neck  and  liver. 

Physical  Signs. — 1.  Inspection. — (a)  A  systolic  yulse  in  the  jugular 
veins  is  due  to  systolic  entrance  of  blood  into  the  veins  from  the  right 
ventricle  through  the  insufficient  valves;  it  is  also  a  sign  that  the  auricle 
and  ventricle  contract  together  or  that  the  auricle  is  paralyzed.  It  is 
presystolic-systolic  and  is  known  as  positive  to  differentiate  it  from  the 
negative  or  diastolic  venous  pulse  which  is  observed  in  many  other  con- 
ditions, and  either  physiologically,  as  on  deep  inspiration  (damming 
back  of  the  blood  by  the  auricular  systole)  or  pathologically,  as  in  stasis. 
It  i5  seen  best  on  the  right  side  because  of  the  more  direct  vertical  connec- 
tion with  the  right  innominate  vein.  It  may  cease  when  the  heart  grows 
weak.  Digitalis  may  cause  it  to  reappear  in  cases  of  relative  and  some- 
times of  organic  leakage.  It  is  best  seen  in  the  dorsal  decubitus.  If 
the  carotid  be  compressed  as  low  down  as  possible,  or  the  pulsating 
jugular  vein  be  compressed  at  the  middle;  the  upper  part  will  then 
pulsate  if  the  carotids  beat  against  it  (transmitted  pulsation)  and  the 
lower  part  will  beat  if  the  pulsation  is  in  the  vein  itself.  It  is  sometimes 
seen  in  the  inferior  vena  cava  or  peripheral  veins.  (6)  A  liver  pulse,  systolic 
in  time,  is  venous  regurgitant  in  origin,  (c)  The  right  heart  pulsates 
iridrly,  while  the  apex  beat  is  weak. 


364 


DISEASES  OF   THE  ENDOCARDIUM 


2.  Palpation. — (a)  This  establishes  the  systolic  phase  of  the  venous 
pulse,  and  (6)  the  systolic  venous  pulsation  of  the  liver,  which  expands  in 
the  bimanual  examination  and  is  easier  to  find  than  the  jugular  pulsa- 
tion.   It  must  not  be  confused  with  an  arterial  liver  pulse,  which  occurs 


Fig.  23. — Negative  (diastolic-presj'stolic)  venous  pulse.     (After  Riegel  and  Sahli.) 

in  aortic  leakage  and  exophthalmic  goitre,  but  is  less  expansile  than 
throbbing,  (c)  A  systolic  thrill  over  the  tricuspid  area;  {d)  tones  or 
thrills  over  the  peripheral  veins;  and  (e)  a  weak  apex  and  radial  pulse 
are  also  found. 


Fig.  24. — Positive  (presystolic-systolic)  venous  pulse.     (After  Riegel.) 

3.  Percussion. — ^This  shows  increased  dulness  to  the  right,  from  dis- 
tention of  the  right  auricle  and  ventricle.  Changes  in  the  left  heart 
mav  indicate  an  older  valvular  lesion  which  causes  the  tricuspid  leakage. 
(See  Plate  X,  Fig.  D.) 


Fig.   25. — Illustrating  the   influence  of  respiration  on  the  positive   (presystolic-systolic) 
venous  pulse  of  the  jugular  vein.     (After  Kovacs.) 

4.  Auscultation. — (a)  A  faint  systolic  murmur  is  heard  over  the  tri- 
cuspid region;  the  causal  mitral  murmur  is  higher  pitched,  more  super- 
ficial and  louder  and  is  heard  in  the  back.  The  murmm-  is  absent  when 
the  right  heart  is  so  weak  that  it  fails  to  produce  the  necessary  vibration 
or  eddy,     (fe)  The  second  lyiilmonic  sound  is  weak  because  the  pulmonary 


ENDOCARDITIS  365 

circuit  is  poorly  filled,  but  varies  with  the  changing  activity  of  the  right 
ventricle,  (c)  Over  the  cervical  veins  may  be  heard  a  systolic  tone  refer- 
able to  closure  of  valves  in  the  veins;  the  tone  may  be  double,  or  pre- 
systolic-systolic ;  or  venous  murmurs  may  replace  the  tones. 

Diagnosis. — The  relative  insufficiency  is  diagnosticated  by  (a)  the 
etiology,  (6)  the  large  right  heart,  (c)  the  faint  systolic  murmur,  {d) 
the  positive  venous  pulse  in  the  neck,  disappearing  under  digitalis  and 
rest  and  {e)  the  weak  second  pulmonic  tone.  Rest  or  digitalis  very 
often  brings  out  the  causal  mitral  lesion.  The  "safety  valve"  action 
of  the  tricuspid  valves  is  compensatory;  guarding  the  door  between 
the  venous  and  arterial  circuits,  their  insufficiency  indicates  serious 
cardiac  failure. 

Tricuspid  Stenosis. — Rarer  than  tricuspid  insufficiency,  it  occurs  alone 
in  only  10  per  cent,  of  the  cases;  it  is  more  often  associated  with  insuffi- 
ciency, or  with  aortic  or  mitral  stenosis;  the  latter  is  coincident  in  half 
the  cases'.  In  half  the  cases  thete  is  a  history  of  rheumatism  or  chorea; 
three-quarters  occur  in  women.  Obstruction  of  this  orifice  induces 
hypertrophy  and  dilatation  of  the  right  auricle,  with  dulness  to  the 
right  of  the  sternum.  In  the  single  lesion  the  other  heart  chambers  and 
the  large  vessels  are  small.  The  pulse  and  second  pulmonic  sound  are 
weak;  a  diastolic  or  presystolic  murmur  and  thrill  to  the  right  of  the 
sternum  are  detected  if  the  heart  is  sufficiently  strong,  but  they  are  often 
absent.  The  lesion  is  most  serious,  because  it  taxes  the  weak  auricle 
and  greatly  engorges  the  venous  system.  In  the  jugular  vein  there  is 
a  presystolic  wave.  The  diagnosis  was  made  in  but  10  of  the  187  cases 
on  record.    (See  Plate  X,  Fig.  D.) 

Combined  Valvular  Lesions. — These  occur,  clinically,  in  33  per  cent, 
of  valvular  cases,  but  anatomically,  a  pure  lesion  is  rare,  and  double 
lesions  are  found  oftener  than  physical  signs  would  indicate.  Single 
lesions  occur  most  often  on  the  arterial  valves.  One  lesion  may  follow 
another;  for  instance,  stenosis  may  gradually  result  from  insufficiency, 
sometimes  with  good  results;  or  combined  lesions  may  develop  simul- 
taneously. 

(a)  Combined  mitral  lesions  are  most  frequent,  though  one  lesion 
usually  predominates;  (6)  combined  mitral  and  aortic  lesions,  e.  g., 
aortic  vegetations  reaching  the  nearest  mitral  cusp,  are  next  in  frequency ; 
(c)  double  aortic  lesions  are  less  common;  {d)  combined  aortic,  mitral 
and  tricuspid  lesions,  e.  g.,  stenosis  of  each  orifice  with  no  signs  other 
than  slowing  of  the  circulation,  occur  in  16  per  cent.,  and  {e)  combined 
mitral  and  tricuspid  lesions  (especially  relative  tricuspid  insufficiency) 
occur  in  9  per  cent. 

Diagnosis. — The  diagnosis  depends  upon  the  character  of  the  pulse, 
the  quality  and  direction  of  transmission  of  the  different  murmurs,  and 
the  hypertrophy  and  dilatation  of  the  right  or  left  heart.  Skoda's  rule 
was  that  a  murmur  is  usually  most  intense  at  its  point  of  origin,  except 
in  cases  of  aortic  insufficiency;  and  Oppolzer  held  that  when  listening 
to  the  mitral  and  pulmonarj^  valves,  murmurs  transmitted  to  them  disap- 
pear as  examination  is  made  more  to  the  left,  while  murmurs  due  to 
lesions  on  these  valves  remain;  on  listening  further  to  the  right,  the 


360  DISEASES  OF   THE  ENDOCARDIUM 

true  tricuspid  and  aortic  murmurs  remain  and  those  which  are  transmitted 
disappear.  Avoidance  of  too  complicated  diagnoses  leads  to  the  most 
practical  results. 

(a)  Aortic  insufficiency  and  mitral  insufficiency  lead  to  dilatation  and 
h^-pertrophy  of  both  ventricles;  the  combination  is  frequent  in  children; 
the  aortic  findings  as  to  pulse  are  frequently  modified;  the  mitral  insuffi- 
ciency may  be  relative  (muscular)  or  organic  (vahiilar),  which  is  deter- 
mined only  by  continued  observation.  (6)  Aortic  stenosis  and  mitral 
insufficiency  are  next  in  frequency  and  are  the  most  common  combination 
in  adults;  less  blood  reaches  the  arteries  than  in  simple  aortic  stenosis; 
the  right  heart  suffers  disproportionately,  whence  the  severity  of  this 
complication.  The  systolic  murmurs  differ  in  location,  transmission 
and  quality.  (c)  Aortic  insufficiency  with  mitral  stenosis  is  a  relatively 
frequent  and  favorable  combination,  because  the  left  ventricle  is  usually 
less  dilated;  both  may  produce  presystolic  apical  murmurs  and  there- 
fore the  state  of  the  right  heart  and  the  second  pulmonic  tone  are  all- 
important  diagnostically.  (d)  In  combined  aortic  and  mitral  stenosis 
the  greater  the  aortic  stenosis  the  more  is  the  h^'pertrophy  of  the  left 
ventricle;  the  more  dominant  the  mitral  stenosis  the  less  is  its  hyper- 
trophy and  the  greater  is  the  dilatation  and  hypertrophy  of  the  right 
ventricle. 

General  Symptoms  of  Valvular  Disease  and  Decompensation. — ^The 
heart  possesses  not  only  a  certain  reserve  yower  but  in  favorable  instances 
its  musculature  hypertrophies.  Every  hypertrophy  is  more  or  less  tem- 
porary in  its  compensation  and  ultimate  cardiac  failure  is  inevitable, 
either  temporarily,  "disturbed  compensation,"  or  permanently,  "loss 
or  rupture  of  compensation,''  the  asystole  of  French  \\Titers.  Failing 
cardiac  competency  is  attended  by  (i)  changes  in  the  heart  itself  and 
altered  movement  of  the  blood;  (ii)  symptoms  in  organs  remote  from 
the  heart,  as  the  congested  liver,  etc. ;  and  (iii)  reflex  symptoms,  as  hyper- 
algesia over  the  heart  or  liver.  All  lesions  tend  to  reduce  arterial  tension, 
increase  venous  pressure,  retard  the  capillary  flow  and  promote  embolism. 
The  blood  stagnating  in  the  veins  may  cause  capillary  resistance  and 
therefore  raise  arterial  pressure,  even  though  the  circulation  is  embar- 
rassed; in  stasis,  also,  the  cyanosis  may  raise  arterial  tension,  from  poor 
aeration  of  the  blood.  Mackenzie  maintains  that  heart  failure  may 
develop  without  fall  in  arterial  pressure,  but  here  there  is  no  loss  of 
tonicity;  when  the  heart  becomes  atonic  (dilated),  the  blood-pressure 
falls  to  rise  again  when  tonicity  is  restored.  Dilatation  of  the  compen- 
satory type  appears  first  and  incites  hypertrophy;  as  liA-pertrophy  reaches 
its  limit,  the  dilatation  of  the  second  type  appears — the  dilatation  causing 
stasis.  Circulatory  disturbances  may  be  spontaneous  or  induced  by 
psychical  excitement,  physical  exertion,  intercurrent  disease,  recurrent 
endocarditis,  malnutrition  or  excessive  use  of  alcohol  or  tobacco. 

1.  Constitutional  Symptoms. — Anemia  is  frequent  (aortic  insufficiency); 
Andral  spoke  of  a  "heart  cachexia;"  polymorphonuclear  leukocytosis 
is  present  in  half  the  mitral  cases;  the  body  temperature  may  be  sub- 
normal from  slow  circulation.  Fever  is  due  to  recurrent  endocarditis, 
embolism  or  intercurrent  disease.     In  tricuspid  stenosis  the  red  cells 


ENDOCARDITIS 


367 


may  be  increased  (polycythemia).  The  nails  are  sometimes  clubbed. 
Skin  hemorrhages  are  due  to  "blood  dissolution"  or  less  frequently  to 
embolism. 

2.  Cardiac  Signs  and  Symptoms.— Apart  from  actual  changes  in  the 
chambers,  such  as  dilatation  and  hypertrophy,  the  heart  itself  is  not 
well  nourished  in  "breaking  compensation,"  for  it  receives  less  arterial 
blood  and  is  engorged  with  venous  blood.  The  importance  of  the  integ- 
rity of  the  heart  muscle  and  its  functions  is  suggested  in  the  introductory 
paragraph  (page  319).  Dilatation  indicates  failure  of  tonicity;  irregu- 
larity is  disturbance  of  rhythmicity;  and  disturbance  in  contractility 
has  its  obvious  results.  Cardiac  insufficiency  develops  when  the  reserve 
force  and  functions  of  the  heart  are  prematurely  exhausted.  The  heart 
muscle  is  in  some  cases  fatty,  and  in  others  is  the  seat  of  myocarditis 
about  the  arteries  or  cyanotic  induration  about  the  veins.  These  changes 
are  less  the  cause  than  the  effect  of  broken  compensation.  Here  and 
there  pressure-atrophy  occurs,  as  in  the  papillary  muscles  (aortic  regur- 
gitation). The  rhythm  is  frequently  disturbed,  especially  in  mitral 
lesions  (stenosis).  The  sphygmogram  sometimes  shows  two  ventricular 
contractions  occurring  very  close  together,  pulsus  bigeminus,  of  which 
every  second  weaker  beat  is  due  to  an  extra-systole  {v.  page  339) ;  when 


Fig.  26. — Pulsus  bigeminus. 


the  pulse  intermits  to  the  finger,  the  tones  of  the  abortive  contraction 
may  be  heard  over  the  heart  with  the  stethoscope,  the  weaker  wave 
failing  to  reach  the  periphery.  The  appearance  of  the  pulsus  alternans 
signifies  serious  disorder  of  contractility  {v.  page  340).  In  general, 
the  pulse  beats  are  fewer  than  the  heart  beats.  The  gallop-rhythm  is 
sometimes  heard  (Bouillaud,  1847),  as  described  on  page  321.  In  great 
irregularity,  as  in  auricular  fibrillation  of  mitral  stenosis  (page  339), 
tones  and  murmurs  are  indistinguishable  {delirium  cordis).  The  pulse 
is  slow  (the  bradycardia  of  aortic  stenosis)  or  faster  than  normal,  tachy- 
cardia (mitral  lesions);  advanced  decompensation  may  be  marked  by 
heart-block  (page  342). 

Among  the  complications  are  pericarditis  (aortic  lesions)  and  recurrent 
endocarditis.  Palpitation  is  frequent,  yet  it  may  be  absent  with  the 
greatest  heart  alteration.  A  sense  of  tension  over  the  heart  is  not  infre- 
quent, and  pain  like  angina  pectoris  occurs  in  aortic  oftener  than  in 
mitral  disease. 

3.  Nervous  Symptoms. — These  are  not  frequent.  Syncope  (aortic 
stenosis  especially)  occurs  with  arterial  anemia  of  the  brain,  cerebral 
arteriosclerosis,  and  sometimes  with  extra-systoles.  Epileptiform  seizures 
are  also  due  to  brain  anemia  and  occur  in  Adams-Stokes's  disease,  nodal 
bradycardia  and  vagus  stand-still  of  the  heart.     Venous  congestion  is 


368  DISEASES  OF   THE  ENDOCARDIUM 

evidenced  by  epistaxis,  vertigo,  tinnitus  or  vniscce  volitantes.  Brain 
hemorrhage  is  infrequent  (mostly  in  aortic  insufficiency).  Chorea  and 
embolism  of  the  Sylvian  arteries  are  sometimes  observed.  The  psychoses 
are  delirium,  mania,  melancholia  and  suicidal  tendencies,  and  are  usually 
of  unfavorable  import;  stasis,  inanition,  carbon  dioxide  narcosis  and 
renal  inadequacy  are  their  cause.  Retinitis  hemorrhagica  and  simple 
retinal  hemorrhages  result  from  stasis  and  anemia. 

4.  Respiratory  Symptoms. — Lung  stasis  is  sometimes  confused  with 
independent  lung  disease.  Cyanosis  occurs  more  often  in  mitral  than  in 
aortic  disease  and  is  most  intense  in  lesions  of  the  pulmonary  orifice. 
Recurrent  laryngeal  paralysis,  described  by  Ortner,  is  commonly  explained 
by  pressure  of  the  dilated  left  auricle  or  pulmonary  artery.  Bronchitis 
and  hemoptysis  are  most  common  in  mitral  affections.  Bronchitis  results 
less  from  congestion  in  the  lesser  circuit  than  from  congestion  in  the 
cava  superior,  into  which  (and  the  azygos)  the  bronchial  veins  empty. 
Though  usually  bilateral,  it  may  predominate  on  one  side  from  local 
causes,  as  pleural  adhesions.  Hemoptysis  results  from  lung  stasis  with 
vessel  rupture,  from  embolism  emanating  from  right-heart  clots,  throm- 
bosis in  the  pulmonary  and  less  frequently  in  the  peripheral  veins,  or 
from  sclerosis  of  the  pulmonary  artery.  ]\Iitral  stenosis  may  simulate 
phthisis,  by  hemoptysis  and  dulness  over  and  below  the  clavicle,  with 
rales,  due  to  pressure  on  the  left  bronchus  by  the  distended  left  auricle 
or  pulmonary  artery.  The  sputum  may  resemble  that  of  pneumonia, 
though  it  is  darker,  more  venous  and  less  viscid.  It  contains  the  "heart- 
disease  cells."  They  are  large  granular  delicate  cells  with  oval  nuclei, 
which  often  contain  hemosiderin  or  more  rarely  hematoidin;  they  are 
probably  alveolar  epithelial  cells  and  also  occur  in  other  lesions-  than 
brown  induration  (as  emphysema,  asthma,  pneumonia  and  phthisis). 
(See  Plate  XL)  Pulmonary  edema  {q.  v.)  is  (a)  due  to  weakening  of 
the  left  ventricle  while  the  right  heart  beats  more  strongly,  (b)  changes 
in  the  bloodvessels  from  stasis  or  (c)  far  less  frequently  is  inflammatory. 
Crepitant  rales  are  frequently  heard.  Li  mitral  disease  the  lungs  fre- 
quently become  distended  and  rigid  from  engorgement  of  the  capillaries, 
and  closely  resemble  emphysema  if  not  identical  with  it  (von  Basch's 
Lungenschwellung  und  Lungenstarrheit) .  Brown  induration  or  cyanotic 
induration  of  the  lungs  has  for  its  anatomical  basis,  (a)  capillary  engorge- 
ment, often  with  fatty  change  in  the  intima,  (b)  increased  interalveolar 
and  perivascular  connective  tissue,  (c)  hemorrhage  into  the  lung  from 
vessel  rupture,  {d)  consequent  pigmentation  of  the  lungs  and  sputum 
by  the  altered  blood  pigment,  and  (e)  the  "heart-disease  cells."  Dysp- 
nea, the  "cry  of  distress  of  the  myocardium"  (Sansom),  is  caused  by 
the  increased  intrapulmonary  blood-pressure,  the  bulging  of  the  turgid 
capillaries  into  the  alveoli,  pressure  of  the  heart,  ascites,  hydrothorax, 
edema,  bronchitis  or  infarcts.  The  intimate  mechanism  of  dyspnea  is 
obscure:  the  disturbed  circulation,  poor  exchange  of  the  inspired  air 
and  lung  air ;  decreased  elasticity  of  the  lung ;  a  reflex  from  the  coronaries 
or  aorta  which  causes  spasm  of  the  pulmonary  vessels;  or  sclerosis 
of  the  right  coronary  artery.  It  may  come  on  without  exertion  when 
there  is  constipation  or  poor  digestion;  or  it  may  occur  especially  at 


PLATE   XI 


'^      &W         '^ 


Heart  Disease  Cells,  sho^A^ing  Alveolar  Epithelial  Cells,  Loaded 
Down  with  Granules  of  Hematin.     (Simon.) 


ENDOCARDITIS  369 

night  when  the  voluntary  deep  and  diaphragmatic  respiration  of  the 
waking  hours  is  not  in  play,  whence  the  respiratory  centre  becomes 
anemic.  Dyspnea  may  be  an  air  hunger  or  sense  of  suffocation;  an 
inability  to  hold  the  breath;  continued  labored  breathing;  or  appear  as 
gasps,  in  sudden  break  of  compensation.  The  dyspnea  is  not  expiratory 
as  in  asthma  but  is  mixed  in  type;  the  breathing  is  more  rapid.  The 
gallop-rhythm  is  rarely  absent,  and  threatens  relapse  of  the  dyspnea; 
arteriosclerosis  and  nephritis  are  important  elements  in  its  production. 
Exertion  not  only  increases  the  heart's  work  but  the  carbon  dioxide  and 
fatigue  substances  from  the  muscles  irritate  the  respiratory  centre,  and 
the  respiratory  muscles  ultimately  become  tired.  C hey ne- Stokes's  breath- 
ing (aortic  stenosis)  results  from  cerebral  anemia,  arteriosclerosis  and 
uremia.  Hydrothorax  results  from  pressure  on  the  azygos  veins  or  pul- 
monary veins  by  the  distended  auricles. 

5.  Gastro-intestinal  Changes. ^Gastralgia,  anorexia,,  hemorrhagic  infil- 
tration, vomiting  or  hematemesis,  results  from  passive  congestion  and 
may  be  mistaken  for  independent  gastric  disease,  such  as  cancer  or 
ulcer.  Delayed  digestion  and  constipation  are  usual.  The  secretion 
of  hydrochloric  acid  is  normal  except  in  marked  weakness  of  the  heart. 
Intestinal  hemorrhage  may  result  from  capillary  congestion,  rarely 
from  embolism  of  the  mesenteric  artery,  and  most  infrequently  from 
mesenteric  venous  thrombosis  {q.  v.). 

6.  Changes  in  the  Liver. — The  liver  suffers  stasis  through  the  congested 
cava  and  hepatic  vein;  this  leads  to  cyanotic  distention  of  the  central 
veins  of  the  liver  lobules  (appearing  dark)  and  to  cloudy  and  fatty  degen- 
eration of  their  periphery  (appearing  lighter),  the  "nutmeg  liver," 
particularly  in  mitral  disease.  Pigmentation  occurs  and  connective  tissue 
develops  in  the  liver  and  its  capsule  (perihepatitis,  "iced  liver").  Small 
granulations  develop  on  its  surface  and  in  some  instances  a  liver  shrinkage 
results  from  "cyanotic  induration"  (cardiac  cirrhosis).  The  liver  is 
symmetrically  large  before  edema  appears;  when  disturbed  compensa- 
tion is  being  restored,  it  is  one  of  the  last  symptoms  to  disappear.  Occa- 
sionally, from  local  changes,  a  tumor-like  enlargement  of  the  liver  may 
simulate  cancer.  There  is  a  feeling  of  tension  and  weight  in  the  right 
hypochondrium  and  the  organ  is  tender  and  variable  in  size ;  it  may  become 
smaller  from  rest  and  digitalis.  Its  edge  is  rounded  and  not  hard  except 
in  the  late  stages.  (See  Differential  Table  of  Hepatic  Diseases.) 
The  icterus  viridis  is  a  combination  of  cyanosis  and  mild  icterus  of  the 
"urobilin"  type;  it  is  rarely  sudden  except  in  the  infrequent  embolism, 
which  may  cause  a  clinical  picture  resembling  acute  yellow  atrophy. 
Decompensation  is  probably  augmented  by  deficient  hepatic  and  renal 
functions.  Ascites  is  usually  late  and  secondary  to  the  liver  congestion; 
its  early  appearance  is  indicative  of  independent  liver  disease  or  peritoneal 
affections. 

7.  Changes  in  the  Spleen. — The  spleen  is  at  times  swollen  from  embolism 
or  liver  disease,  but  is  often  hard  and  small. 

8.  Changes  in  the  Kidneys. — The  kidneys  are  enlarged  from  hyper- 
emia and  the  capsule  strips  readily.  The  stellulce  Verheynii  and  glo- 
meruli are    prominent.     Epithelial    degeneration   follows  malnutrition 

24 


370  DISEASES  OF   THE  ENDOCARDIUM 

and  cyanotic  induration  occurs  in  cases  of  long  standing.  Deformity 
from  the  stellate  scars  of  healed  embolism^  and  fresh  infarcts  are  often 
encountered. 

Renal  symptoms  are  greater,  the  higher  the  venous  and  the  lower 
the  arterial  blood-pressure.  The  urine  is  decreased — its  daily  amount 
being  a  gauge  of  the  heart's  force;  it  is  of  higher  specific  gravity  (1.020)  to 
1.030),  very  acid,  and  highly  colored  from  lu-ates  and  increased  uric  acid; 
the  urea  is  decreased  and  also  the  chlorides;  albumin  is  frequent;  and 
red  disks  are  usually  due  to  embolism  or  acute  nephritis.^  The  kidney 
functional  tests  give  fair  results,  compared  with  nephritis.  Krehl  found 
granular  as  well  as  hyaline  casts,  contrary  to  the  usual  experience. 
Chronic  nephritis  may  coexist.  (See  Differential  Table  of  Diffuse 
Rexal  Diseases.)  Rest  and  digitalis  increase  the  amount  of  urine  and 
decrease  or  remove  the  albumin.  In  women  profuse  menstruation 
frequently  results  from  stasis. 

9.  Embolism. — In  about  one-third  of  the  cases  embolism  occurs  as  in 
acute  endocarditis  but  its  effects  are  wholly  mechanical.  Though  most 
common  in  the  kidney  (77  per  cent.)  and  spleen  (54.7  per  cent.),  it  also 
occurs  in  the  left  Syhdan  artery  (22.7  per  cent.),  extremities,  retina, 
liver,  aorta  (wdth  paraplegia)  and  mesenteric  vessels  (in  1  per  cent.). 
In  the  lungs  it  results  from  right-heart  clots  or  thrombosis  in  the  large 
peripheral  or  pulmonary  veins.  The  visceral  features  of  embolism  will 
be  discussed  under  Diseases  of  the  Brain,  Lung,  Kidney,  etc. 

10.  Edema. — This  results  from  venous  stasis  transmitted  to  the 
lymph  vessels  and  interspaces,  and  from  changes  in  the  vessel  walls 
from  alteration  of  the  blood  (capillary  dystrophy).  It  appears  first  in 
the  connective  tissue  of  the  lower  extremities  (right  leg):  it  disappears 
over  night;  and  it  extends  upward  to  the  vulva  or  scrotum,  abdomen, 
chest  and  serous  sacs  (ascites,  hydrothorax,  hydropericardium  and 
hydrocephalus).  The  loss  of  fluid  to  the  system  is  unfavorable;  the 
anasarca  impedes  the  arterial  circulation,  threatens  life  from  involve- 
ment of  the  glottis  or  lungs,  increases  the  tendency  to  secondary  infec- 
tions and  may  lead  to  hypertrophy  of  the  connective  tissue  about  the 
genitalia — cardiac  elephantiasis.  It  is  most  common  in  mitral  disease. 
The  prognosis  is  less  favorable  if  the  liver  becomes  very  large  before 
edema  appears. 

11.  Changes  in  the  Joints. — Swollen  joints  and  tabes  dorsalis  (aortic 
insufficiency)  are  occasionally  associated  with  valvular  disease. 

Prognosis  of  Valvular  Disease. — Patients  may  live  for  years  with 
compensated  valvular  afi'ections;  a  case  of  aortic  leakage  lived  thirty- 
eight  years  and  one  of  mitral  leakage  lived  for  sixty-six  years.  Though 
prognostic  circumspection  is  necessary,  pessimism  leads  to  even  more 
errors.    The  chronic  course  is  influenced  by  the  following  conditions: 

1.  State  of  the  Heart  Muscle. — The  myocardium  is  the  basis  of  hyper- 
trophy and  compensation.  ^Myocarditis  and  coronary  disease  are  most 
unfavorable,  for  digitalis  then  has  less  eftect  on  the  heart  muscle.     In 

1  Bittorf  and  Kohler  demonstrated  cells  resembling  the  heart-failiire  cells  of  the  sputum. 
In  60  per  cent,  of  patients  with  chronic  passive  congestion,  "heart-failure  ceUs"  are  found. 


ENDOCARDITIS  371 

cases  where  digitalis  has  immediate  effect,  the  prognosis  is  favorable. 
Great  dilatation  or  dilatation  without  hypertrophy  is  most  unfavorable. 

2.  Sex. — The  prognosis  is  generally  better  in  women,  because  they  are 
less  exposed  to  infections,  physical  strain  and  coronary  disease.  Preg- 
nancy as  a  rule  is  a  rather  unfavorable  complication.  Peter  advises, 
"In  girls  (with  valvular  lesions),  no  marriage;  in  wives,  no  pregnancy; 
in  mothers,  no  nursing." 

3.  Age. — In  the  first  decade  of  life  the  prognosis  is  poor,  even  though 
the  heart  and  coronary  vessels  are  young,  because  hypertrophy  and 
dilatation  are  extreme,  exercise  is  difficult  to  regulate,  the  valvular 
lesion  tends  to  recur  and  the  endocarditis  develops  into  carditis  (pan- 
carditis).   After  puberty  the  outlook  is  better. 

4.  Valve  Involved. — Opinions  vary  widely.  In  aortic  insufficiency, 
the  outlook  depends  on  the  type,  being  fair  in  the  endocarditic  and 
ominous  in  the  atheromatous  or  luetic  type.  Subjects  of  mitral  insuffi- 
ciency have  the  more  favorable  prospects.  Broken  compensation  is 
more  likely  to  be  restored  in  mitral  insufficiency  than  in  mitral  stenosis 
or  in  aortic  lesions.  Marked  mitral  stenosis  is  less  favorable,  although 
it  is  often  found  in  women  at  an  advanced  age.  Aortic  stenosis  is  also 
found  at  an  advanced  age.  Combined  or  multiple  lesions,  with  some 
exceptions,  are  unfavorable.  The  writer  observed  a  complete  recovery 
from  a  double  mitral  lesion,  after  eight  years.  Pulmonic  lesions  predis- 
pose to  early  tuberculosis. 

5.  Mode  of  Life. — The  social  scale,  hygiene,  necessity  of  hard  work, 
psychical  excitement,  alcoholism,  exposure  and  the  individual  constitution 
are  most  important  factors. 

6.  Unfavorable  Symptoms. — Angina  pectoris,  embolism,  persistent 
palpitation,  dyspnea  and  irregular  pulse  are  unfavorable  symptoms. 
The  "reserve  heart  power"  of  Martius  is  not  present  in  all  cases  (failure 
of  the  coronary  vessels  to  increase  their  caliber). 

7.  Favorable  Conditions. — These  are  good  general  health,  proper  living 
and  absence  of  rheumatic  tendencies,  endocarditic  (not  atheromatous) 
origin,  sound  ventricles  and  arteries,  and  freedom  from  stasis  in  the 
lungs,  liver  and  kidneys. 

8.  Sudden  Death. — In  most  cases,  sudden  death  occurs  in  aortic  affec- 
tions from  coronary  disease,  especially  in  subjects  over  thirty  with  com- 
bined aortic  and  mitral  disease,  or  when  valvular  disease  is  associated 
with  emphysema,  myocarditis,  contracted  kidney  or  aneurysm;  it  may 
also  result  from  cerebral  or  pulmonary  embolism,  thrombosis  cordis, 
heart  rupture,  sudden  ventricular  dilatation  and  glottis  edema. 

9.  Intercurrent  or  Associated  Disease. — Tabes,  syphilis  and  chorea  have 
been  mentioned.  The  acute  fevers  greatly  tax  the  myocardium.  Tuber- 
culosis (g.  V.)  is  found  in  8  per  cent,  of  autopsies. 

Treatment  of  Valvular  Disease. — (A)  In  Compensated  Lesions. — In 
compensated  lesions  medicinal  treatment  is  unnecessary.  With  some 
exceptions,  the  patient  is  informed  of  the  nature  of  his  trouble  that  his 
cooperation  may  be  enlisted.  The  77iode  of  life  is  important,  i.  e.,  regular, 
orderly  living,  as  free  as  possible  from  psychical  or  sexual  excitement, 
worry  or  hurry,  especially  in  aortic  cases.    Much  depends  on  the  social 


372  DISEASES  OF   THE  EXDOCARDIUM 

status  of  the  patient.  The  diet  should  be  simple  but  not  too  schematic. 
Tobacco  and  alcohol  should  be  interdicted  as  a  rule;  red  wine,  brandy  or 
cognac  are  permissible  in  some  adults  and  in  the  aged.  Coffee  may  be 
given  in  the  morning  but  should  not  be  strong,  for  cardiac  irregularity 
frequently  results.  A  breakfast  of  milk  may  be  taken  before  rising, 
and  the  noon  meal  should  be  the  heartiest  of  the  day.  Nitrogenous 
food  is  best,  with  light  carbohydrates,  as  toast;  foods  which  ferment, 
such  as  cabbage,  beans  or  brown  bread,  should  be  avoided  and  the 
amount  of  fluid  ingested  should  be  moderately  restricted.  Foods  which 
load  the  stomach  heavily  are  prone  to  elevate  the  diaphragm,  and  every 
meal  somewhat  taxes  the  heart.  A  light  meal  at  night  is  the  best  precau- 
tion against  gastric  and  cardiac  oppression  during  the  sleeping  hours. 

Exercise. — ^Exercise  in  cases  not  too  far  advanced  is  advisable, 
for  it  reflexly  stimulates  the  heart  muscle.  Palpitation,  recurrent  endo- 
carditis and  intercurrent  fever  necessitate  keeping  the  patient  in  bed. 
jNIoderate  massage  and  deep  breathing  are  beneficial.  Tepid  are  more 
beneficial  than  cold  or  hot  baths. 

CLnL^.TE. — High  altitudes  are  avoided,  although  moderate  elevations 
are  tonic.  The  seashore  often  disagrees  with  rheumatic  or  catarrhal 
subjects.     A  warm  climate  should  be  chosen  for  the  winter. 

(B)  Broken  Compensation. — Broken  compensation  may  be  acute, 
gradual  or  terminal,  as  by  coronary  occlusion,  and  is  evidenced  at  first 
by  s}-mptoms  not  necessarily  cardiac,  as  fatigue,  vague  thoracic  or 
abdominal  pain  or  hyperesthesia,  so-called  neurasthenic  symptoms, 
inertia,  heaviness  of  the  limbs,  etc.  The  greatest  therapeutic  success 
follows  the  recognition  of  these  extracardial  evidences,  not  awaiting  the 
severer  signs  of  stasis,  e.  g.,  dyspnea,  irregular  pulse  and  dilatation. 
The  indications  are  as  follows: 

1.  Absolute  Rest  tx  Bed. — Liebermeister's  case  of  severe  cardiac 
disease  which  recovered  while  in  bed  with  a  broken  leg,  is  an  example 
of  compensation  restored  -without  digitalis.  Rest  is  imperative  in  inter- 
current fevers,  bronchitis,  recurrent  endocarditis  and  cardiac  insuffi- 
ciency. Bed-sores  can  be  prevented  by  water-cushions  and  cleanliness. 
Some  patients  are  obliged  to  sit  up  because  of  dyspnea.  The  head  may 
be  propped  up  by  back-rests,  but  they  should  have  side  supports  so  that 
falling  to  sleep  "u-ill  not  waken  the  patient. 

2.  Diet. — Karell's  treatment  is  a  low  calorie  diet — a  glass  of  milk 
every  four  hours;  its  effects  are  often  striking  in  dyspnea  and  it  rests 
the  tissues,  reduces  the  fluids  ingested,  is  poor  in  salt  and  lessens  alimen- 
tary intoxication. 

3.  Salixe  Pergatiox. — Epsom  or  Glauber  salts  Bss-j  in  concentrated 
form  should  be  given  in  the  morning  or  compound  jalap  powder  5  ss-j 
at  night.  These  remedies  deplete  the  portal  circulation  and  relieve  the 
heart.    Constipation  increases  the  size  of  the  left  heart. 

4.  Vexesectiox. — ^\MLen  indicated  by  extreme  venous  engorgement 
evidenced  by  cyanosis,  orthopnea,  dilatation  or  tricuspid  leakage,  one 
pint  may  be  dra^ii.  The  effects  are  often  transient  but  are  sometimes 
wonderful.  A'enesection  raises  low  blood-pressure  by  ^elie^'ing  the 
heart,  and  lowers  high  blood-pressure  due  to  excess  of  CO2  in  the  blood. 


ENDOCARDITIS  373 

In  tAVO  cases  apparently  moribund,  no  blood  could  be  obtained  from  the 
arms  and  the  external  jugular  veins  were  opened;  the  patients  lived 
more  than  a  year  afterward.  Venesection  is  not  to  be  left  until  the 
patient  is  in  extremis.- 

5.  The  Oertel  and  Sci-iott  Methods. — (See  page  323.) 

6.  Digitalis.— Digitalis  was  first  recommended  by  Wm.  Withering 
(1775)  and  its  physiological  action  demonstrated  by  Traube.  Digitalis 
attaches  itself  to  the  heart  muscle,  and  becoming  fixed  in  the  tissue,  it 
is  slowly  given  off  and  eliminated.  Operating  on  the  myocardium, 
vagus,  vasomotors  and  other  muscular  tissue,  it  aids  the  heart  to  elicit 
and  coordinate  all  its  latent  power,  but  the  drug  cannot  augment  the 
absolute  power  of  the  heart.  _ 

Its  cjeneral  indications  are:  (a)  Dilatation;  digitalis  restores^  tonicity, 
to  the  heart  muscle  upon  which  the  drug  exercises  its  main  influence, 
i.  e.,  it  overcomes  dilatation.  (6)  Irregularity,  or  functional  dissociation, 
is  often  corrected  by  digitalis;  it  stimulates  the  function  "rhythmi- 
city"  by  action  on  the  heart  muscle,  the  ganglia  and  the  peripheral 
filaments  of  the  vagus.  In  about  80  per  cent,  of  patients  helped  by  digi- 
talis, there  is  continuous  irregularity  due  to  auricular  fibrillation  (Mac- 
kenzie); in  this  condition,  the  auricles  contract  rapidly  and  disorderly 
and  convey  impulses  to  the  ventricles  more  rapidly  than  normal;  digitalis 
regulates  by  decreasing  conduction  through  the  bundle  of  His,  thereby 
protecting  the  ventricles  from  undue  stimulation  from  the  auricles 
(page  339).  Digitalis  does  not  help  extra-systoles,  (c)  Rapid,  weak, 
heart  action:  digitalis  slows  the  heart  by  action  on  the  vagus.  It  tends 
to  abolish  abortive  cardiac  contractions  and  synergizes  the  systole  of 
the  chambers  (increased  contractility),  as  is  shown  by  the  strong  systolic 
spasm  of  the  heart  in  cases  of  digitalis  poisoning.  The  slower  and  stronger 
systole  empties  the  heart  chambers  more  completely,  forces  the  venous 
and  arterial  blood  into  the  main  arteries,  and  squeezes  the  venous  blood 
out  of  the  heart  muscle  itself,  thereby  improving  the  intrinsic  circulation 
of  the  heart.  The  slower,  more  complete  diastole  allows  better  filling 
of  the  heart  and  drainage  of  the  engorged  veins.  Digitalis  raises  the 
arterial  tension  by  increasing  the  working  power  of  the  heart  and  by 
its  centric  and  local  action  on  the  vasomotors;  often  arterial  pressure 
is  not  raised  and  then  digitalis  probably  equalizes  the  distribution  of 
the  blood  and  lessens  tension  due  to  edema  and  poor  aeration  of  the 
blood.    The  most  marked  vasoconstriction  is  in  the  splanchnic  area. 

It  is  seen  then  that  digitalis  increases  tonicity,  rhythmicity  and  con- 
tractility, while  lessening  excitability  and  conductivity.  All  in  all,  aside 
from  details,  digitalis  is  indicated  for  cardiac  insufficiency  of  whatsoever 
type;  which  fact  must  be  kept  in  view,  when  we  consider  its  contra- 
indications. 

In  the  individual  lesions:  (a)  in  mitral  stenosis  the  longer  diastole 
drains  the  left  auricle  and  lung  vessels  and  the  stronger  systole  forces 
the  retarded  blood  through  the  stenotic  orifice;  particularly  in  this 
lesion  auricular  fibrillation  arises;  (b)  in  mitral  insufficiency  the  best 
results  are  obtained ;  the  leaking  cusps  are  better  coapted  and  the 
stronger   systole   fills   the   aorta    and    pulmonary    artery;  (c)  in    aortic 


374  DISEASES  OF   THE  ENDOCARDIUM 

stenosis,  when  dilatation  occurs  or  the  hypertrophy  is  inadequate,  digitalis 
is  valuable;  (f/)  in  aortic  regurgitation  it  is  theoretically  contra-indicated, 
since  it  increases  the  diastole  and  hence  the  leakage;  it  is,  however, 
as  valuable  in  aortic  decompensation  as  in  mitral. 

Digitalis  is  contra-indicated  (a)  in  balanced  compensation;  (b)  when 
the  vessels  are  fragile,  as  in  aneurysm,  and  advanced  atheroma  on 
account  of  the  risk  of  brain  hemorrhage;  (c)  in  fatty  degeneration  of 
the  heart,  except  when  resulting  from  stasis  and  malnutrition;  (d)  in 
vascular  contraction.  In  this  last  instance,  it  is  combined  with  nitro- 
glycerin, strophanthus  or  potassium  iodide,  to  "unlock  the  arteries." 
The  drug  is  not  absolutely  contra-indicated  in  the  high  tension  of 
arteriosclerosis  and  nephritis,  for  paradoxical  as  this  may  seem  it  may 
relieve  by  lessening  dyspnea  and  carbon  dioxide  narcosis  and  equalizing 
the  circulation,  (e)  Of  late,  irregularity  of  the  heart  is  considered  a 
contra-indication,  especially  by  ^Mackenzie,  who  stops  digitalis  as  soon 
as  irregularity  develops.  In  partial  heart-block  digitalis  may  work  harm; 
it  may  prove  beneficial  in  some  cases  of  complete  heart-block.  ^Mackenzie 
discontinues  digitalis  in  severe  cases  of  mitral  stenosis,  where  the  presys- 
tolic murmur  disappears  or  when  systolic  waves  appear  in  the  jugulars, 
for  then  some  heart-block  has  developed.  Extra-systole  is  also  a  contra- 
indication. (/)  Idiosyncrasy:  individuals  react  differently  to  the  drug, 
some  exhibiting  hypersensitiveness  (v.  i.,  toxic  symptoms).  (17)  As 
Janeway  pertinently  remarks,  digitalis  is  indicated  only  in  ventricular 
weakness  and  not  in  paroxysmal  tachycardia,  nephritic  edema,  inflam- 
matory^ effusions  or  palpitation.  (/?)  Digitalis  may  fail  to  operate  unless 
rest,  free  purgation,  venesection  and  mechanical  removal  of  the  anasarca 
have  been  first  employed.  (The  Leipzig  School  uses  digitalis  on  the  first 
sign  of  decompensation.)  Many  of  these  contra-indications  are  relative 
only,  since  digitalis  is  indicated  by  cardiac  insufficiency  of  any  of  the 
five  types  of  Sahli  (cardiac,  pulmonary,  high-pressure  stasis,  vasomotor 
or  splanchnic  insufficiency) ;  it  may  be  tested  out,  then,  in  decompensa- 
tion due  to  acute  endocarditis  (where  experimental  evidence  favors 
its  use),  chronic  myocarditis,  arteriosclerosis,  hypertension,  coronary 
disease,  tachycardia,  etc. 

Toxic  Manifestations. — Gastro-intestinal  symptoms  are  generally 
from  stasis;  sometimes  vomiting  is  due  to  rejection  of  the  drug  by  a 
disordered  stomach,  or  later,  to  toxic  irritation  of  the  stomach  or  the 
medulla,  by  the  absorbed  drug;  there  may  be  diarrhea,  with  green  stools. 
Digitalis  causes  contraction  of  all  unstriped  muscular  tissue  (gastric, 
intestinal,  vascular).  It  may  cause  delirium,  headache,  diplopia,  blind- 
ness to  green  colors,  blueness  of  the  sclerse,  exophthalmos,  precordial 
oppression,  palpitation,  extreme  weakness,  pallor,  renal  suppression, 
violent  cardiac  overaction,  or  convulsions. 

Cumulative  action  may  attend  the  use  of  any  efficient  preparation, 
since  the  heart  never  becomes  anesthetic  to  digitalis;  digitalis  prepara- 
tions, without  cumulative  action,  are  inert.  It  is  averted  (a)  by  inter- 
mittent administration,  although  some  patients  tolerate  digitalis  con- 
tinuously for  months  or  years,  as  Thomeyer's  patient  who  in  eight  and 
a  half  years,  took  over  15  ounces  of  pure  digitalis;  (h)  by  great  care 


EMWCARDITIS  375 

In  ambulatory  cases;  (c)  by  care  in  cardiac  dropsy,  on  relief  of  which 
toxic  quantities  may  be  resorbed  from  the  tissues;  (d)  by  care  in  inter- 
current febrile  affections,  for  toxic  effects  often  follow  the  fall  of  tempera- 
ture; toxemia  considerably  neutralizes  the  slowing  action  of  the  vagus; 
(e)  by  withdrawal  on  the  appearance  of  vomiting,  syncope,  reduced 
urine  or  irregular  or  very  slow  pulse,  a  sign  of  danger;  here  atropine 
may  be  advantageously  combined  with  the  digitalis. 

Preparations  and  Administration. — Among  the  standardized  official 
preparations,  the  powdered  leaves  stand  first;  the  powder  deteriorates 
little,  even  after  eight  years  and  is  given  in  doses  of  gr,  j-iss.  The 
tincture  (lUx)  deteriorates  but  much  less  than  the  infusion  (Sj-ij)-  For 
hypodermic  use,  the  fluidextract  (TTlij),  well  diluted,  is  least  irritating. 
Beginning  with  small  doses  of  digitalis  to  avoid  sudden  overtaxing  of 
the  heart,  the  dosage  is  increased;  Withering,  who  discovered  digitalis, 
pushed  the  drug  until  it  acted  on  the  pulse,  kidneys,  stomach  or  bowels, 
etc.,  its  effects  appearing  in  two  or  three  days. 

I^ — Infusi  digitalis Sii.i 

Spts.  setheris  nitrosi 3.i 

Potas.  bicarbonatis 5ss 

Aquae Sij 

M.  et  S. — One  tablespoonful  after  meals. 

The  infusion  is  excellent  for  rectal  use  when  the  stomach  is  irritable. 
Regarding  the  active  principles  there  is  the  greatest  confusion.  The 
tincture  is  thought  to  be  the  best  cardiant  because  it  contains  digitalin 
and  digitoxin.  The  writer  has  found  digitalin  almost  inert.  Digitoxin 
in  the  author's  hands  has  often  strengthened  the  weak  and  irregular 
heart  when  digitalis  has  failed  (gr.  4^-Q  t.  i.  d.);  it  easily  disorders  the 
stomach,  and  often  cannot  be  given  for  more  than  six  or  eight  doses. 
Frankel  finds  the  therapeutic  and  toxic  doses  very  similar  and  fears  its 
use.  Digitoxin  is  often  advantageously  combined  with  champagne. 
Cloetta's  digalen  is  a  soluble  non-irritant  digitoxin,  and  may  be  given 
intravenously,  1  c.c.  equalling  0.3  mg.,  or  y|q-  grain.  The  preparation 
acts  promptly,  though  it  is  somewhat  irritating  when  given  hypoder- 
mically.  Cumulative  effects  are  least  likely  when  the  kidneys  are 
intact.  Digijnirattwi  is  an  active  purified  product,  from  which  is  elimi- 
nated the  digitonin — the  element  irritating  the  stomach  and  intestines; 
it  is  given  in  powder  or  tablet  form  (0.1  gm.,  grains  iss)  every  twelve 
hours,  or  as  a  fluid  in  sterilized  tubes  for  emergency  intravenous  use. 
Rapid  absorption,  lack  of  alimentary  irritation,  and  free  diuresis  are 
claimed  for  it.    Like  digalen  and  digitalone  it  is  expensive. 

Combinations  are  suggested  in  the  following  prescriptions  {v.  i.) : 
7.  Other  Cardiants. — (a)  Strophanthus,  TUv-x  of  the  tincture  every 
eight  hours,  may  be  given.  Advantages:  it  is  more  rapid  in  action 
than  digitalis,  perpetuates  the  effects  of  digitalis  and  is  indicated  in  the 
irregular  heart  of  mitral  disease;  in  children  under  twelve  years;  in 
cases  where  we  are  waiting  for  the  digitalis  to  act;  and  in  dilatation 
where  the  blood-pressure  is  high.  Disadvantages:  it  is  less  certain  and 
less  energetic;  it  is  inferior  in  edema  and  does  not  give  tone  to  the  vessels. 


376  DISEASES  OF   THE  ENDOCARDIUM 

The  tincture  deteriorates  rapidly  in  dilution  or  aqueous  compounds. 
Of  late  strophanthin,  gr.  -g^^j  once  daily,  has  been  recommended  for  intra- 
venous administration.  It  is  said  to  be  rapid  in  action  and  efficient. 
Its  therapeutic  dose  and  toxic  dose  are  not  far  apart  and  it  is  inferior 
to  digitalis.  It  must  be  used  with  caution  in  nephritis,  high  arterial 
pressure  and  bradycardia.  Its  toxic  symptoms  are  those  of  digitalis 
poisoning,  including  irregularity,  partial  heart-block,  vomiting,  etc.  It 
is  eliminated  by  the  bowel.  It  may  not  be  used  if  digitalis  has  been 
recently  employed,  (b)  Strychnine  stimulates  the  vagus,  vasomotors 
and  the  nervous,  gastric  and  blood-making  tissues  {v.  page  76).  Given 
carelessly,  it  may  irritate  the  heart,  decrease  the  urine  by  spasm  of  the 
renal  vessels,  or  even  induce  rupture  of  the  vessels,  (c)  SparteincB  sul- 
phas is  given  in  capsule  because  of  its  bitterness  (gr.  |-|  every  eight 
hours) ;  larger  doses  may  be  given,  gr.  j-iss ;  it  seems  also  to  quiet  the 
nervous  system  but  is  inferior  to  digitalis.  It  does  not  contract  the 
vessels. 

8.  Symptomatic  Treatment. — (a)  Dropsy. — Saline  or  hydragogue 
catharsis  often  relieves  moderate  edema.  Digitalis  is  often  combined  with 
calomel,  or  blue  mass  and  squills  (Guy's  pill,  also  known  as  Addison's 
or  Niemeyer's). 

I^ — Digitalis gr.  x 

Massae  hydrargyri gr.  vj 

ScillEe gr.  X 

M.  et  ft.  capsulse  x. 

S. — One  after  meals  for  one  or  two  days. 

Mercurials  must  be  used  with  the  greatest  care.  The  author  saw,  in 
consultation,  a  case  complicated  by  nephritis  in  which  the  tongue  sloughed 
off  after  5  grains  of  calomel  had  been  given.  Desperate  stomatitis 
may  result  in  alcoholic,  myocarditic  or  nephritic  subjects.  Calomel 
acts  by  its  conversion  into  bichloride,  which  often  incites  a  bichloride 
nephritis.  In  isolated  luetic  aortic  leakage,  mercurials  may  prove 
specific.  Excess  of  digitalis  is  held  to  suppress  the  urine  by  inducing 
renal  spasm.  It  is  better  to  use  potassium  salts,  as  potassium  acetate 
gr.  XXX,  t.  i.  d.,  which  are  less  abundant  in  the  tissues  than  the  sodium 
salts.  Diuresis  following  digitalis  is  associated  with  increase  of  sodium 
chloride  elimination;  restriction  of  salt  has  few  benefits.  Caffeine 
with  digitalis  is  beneficial  in  dropsy  when  the  pulse  is  slow,  the  mind 
dull  and  the  digestion  sluggish;  anginoid  pains  are  often  relieved  by  it; 
it  may  cause  nervousness  or  insomnia  (therefore  given  early  in  the  day), 
irregular  pulse  (therefore  combined  w4th  rum  or  brandy),  or  biliousness; 
gr.  V  should  be  given,  but  not  for  more  than  three  days — - 

IJ — Cafleinse  citratae 5ss 

Sodii  benzoatis 3ss 

Aquse "  3iij 

M.  et  S. — One  hypodermicful  (3ss)  as  indicated. 

Caffeine  stimulates  the  bulbar  vasomotor  centre,  and  also  the  per- 
ipheral vasomotor  system,  whereby  some  elevation  of  arterial  pressure 
is  accomplished;  it  also  acts  as  a  direct  renal  stimulant;  and  in  shock 


ENDOCARDITIS  377 

and  collapse  surpasses  strychnine  and  camphor  (Rhomberg).  Diuretin, 
sodiosahcylate  of  theobromine  (oj-iss  daily)  may  act  marvellously  or 
not  at  all,  operating  on  the  renal  cells  directly,  and  possibly  also  on 
the  heart  and  vessels.  Theocin  sodium  acetate  is  easily  soluble__^in  water, 
and  in  doses  of  gr.  iij  may  act  when  others  of  this  type  fail.  Canadian 
hemp  (fluidextr.  apocyni  TTlxv)  is  hard  to  obtain  pure  but  sometimes 
justifies  Benjamin  Rush's  term,  "a  vegetable  trochar."  Sweats  and 
the  use  of  pilocarpine  are  both  dangerous  and  injurious.  ]Mechanical 
drainage  is  recommended,  by  scarification,  by  multiple  knife  or  pin-pricks, 
or  by  Southey's  capillary  tubes;  but  the  best  method  is  by  a  single, 
long,  deep  incision  down  to  the  bone,  by  which  a  quart  to  a  gallon  of  fluid 
seeps  away  in  a  day  (and  up  to  40  gm.  of  albumin).  Ascites,  from 
heart  disease  alone,  rarely  necessitates  puncture;  it  is  indicated  chiefly 
in  coincident  liver  cirrhosis  or  chronic  peritonitis.  Hydrothorax  is  far 
more  important,  and  thoracocentesis  should  not  be  delayed  when  dyspnea 
is  urgent. 

(6)  Anemia. — Digitalis  with  iron  and  arsenic,  or  the  latter  two  drugs 
alone,  often  produce  remarkable  improvement. 

I^ — Digitalis gr.  xx 

Ferri  reducti 3ss 

Arseni  trioxidi gr.  ss 

M.  et  ft.  pilulse,  xx. 

S. — One  pill  after  meals;    take  for  a  week  only. 

(c)  Insomnia. — It  is  often  difficult  to  relieve  insomnia  or  unrestful 
sleep,  broken  by  nightmare  or  sudden  "heart  starts."  Spts.  chloroformi, 
spts.  camphorse  and  spts.  etheris  compos,  aa  5  ss  are  often  helpful.  Sul- 
phonal,  gr.  xx  in  hot  milk  at  bed-time,  may  be  tried  but  is  somewhat 
dangerous  in  stasis,  when  used  more  than  three  nights  in  succession. 
Chloral  hydrate  is  excellent  in  high  tension.  In  morphine  we  place  our 
chief  reliance. 

{d)  Dyspnea. — The  ice-bag,  chloral,  and  spiritus  glyceryhs  nitratis  lUj 
are  of  value  for  high  tension.  Morphine  may  be  given  in  the  early  stages 
without  hesitation  and  especially  at  night,  for  restlessness  and  dyspnea; 
it  is  excellent  while  waiting  for  digitalis  to  act.  It  is  almost  specific 
and  lessens  the  irritability  of  the  respiratory  centre.  Heroine  hydro- 
chloride (gr.  tV^s)  operates  similarly,  but  in  some  instances  apparently 
it  can  be  used  longer  than  morphine.  Opiates  require  care  in  weak  heart 
or  Cheyne-Stokes's  breathing.  Dyspnea  is  often  renal  or  'due  to  right- 
sided  hydrothorax,  chronic  bronchitis  or  excessive  dilatation,  when  the 
appropriate  treatment  is  catharsis,  paracentesis,  potassium  iodide  or 
digitalis,  respectively. 

(e)  Respiratory  Symptoms. — Cough,  cyanosis,  pulmonary  edema  and 
hemoptysis  are  usually  cardiac  symptoms  (pulmonary  engorgement  or 
brown  induration)  and  are  relieved  by  the  cardiants. 

I^ — Ammonii  carbonatis 3j 

Tr.  hyoscyami oiv 

Potassii  iodidi 3J 

Tr.  digitalis 5j 

Infusi  calumbiB Q.  s.  ad.  Svj 

M.  et  S. — One  teaspoonful  every  four  hours. 


378  DISEASES  OF   THE  ENDOCARDIUM 

Expectorants  usually  nauseate.  Hemoptysis  is  often  beneficial,  being  a 
species  of  lung  venesection  and  is  seldom  urgent  or  fatal.  Pulmonary 
edema  necessitates  phlebotomy,  a  30-grain  dose  of  lead  acetate,  gr. 
YT^  of  nitroglycerin  and  gr.  |  of  morphine. 

(/)  Palpitation  and  Pain.— For  palpitation  and  throbbing,  the  ice- 
bag  is  the  best  calmative;  a  precordial  blister  or  a  few  minims  of  tr. 
belladonnas  and  tr.  aconiti  are  often  helpful,  with  morphine,  if  necessary. 

I^ — Fluidextracti  belladonnae gtt.  xv 

Tr.  digitalis gj 

Aq.  laurocerasi q.  s.  ad.  gj 

M.  et  S. — One  teaspoonful  two  or  three  times  daily. 

A  light  evening  meal  and  laxatives  are  helpful.  Iodide  of  potash  and 
nitroglycerin  relieve  the  pain,  weakness,  pallor  or  headache  of  aortic 
lesions. 

(g)  Gastric  Symptoms. — These  are  ominous  when  the  liver  is  enlarged 
and  there  is  not  much  edema.  They  are  due  to  portal  stasis  more  often 
than  to  digitalis,  which  should  then  be  given  by  rectum.  Phenol,  gr.  | 
every  half-hour  for  five  doses,  and  rectal  nourishment  are  indicated. 


CONGENITAL   HEART   DISEASE. 

These  infrequent  cases  are  complicated  and  occur  largely  in  the  right 
heart,  upon  which  more  work  devolves  in  fetal  life.  The  causes  are 
(a)  developmental  errors,  by  far  the  most  frequent  cause;  (6)  fetal  endo- 
carditis, nearly  always  sclerotic;  (c)  fetal  myocarditis  or  {d)  adidt  endo- 
carditis developing  upon  developmental  anomalies.  They  occur  largely  in 
males. 

1.  Pulmonary  Stenosis.— This,  by  far  the  most  frequent  congenital 
lesion,  occurs  in  various  forms:  (a)  Stenosis  or  actual  atresia  of  the 
orifice  itself;  the  second  pulmonic  tone  is  weak  or  absent;  (6)  Constric- 
tion of  the  conns  arteriosus  which  obstructs  the  flow  of  blood,  and  may 
make,  as  it  were,  a  second  ventricle;  the  second  pulmonic  sound  is 
clearly  heard,  (c)  The  pulmonary  artery  beyond  the  valves  is  narrowed 
or  atresic — a  grave  type.    The  second  pulmonic  sound  is  usually  heard. 

The  physical  signs  are  hypertrophy  and  dilatation  of  the  right  ven- 
tricle, a  thrill  over  the  pulmonic  area,  and  a  systolic  murmur  prop- 
agated into  the  neck  when  there  is  a  defect  in  the  interventricular  septum 
(when  a  defect  is  lacking,  the  right  ventricle  is  atrophic  and  the  subject 
rarely  lives  over  a  year).  Other  congenital  abnormalities  are  common: 
If  the  stenosis  arises  before  the  end  of  the  second  fetal  month,  the  inter- 
ventricular septum  fails  to  close  in  75  per  cent,  of  cases  and  is  pushed  to 
the  left,  so  that  the  aorta  may  partly  or  entirely  originate  in  the  right 
ventricle.  If  the  closure  develops  after  the  second  month,  the  foramen 
ovale  remains  patent  (6  per  cent.).  Upon  these  openings  acute  endocar- 
ditis is  prone  to  develop.  The  ductus  Botalli  usually  remains  patent,  and 
conducts  blood  from  the  aorta  to  the  pulmonary  artery  and  lungs.  Should 
the  ductus  Botalli  and  the  pulmonary  orifice  be  closed,  collateral  circu- 
lation is  possible  through  the  esophageal,  pericardial  and  bronchial 
arteries.    The  right  ventricle  usually  hypertrophies  and  the  left  atrophies. 


CONGENITAL  HEART  DISEASE  379 

2.  Defects  of  the  Interauricular  Septum. — The  foramen  ovale  is  open 
to  some  extent  in  44  per  cent,  of  all  autopsies  and  in  33  per  cent,  of  con- 
genital heart  lesions;  it  usually  closes  in  the  first  week  of  life,  but  fails 
to  adhere  when  low  pressure  in  the  left  auricle  exists.  Entire  absence  of 
the  septum,  the  most  extreme  defect,  is  called  the  '^  reptilian  heart,'"  or 
cor  biloculare  when  the  interventricular  septum  is  also  absent  or  the 
cor  triloculare  when  the  ventricular  septum  is  present.  Its  patency  is 
almost  a  necessity  when  the  valvular  orifices  are  narrowed  or  closed  or 
when  the  great  vessels  are  transposed.  Several  cases  have  been  found 
in  subjects  over  seventy  years  of  age.  Symptoms  are  absent  or  are 
those  of  the  more  important  associated  trouble.  Rare  occurrences  are 
presystolic  murmur  at  the  level  of  the  third  or  fourth  ribs;  "crossed 
or  paradoxical  embolism,"  e.  g.,  in  the  brain  from  a  clot  in  the  leg,  passing 
directly  from  the  right  to  the  left  auricle;  and  positive  venous  pulse  in 
mitral  regurgitation. 

3.  Defects  of  the  Interventricular  Septum  {Maladie  de  Roger,  1879). 
They  are  observed  in  37  per  cent,  of  congenital  lesions  and  may  be 
single,  associated  with  pulmonary  stenosis,  or  result  from  myocarditis. 
The  deficit  occurs  oftenest  in  the  upper  "undefended"  part  of  the  septum. 
When  wholly  absent,  the  heart  has  but  three  chambers  {cor  triloculare 
hiatr latum) .  Symptoms  are  absent,  complicated  or  ambiguous.  At 
times  the  signs  are  those  of  mitral  leakage  without  pulmonary  stasis. 
A  loud,  prolonged  systolic  murmur  and  thrill  are  found  over  the  upper 
third  of  the  precordium. 

4.  Patency  of  the  Ductus  Botalli. — The  duct  usually  closes  within  the 
first  month,  because  the  pulmonary  blood-pressure  is  lowered  after 
birth.  Patency  occurs  in  26  per  cent,  of  congenital  heart  lesions  and  is 
favored  by  other  congenital  lesions  or  by  atelectasis  or  pneumonia  in  the 
newborn.  It  leads  to  increased  blood  tension  in  the  lung.  The  diag- 
nosis has  been  made  in  50  cases.  The  second  pulmonic  sound  is  accent- 
uated, and  the  artery  is  frequently  dilated,  whence  the  dulness  in  the 
second  left  interspace,  with  thrill,  pulsation  and  long  vibratory  systolic 
murmur  which  may  reach  the  cervical  vessels  or  the  fourth  dorsal  vertebra 
behind.  Sometimes  the  vessel  compresses  the  recurrent  laryngeal 
nerve.  The  x-rays  show  the  large  artery  and  the  wide  right  heart  ("round 
mitral  heart").  It  is  distinguished  from  pulmonary  stenosis  by  the 
greater  cyanosis  of  the  latter  lesion,  the  less  frequent  propagation  to  the 
neck  and  the  absence  of  the  second  pulmonic  sound. 

5.  Persistent  Isthmus  Aortse. — The  fetal  narrowing,  described  by  Paris 
(1789),  is  located  in  46  per  cent,  below  the  duct,  37  per  cent,  at  the  duct, 
and  17  per  cent,  over  it,  and  is  characterized  (a)  by  hypertrophy  of  the 
left  ventricle  (50  per  cent.)  to  overcome  the  stenosis,  and  sometimes  by 
a  systolic  murmur  in  the  interscapular  region;  (6)  by  largeness  and  ful- 
ness of  the  aorta  above  the  isthmus  and  of  the  arteries  of  the  head,  neck 
and  arms  (25  per  cent.) ;  (c)  by  a  small,  retarded,  abdominal  and  femoral 
pulse  (below  the  isthmus) ;  {d)  by  a  pronounced  collateral  circulation 
})etween  the  branches  of  the  aortic  arch  and  those  of  the  thoracic  and 
abdominal  aorta  (internal  mammary,  inferior  thyroid  and  transversalis 
colli  arteries).    Maud  Abbott  finds  198  cases  on  record. 


380  DISEASES  OF   THE  ENDOCARDIUM 

The  pathologist  makes  the  diagnosis,  as  he  cuts  through  the  large 
vessels  in  the  chest  and  abdomen,  and  the  clinician  suspects  the  lesion 
when  he  feels  these  thrilling  large  vessels  or  hears  the  murmur.  Broken 
compensation  may  intervene,  though  latency  is  common.  Aneurysm 
and  mediastinal  tumor  are  frequently  confused  with  it.  The  aorta 
ruptures  in  12  per  cent,  of  cases.  The  lesion  is  twice  as  common  in  the 
newborn  as  in  adults. 

6.  Aortic  Atresia  or  Stenosis. — Moon  (1912)  collected  129  cases  of 
congenital  atresia.  If  the  lesion  is  developmental,  the  interventricular 
and  -auricular  septa  are  open;  if  endocarditic  or  myocarditic,  they  are 
closed,  provided  the  lesion  develops  after  the  third  month  of  fetal  life. 
The  left  ventricle  hypertrophies  in  stenosis  or  atrophies  in  atresia,  while 
the  right  ventricle  hypertrophies  in  order  to  force  the  blood  from  the 
pulmonary  artery  through  the  ductus  Botalli  into  the  aorta. 

7.  Tricuspid  Stenosis  or  Atresia. — In  developmental  or  inflammatory 
atresia,  both  septa  are  open  and  the  right  heart  is  atrophic.  Tricuspid 
insufficiency  is  most  rare. 

8.  Transposition  of  the  Arteries  and  Veins. — In  this  lesion  the  fora- 
men ovale  remains  open;    the  aorta  originates  in  the  right  heart. 

9.  Valvular  Anomalies. — The  semilunar  valves,  especially  the  pul- 
monary, may  be  increased  in  number  from  three  to  five;  or  they  may 
be  decreased  to  two,  which  occurs  especially  in  the  aortic  valves.  Acces- 
sory or  abnormal  valves  are  particularly  prone  to  endocarditis.  Mitral 
anomalies  are  rare. 

10.  Anomalies  in  Location  and  Development. — These  are  absence  of 
the  heart  (acardia),  double  heart,  or  ectopia  cordis,  where  the  heart  lies 
in  the  abdomen,  or  chest  (with  fissured  sternum). 

Dextrocardia  (dexiocardia),  described  by  Servius  (1643),  occurs  with 
situs  viscerum  inversus;  the  mitral  valve  has  three  cusps,  the  tricuspid 
has  but  two;  the  pulmonary  veins  empty  into  the  right  auricle;  the 
pulmonary  artery  arises  from  the  left,  and  the  aorta  from  the  right, 
ventricle;  the  aorta  runs  to  the  right  of  the  spine  and  esophagus  and 
to  the  left  of  the  cava;  the  innominate  artery  and  vena  azygos  are  on 
the  left  and  hemiazygos  is  on  the  right;  the  right  lung  has  two  lobes, 
the  left  three;  the  bronchial  fremitus  is  greater  on  the  left  side,  the  left 
bronchus  being  larger;  the  spleen,  liver,  stomach  and  colon  are  trans- 
posed; the  right  kidney  and  testicle  are  higher  than  the  left.  The 
heart  is  rarely  transposed  alone.  Pollock  and  Jewell  (1909)  collected 
323  cases. 

Symptoms  of  Congenital  Heart  Disease. — Intense  cyanosis  develops 
chiefly  in  transposition  of  the  great  vessels,  pulmonary  stenosis  with 
interventricular  defects  and  in  pulmonary  and  tricuspid  atresia.  Morbus 
ccBruleus  is  general  or  limited  to  the  nose,  fingers,  etc. ;  the  purple  skin 
is  due  to  mixing  of  the  arterial  and  venous  currents,  to  sluggish  circula- 
tion or  to  impaired  function  of  the  red  cells.  Sometimes  the  cyanosis  is 
paroxysmal.  A  most  striking  increase  of  the  red  cells  up  to  10  or  12 
millions  (polycythemia  rubra)  is  seen  in  some  cases,  probably  as  a  com- 
pensatory efl"ort.  The  hemoglobin  may  register  230.  Dyspnea,  cough, 
convulsions  and  marked  clubbing  of  the  fingers  and  toes  are  frequent. 


PERICARDITIS  381 

The  temperature  is  often  subnormal.  ^lental  and  physical  development 
is  incomplete  and  exophthalmos,  s^Yelling  of  the  face,  lips  and  nose  and 
of  the  optic  disk  are  frequent.  Edema  and  stasis  are  not  frequent. 
Coincident  maldevelopment  occurs  in  10  per  cent,  of  cases  in  the  stomach, 
colon,  kidney,  etc.;  imperforate  anus,  hypospadias,  cryptorchismus, 
polydactylia,  hare-lip,  spina  bifida  and  anencephalus  also  occur.  The 
murmurs  are  usually  sj'stolic  and  rough,  although  very  complicated 
lesions  may  exist  with  normal  heart  tones;  in  a  few  instances  the  fetal 
murmur  was  heard  before  birth.  The  dulness  concerns  the  right  ventricle 
chiefly. 

Prognosis. — The  lesion  is  incurable  and  compensation  is  incomplete. 
The  patient  in  25  to  40  per  cent,  of  cases  succumbs  to  cardiac  failure 
or  to  pulmonary  tuberculosis  in  the  second  decade  (81  per  cent.),  hence 
Rokitansky's  rule,  that  cyanosis  protects  the  lungs  from  tuberculosis,  is 
not  absolute. 

Treatment. — ^The  treatment  is  symptomatic.  The  body  should  be 
kept  warm;  baths  should  be  employed  to  guard  against  colds;  mental 
and  bodily  strain  should  be  avoided;  and  in  general  the  therapy  of 
adult  valvular  disease  should  be  followed,  except  that  the  heart  stimu- 
lants must  be  used  with  considerable  caution. 


DISEASES  OF  THE  PEEICARDIUM. 

PERICARDITIS. 

Definition. — An  inflammation  of  the  pericardium.  Known  anatomic- 
ally to  Morgagni,  it  was  first  described  clinically  by  Senac  (1749). 

Etiology. — The  so-called  primary  cases  are  tuberculous,  rheumatic  or 
septic.  Cold,  exposure  and  trauma  only  reduce  the  physiological  resist- 
ance to  bacterial  invasion.  Pericarditis  is  mycotic,  the  organisms  of 
suppuration,  pneumonia  and  tuberculosis  being  most  frequently  found; 
perhaps  toxins  alone  may  excite  inflammation. 

Pericarditis  is  secondary  (a)  to  infectio2is  diseases,  of  which  rheumatism 
(40  per  cent.)  is  foremost,  particularly  when  many  joints  are  involved 
in  rapid  succession,  usually  developing  within  half  a  week  to  two  weeks. 
It  may  be  the  only  manifestation  of  rheumatism.  It  occurs  with  recur- 
rent rheumatism,  endocarditis  and  sometimes  chorea.  It  is  commonl}^ 
serofibrinous. 

It  is  common  in  pneumonia,  septicopyemia,  puerperal  fever,  ulcera- 
tive endocarditis,  osteomyelitis,  scarlatina — more  rarely  in  other  exan- 
themata— and  in  pulmonary  or  multiple  serous  tuberculosis.  In  children 
scarlatina  and  rheumatism  are  most  important. 

(b)  It  is  secondary,  by  contiguity,  to  disease  of  adjacent  organs;  to 
pleurisy,  pneumonia  and  aneurysm;  to  disease  of  the  ribs,  myocardium 
and  endocardium,  sternum,  bronchial  glands,  spine,  esophagus,  stomach, 
spleen,  liver,  peritoneum;    and  to  cervical  cellulitis. 


382  DISEASES  OF   THE  PERICARDIUM 

(c)  It  is  secondary  to  ceriain  diseases  of  the  pericardium,  as  tuber- 
culosis, carcinoma  and  other  processes.  In  30  per  cent,  of  Matter's 
"  cryptogenetic"  cases,  tuberculosis  was  found  at  autopsy.  Scaglios 
(1904)  could  find  but  8  cases  of  primary  pericardial  tuberculosis. 

{d)  It  is  secondary  to  cachexice  or  dyscrasice,  e.  g.,  nephritis  (especially 
contracted  kidney),  gout,  diabetes,  carcinoma,  alcoholism,  blood  diseases, 
etc.;  and  often  as  a  terminal  infection;  this  chiefly  adult  type  easily 
escapes  clinical  recognition.  Pericarditis  is  most  frequent  between  the 
fifteenth  and  thirtieth  years. 

Fibrinous  (Plastic)  Pericarditis. — A  strict  division  into  dry  (plastic) 
and  exudative  (effusive)  pericarditis  is  impossible,  because  these  forms 
are  usually  combined.  Dry  (plastic,  fibrinous)  pericarditis  fs  circum- 
scribed over  the  base  and  large  vessels,  or  is  diffuse,  and  consists  patho- 
logically of  vascular  injection,  punctate  ecchymoses,  loss  of  the  smooth, 
glistening  appearance  of  the  serous  membrane,  and  exudation  of  plastic 
lymph  in  small  particles  or  irregular  lamellae,  which  may  appear  smeared 
as  with  butter,  spongy,  shaggy  or  hairy  (cor  villosum) .  Some  fluid  is  found 
in  the  meshes  of  fibrin.  Stripping  off  of  the  fibrin  may  reveal  tubercles. 
The  subjacent  myocardium  often  suffers  infiltration  and  degeneration. 

Symptoms. — Symptoms  are  lacking  in  most  cases;  pain  is  inconstant 
and  when  present  is  by  no  means  characteristic. 

Physical  Findings. — InsJDection  and  percussion  are  negative.  The 
writer  has  seen  a  strong  apex  beat  where  the  autopsy  revealed  a  fibrin 
deposit  an  inch  in  thickness.  Palpation  and  auscultation  may  disclose 
a  friction  fremitus,  fully  described  under : 

Pericarditis  with  Effusion. — This  form  has  been  called  the  second 
stage,  the  fibrinous  form  being  the  first  stage.  The  fluid  may  be  serous 
with  much  or  little  cellular  or  fibrinous  admixtlire  (serofibrinous);  the 
hemorrhagic  type  is  observed  in  the  aged,  in  scurvy,  cancer,  tuberculosis, 
purpura,  hemorrhagic  exanthemata  or  Bright's  disease,  the  exudation 
being  tinged  w^ith  fresh  or  altered  blood;  the  purulent  type  is  usually 
fibrinopurulent  rather  than  purely  purulent,  and  is  often  associated 
with  pyemia  or  contiguous  suppuration;  the  effusion  may  be  putrid, 
when  caused  by  pyemia,  carcinoma  of  the  esophagus  or  stomach,  or 
lung  cavities.  Sixty-seven  per  cent,  of  pericarditides  are  serofibrinous, 
19  per  cent,  hemorrhagic  and  14  per  cent,  purulent.  The  pathological 
sequences  of  pericarditis  are  fatty  and  cloudy  degeneration,  inflammatory 
infiltration,  or  actual  exulceration  of  the  heart  muscle;  rupture  of  a  puru- 
lent exudation  externally  into  the  tissues  of  the  chest,  or  possibly  into 
neighboring  organs  or  cavities;  inflammatory  extension  outside  of  the 
pericardium  (pericarditis  externa),  to  the  mediastinum  or  pleura;  for- 
mation of  polypi,  which  may,  in  rare  cases,  become  foreign  bodies;  com- 
plete resorption  of  the  exudate  and  restitutio  ad  integrum,  which  is  a 
rather  uncommon  issue ;  organization  of  connective  tissue,  either  as  local 
adhesions,  mostly  near  the  fixed  base  of  the  heart,  because  the  heart's 
movements  may  detach  apical  adhesions,  or  as  general  obliteration  of  the 
sac  (concretio  pericardii) ;  and,  finally,  desiccation  of  the  exudate,  leaving 
a  cheesy  mass  which  may  calcify.  Endocarditis  is  less  a  sequence  than  an 
9,ssociate  or  cause  of  pericarditis. 


PERICARDITIS  383 

Symptoms. — No  symptom  is  diagnostic.  Total  latency  of  symptoms 
obtains  in  55  per  cent,  of  cases.  Daily  examination  of  the  heart  in  those 
diseases  likely  to  cause  pericarditis  may  save  many  diagnostic  errors. 
Irregular  fever  may  exist  from  the  disease  or  the  causal  affection.  It 
is  often  absent,  especially  in  terminal  pericarditis,  and  the  temperature 
may  be  subnormal,  even  in  purulent  effusions.    High  fever  is  infrequent. 

Dyspnea  or  thoracic  oppression  occurs  in  90  per  cent.,  due  largely 
to  heart  compression  by  the  exudate  or  extension  of  inflammation  to 
the  myocardium,  and  less  frequently  due  to  vagus  irritation,  phrenic 
neuritis,  venous,  pulmonary  and  arterial  compression.  It  is  remarkable 
that  patients  sometimes  walk  into  the  hospital  with  enormous  peri- 
cardial effusions.    The  respirations  are  increased. 

Pain. — Painlessness  in  pericarditis  is  the  rule  and  is  often  absent  in 
secondary  pericarditis  and  is  more  common  in  small  effusions;  severe 
pain  oftener  indicates  pleurisy  than  pericarditis.  Like  Andral,  the 
writer  has  observed  anginal  pain  radiating  to  the  shoulder,  arm  and 
neck.  Epigastric  pain  may  precede  pain  elsewhere  (Gueneau  de  Mussy) 
and  the  writer  observed  initial  pain  over  the  appendix.  Barlow's  patient 
put  on  a  belt  to  relieve  his  pain.  Precordial  tenderness  is  at  times  present, 
and  palpitation  is  common. 

Delirium,  restlessness,  mania,  convulsions,  psychoses  or  even  coma 
may  be  due-'to  pericarditis  or  to  complicating  uremia  or  endocarditis. 
The  symptoms  may  suggest  gastritis,  while  pericarditis  is  found  on 
examination.  Vomiting,  singultus,  dysphagia,  recurrent  laryngeal 
paralysis  and  tracheal  cough  are  pressure  symptoms. 

Physical  Findings. — On  these  rests  the  diagnosis: 

1.  Inspection. — Precordial  prominence,  wussure,  first  noted  by 
Corvisart  and  Louis,  may  develop  when  the  chest  is  plastic,  as  in  women 
and  children,  and  when  the  intercostal  muscles  are  inflamed  or  paretic. 
The  left  chest  often  moves  less,  since  that  lung  is  usually  compressed. 
The  apex  beat  is  somewhat  lower  when  exudation  depresses  the  dia- 
phragm; it  is  more  to  the  left  and  the  dulness  transcends  the  apex  to  the 
left  (see  Percussion).  The  greater  the  effusion,  the  weaker  the  apex 
becomes,  and  disappearance  of  the  previously  distijict  apex  beat  is  all- 
important.  There  may  be  only  an  indefinite,  diffuse  cardiac  impulse. 
On  bending  forward,  the  apex  beat  or  cardiac  impulse  usually  reappears. 
The  interspaces  may  bulge.  Collateral  edema  of  the  chest  wall  and 
undulation  due  to  the  heart  itself  are  most  rare.  Graves  and  Stokes 
described  tumor-like  extrusion  of  the  compressed  lung  above  the  clavicle. 
The  upper  edge  of  the  first  rib  can  be  felt  at  its  sternal  attachment,  being 
separated  from  the  clavicle  (Ewart's  "first  rib  sign").  An  epigastric 
tumor-like  bulging  of  the  luxated  liver  was  noted  by  Auenbriigger  and 
Corvisart.  The  veins  of  the  thoracic  wall  are  large.  The  decubitus 
is  usually  half-erect,  dorsal  or  left-sided,  to  spare  the  sound  lung;  the 
attitude  is  fixed  and  there  is  abdominal  inactivity  during  respiration. 
During  convalescence  the  apex  may  retract  during  the  systole,  from 
adhesions. 

2.  Palpation.— The  friction-rub  is  often  felt.  Palpation  localizes  the 
apex.     Disappearance  of  an  apex  beat  previously  observed,  and  the  presence 


384  DISEASES  OF  THE  PERICARDIUM 

of  a  strong  radial  -pulse,  are  wry  important;  mere  absence  of  the  apex  is 
observed  in  many  conditions.  Tenderness  beside  the  ensiform,  or  between 
the  attachments  of  the  sternomastoid,  is  dne  to  inflammation  of  the 
phrenic  nerve.    Fluctuation  is  never  felt. 

3.  Percussion. — Dulness  was  first  described  by  Auenbriigger.  In 
good-sized  effusions,  nearly  all  the  dulness  is  absolute.  Three  to  five 
ounces  of  fluid  are  usually  necessary  to  produce  distinct  physical  signs. 
There  are  two  complementary  recesses  in  the  pericardium :  one  over  the 
basal  vessels,  where  the  fluid  may  accumulate,  in  which  case  it  is  early 
revealed  by  a  triangular  dulness,  whose  apex  is  directed  downward 
(Skoda,  Oppolzer),  which  may  compress  the  large  vessels;  and  the  other 
in  the  fifth  right  intercostal  space  (Rotch,  Ebstein),  where  the  fluid 
exudate  replaces  the  relative  liver  dulness;  Epstein's  angle,  the  right- 
angled  junction  of  the  right  border  of  the  heart  and  the  liver,  becomes 
more  obtuse.  Extensive  exudates  produce  a  triangular,  pyriform  or 
trapezoidal  dulness,  broad  nearest  the  diaphragm  and  with  the  blunt 
apex  near  the  manubrium  (see  Plate  X,  Fig.  F.).  Though  the  outline 
is  roughly  triangular,  the  right  border  is  more  vertical  than  the  oblique 
lejt  border,  which  is  beyond  the  apex  beat,  if  the  latter  remains  visible 
(Skoda).  The  dulness  may  even  reach  the  interclavicular  notch,  the 
right  nipple,  the  left  axilla,  or  Traube's  semilunar  space,  and  compress 
the  lungs  and  depress  the  diaphragm.  The  apex  beat  shifts  abnormally 
when  the  patient  lies  on  his  side,  because  the  distended  pericardial  sac 
permits  greater  cardiac  movement.  Skoda  taught  that  the  heart  falls 
back  in  the  fluid,  but  the  heart  lies  above  the  fluid  and  close  to  the  chest 
wall.  The  dulness  varies  with  fluctuations  in  the  effusion  and  with  re- 
sorption. The  pericardial  dulness  is  least  typical  when  the  effusion  is 
covered  by  emphysematous  lungs,  or  when  an  adherent  lung  cannot  be 
pushed  back  by  the  effusion.  In  the  erect  posture,  the  dulness  may  be 
one-third  to  one-half  as  broad  again  as  when  in  the  dorsal  position; 
it  also  is  not  so  high;  these  signs  may  also  occur  in  enlarged  heart  and 
valvular  disease.  Change  of  the  dulness,  especially  when  the  patient 
lies  on  the  right  side  is  uncommon  physiologically,  whereas  the  shifting 
in  the  left  decubitus  is  of  minor  value. 

Dulness  may  persist  from  cardiac  dilatation,  massive  adhesions  or 
pulmonary  retraction.  The  effusion  may  be  enormous  (10  quarts, 
Kyber;  or  8  pounds,  Corvisart),  and  may  lead  to  a  diagnosis  of  pleurisy, 
or  pleurisy  plus  pericarditis.  As  the  normal  pericardial  sac  holds  only 
G50  to  800  c.c,  the  pericardium  must  be  greatly  relaxed  by  the  inflam- 
mation, to  allow  such  large  effusions. 

4.  Auscultation. — Auscultation  reveals  the  chief  and  most  reliable 
diagnostic  sign,  the  pericardial  friction  due  to  attrition  of  the  inflamed 
pericardial  surfaces,  first  fully  described  by  Collin,  Laennec's  assistant, 
in  1824.  (a)  It  is  usually  a  "  to-and-fro"  rubbing  not  exactly  synchronous 
with  the  systole  or  diastole,  which  character  is  most  clear  when  the 
heart  is  slow.  It  is  less  often  single,  and  then  is  late  in  the  systole;  it 
may  be  triple,  i.  e.,  presystolic,  systolic  and  diastolic.  It  depends  less 
on  the  intensity  of  the  inflammation,  than  upon  the  accidental  quality 
and  location  of  the  eft'used  lymph.    It  is  often  absent  in  very  soft  fibrin- 


PERICARDITIS  385 

ous  deposits,  hemorrhagic  or  purulent  inflammation.  In  contradistinc- 
tion to  pleurisy,  where  the  effusion  of  fluid  abolishes  the  primary  friction, 
it  usually  persists,  even  with  great  exudation  (Stokes),  especially  at  the 
base,  since  here  the  heart  may  touch  the  parietal  pericardium.  (6)  In 
quaUiy,  it  may  be  harsh,  soft,  like  a  gentle  interrupted  scratching  of  the 
ear  with  the  finger,  creaking,  crunching,  musical  or  even  metallic  (reso- 
nance from  the  stomach  or  intestines),  (c)  In  location,  it  is  most  often 
heard  over  the  base  or  the  tricuspid  region,  where  it  is  especially  signifi- 
cant. It  may  also  be  heard  over  the  apex,  or  possibly  most  clearly  at 
the  angle  of  the  left  scapula,  {d)  It  is  very  superficial  and  close  to  the 
ear,  not  deep  as  in  endocardial  murmurs.  Superficiality  of  the  friction 
sound  is  absent  when  partial  adhesions  exist  anteriorly,  and  the  peri- 
carditis is  most  intense  behind  the  heart,  {e)  Its  propagatio?i  is  not 
wide  (il  nait  et  meurt  sur  place,  Jaccoud),  though  it  has  been  heard  at  a 
distance  of  nine  feet.  The  murmur  usually  ceases  abruptly  when  the 
stethoscope  has  been  removed  a  short  distance.  It  does  not  follow  the 
same  lines  of  propagation  as  in  vahnalar  heart  disease.  Propagation  along 
the  sternum  is  common.  In  children  or  sometimes  in  adults,  the  author 
has  heard  it  over  the  whole  chest.  Coincident  hydrothorax  (Graves)  and 
cardiac  hypertrophy — almost  exclusively  in  chronic  nephritis — by  bringing 
the  heart  closer  to  the  chest  wall,  diffuse  the  friction  more  widely  (Stokes). 
(/)  Inspiration  usually  increases  the  murmur,  due  to  the  closer  apposition 
of  the  pericardial  leaves,  caused  by  the  wedge  of  expanding  lung  (Traube). 
(g)  Moderate  pressure  usually  increases  the  friction,  especially  in  plastic 
chests.  Change  of  posture,  e.  g.,  leaning  forward,  often  makes  the 
miu'mur  clearer  (Corrigan,  Stokes).  (A)  The  murmur  is  variahle,  now  pres- 
ent, now  absent,  now  systolic,  or  again  systolic  and  diastolic,  varying  in 
acoustic  properties,  or  changing  with  change  of  posture;  it  is  often 
short-lived,  lasting  sometimes  but  two  to  six  hours.  Disappearance  of 
the  rub  is  explained  by  regression,  adhesions  or  weak  heart.  As  a  rule, 
the  heart  tones  gradually  become  more  or  less  weakened  and  distant.  The 
.i-rays  outline  the  pericardial  effusion;  Maragliano  comments  upon  the 
absence  of  pulsation  in  the  gastric  bubble. 

Secondary  Physical  Signs, — Cardiac  incompetence  is  due  to  the  mechani- 
cal hindrance,  by  the  fluid,  of  the  diastole,  especially  of  the  auricles ;  then 
the  face  is  pale;  it  is  also  due  to  myocardial  degeneration;  then  the  face 
is  cyanotic.  The  signs  of  cardiac  incompetence  are  hepatic  and  renal 
stasis,  ascites,  dyspnea,  cerebral  anemia  (syncope),  edema  of  the  lungs, 
etc.  The  pulse  at  first  undergoes  irritative  acceleration,  but  lasting 
frequency  indicates  myocardial  change;  rarely  is  it  normal  or  slow  (to 
36),  as  a  result  of  compression;  dicrotism  is  frequent;  there  may  be  the 
pulsus  paradoxus,  weakening  or  intermitting  with  each  inspiration 
(Traube).  A  very  strong  or  water-hammer  pulse  may  suggest  under- 
lying aortic  disease.  Irregularity  is  occasional,  as  is  the  pulsus  differens 
and  difference  in  the  pupils.  Lung  compression  is  frequent.  Bamberger 
oliserved  a  small  area  of  compression,  the  size  of  a  dollar,  at  the  angle  of 
the  left  scapula,  where  bronchial  breathing,  dulness  (or  tympany)  and 
increased  fremitus  are  noticed;  the  compression  clears  up  when  the 
patient  assumes  the  knee-chest  posture.     Pleural  puncture  excludes  the 


386  DISEASES  OF   THE  PERICARDIUM 

possibility  of  fluid,  and  the  absence  of  crepitant  rales  excludes  pneumonia. 
Bamberger's  sign  also  occurs  in  hemopericardium.  There  may  be  tym- 
pany (or  dulness)  under  the  left  clavicle  and  to  the  left  (and  sometimes 
to  the  right)  of  the  heart  in  fair-sized  effusions.  Ewart  describes  tubular 
breathing  near  the  right  mamma.  Tracheal  compression  and  thrombosis 
of  the  innominate  veins  may  result  from  compression.  The  second  pul- 
monic sound  may  be  early  and  sharply  accentuated.  The  second  tone 
may  be  split.  Metallic  heart  tones  may  be  due  to  an  adjacent  cavity, 
pneumothorax  or  the  distended  stomach  and  intestines.  A  systolic 
murmur  over  the  aorta  has  been  explained  by  pressure  or  inflammatory 
relaxation  interfering  with  its  normal  vibration. 

Diagnosis. — Differentiation  rests  upon  the  friction,  dulness  and  apex 
beat.  Puncture  alone  reveals  the  character  of  the  exudate.  Fibrin  for- 
mation and  serous  exudation  usually  coexist. 

1.  The  pericardial  rub  is  practically  pathognomonic  of  pericarditis 
(von  Dusch).  (It  occurs  very  rarely  in  cholera,  pericardial  tubercles, 
cancer,  soldier's  spots,  hypertrophied  heart,  and  the  heart  beating 
against  an  inflamed  diaphragm  or  peritoneum.) 

(a)  In  distinguishing  it  from  endocardial  murmurs,  its  acoustic  quality, 
superficiality,  lack  of  rhythmic  precision,  variability,  slight  propagation, 
palpatory  differences  in  the  rub,  its  basal  location  and  increase  by  press- 
ure or  inspiration  are  most  decisive.  Valsalva's  experiment — i.  e.,  a 
long  inspiration  followed  by  expiration  with  closed  glottis  and  tense 
abdominal  muscles — intensifies  pericardial  friction  and  decreases  endo- 
cardial murmurs.  Frequently  pericarditis  is  a  complication  or  coordinate 
phenomenon  of  endocarditis  which  may  become  manifest  only  after  the 
pericarditis  subsides. 

(6)  In  pleuropericardial  (extrapericardial)  friction  originating  in  an 
inflamed  pleura,  friction  depends  not  only  on  respiration,  but  also  on 
the  heart's  action.  The  distinction  lies  (i)  in  the  close  connection  of  the 
pericardial  rub  with  the  cardiac  activity,  persisting  during  expiration, 
and  (ii)  in  the  location  of  the  pleuropericardial  friction  along  the  lingual 
lobe,  in  its  intimate  relation  to  respiration  and  in  its  cessation  in  extreme 
inspiration  or  expiration  (inspiration  also  augments  true  pericardial 
friction).  Valsalva's  test  is  also  useful  {v.  s.).  Pericardial  friction  toward 
the  base  or  sternum  is  less  often  confused  with  pleural  friction.  Difter- 
entiation  is  difficult  when  the  basal  vessels  beat  against  a  tuberculous 
cavity  or  pneumonia. 

(c)  In  precordial  emphysema  the  crackling  sounds  of  interstitial  emph.\'- 
sema  (air)  in  the  anterior  mediastinum  resemble  rales,  but  closely  follow 
the  heart's  action  and  are  often  metallic.  The  condition  of  the  heart 
tones  is  decisive. 

{d)  Pericardial  splashing  (see  Pneuiviopericardiuim)  . 

(e)  Crepitant  rales  are  easily  difl^erentiated. 

2.  The  dulness  of  pericardial  exudation  is  typically  pyriform  or 
triangular.  The  markedly  increased  relative  cardiac  dulness  should  be 
considered  rather  than  the  absolute  dulness  (which  is  often  little  altered 
in  pleural  adhesions  or  pulmonary  emphysema). 


PERICARDITIS  387 

(a)  Ilydroyericardium  and  effusive  pericarditis  may  be  confused, 
because  the  friction  may  disappear,  and  fever  may  be  lacking  (chronic 
pericarditis).  Hydropericardium  is  distinguished  by  its  etiological 
factors  {q.  v.),  hydrothorax  which  almost  always  develops  first,  by  lower 
dulness,  by  resorption  under  digitalis  and  purges;  and  by  absence  of 
friction ;  paracentesis  reveals  the  usual  differences  between  exudates  and 
transudates  in  their  opacity,  specific  gravity  and  percentage  of  albumin 
(see  Pleurisy). 

(b)  Hemojjericardium,  resulting  from  trauma,  rupture  of  a  coronary 
artery  or  ventricular  or  aneurysmal  rupture,  is  usually  sudden,  is  attended 
by  syncope  and  blood  is  removed  by  puncture. 

(e)  Pneumopericardmm  (q.  v.). 

(d)  From  cardiac  dilatation  the  differentiation  may  be  most  difficult, 
expecially  when  there  is  dilatation  plus  hydropericardium,  in  which 
case  drastics,  digitalis,  friction,  the  history  and  evolution  only,  may 
decide.  In  dilatation  the  dulness  is  rarely  triangular  but  rather  is  in- 
creased laterally,  the  shock-like  impulse  of  the  heart  is  more  marked  and 
often  contrasts  sharply  with  the  weak  radial  pulse,  compression  of  the 
lung  is  much  less  common,  and  the  heart  tones  are  more  clear  and 
"snappy".  The  .r-rays  are  often  decisive.  The  very  distinctive  relation 
between  the  apex  and  the  outer  dulness  to  the  left  is  rarely  fallible  (v.  s.). 
If  the  pulse  is  strong  and  the  apex  weak,  pericarditis  is  present;  but  com- 
pression or  weakness  of  the  heart  in  pericarditis  necessitates  a  weak,  rapid 
pulse.  Leaning  forward  may  clearly  demonstrate  the  apex  within  the 
dulness  of  the  exudate.  When  the  patient  lies  on  his  right  side  the  apex 
in  pericardial  effusion  becomes  visible,  which  does  not  obtain  in  extreme 
dilatation ;  in  children  dulness  oftener  signifies  dilatation  than  pericardial 
effusion. 

(e)  When  there  is  retraction  of  the  left  lung  away  from  the  heart,  the 
diaphragm  is  high,  the  apex  and  outer  cardiac  dulness  coincide,  the  spleen 
is  high,  the  pulmonary  artery  is  exposed,  and  the  proper  signs  of  pulmo- 
nary retraction  are  elicited. 

(/)  In  mediastinal  tumor  the  dulness  is  irregular;  there  is  no  variation 
of  dulness  on  postural  change;  and  signs  of  increased  conduction  and 
bronchial  breathing  are  noted. 

(g)  From  aneurysm  the  differentiation  is  usually  possible,  as  well  as 
from  marginal  infiltration  of  the  lung;  callous  pleura,  encapsulated 
pleurisy,  and  anterior  mediastinitis  (usually  with  friction,  but  with  more 
vertically  elongated  dulness). 

Diagnosis  of  the  Character  of  the  Exudate. — The  fluid  is  serofibrinous  in 
rheumatism;  ichorous  in  perforation  from  hollow  viscera;  hemorrhagic 
in  scurvy,  carcinoma,  tuberculosis,  hemorrhagic  exanthemata  and  alco- 
holism; and  purulent  in  sepsis  and  empyema.  Paracentesis  is  the  only 
certain  test.  Tuberculous  pericarditis,  even  in  clearly  tuberculous  cases, 
can  be  diagnosticated  positively  only  by  detection  of  tubercle  bacilli  in 
the  aspirated  exudate;  a  chronic  pericarditis  is  probably  tuberculous. 
In  children  30  per  cent,  of  pericarditides  are  suppurative  and  17  per  cent, 
tuberculous. 


388  DISEASES  OF   THE  PERICARDIUM 

Course. — Exudation  may  follow  the  friction  at  once  or  only  after  many 
days.  The  exudate  may  be  rapidly  absorbed  in  a  few  days  or  endure 
for  months.    The  average  duration  is  one  or  two  weeks. 

Prognosis. — The  prognosis  depends  largely  upon  the  causal  disease  and 
the  character  and  quantity  of  the  fluid;  it  is  usually  good  in  rheumatic 
and  serofibrinous  cases.  Septic,  purulent,  putrid  or  hemorrhagic  types 
are  serious.  The  pneumococcic  form  is  fatal  in  62  per  cent.  Death  may 
be  rapid  in  hemorrhagic  cases;  it  usually  is  due  to  cardiac  exhaustion, 
especially  in  chronic  cases,  and  results  from  myocarditis  rather  than  from 
simple  pressure.  The  prognosis  is  more  favorable  in  men  than  in  women, 
young  children  or  aged  subjects.  Benign  cases  may  result  seriously  from 
concretio  cordis. 

Treatment. — 1.  The  hygienic  treatment  is  managed  as  in  any  acute 
infection  with  cardiac  involvement.  Absolute  rest  in  bed  is  indicated, 
even  during  convalescence,  to  spare  the  heart.  The  patient  should 
never  sit  up  to  urinate  or  defecate,  for  fatal  syncope  may  follow  the 
effort. 

2.  Laxatives  should  be  given  (sod.  phosphate  5ss-ij),  for  constipa- 
tion per  se  may  increase  the  heart  action,  and  difficult  bowel  movements, 
with  the  attendant  straining,  may  precipitate  syncope. 

3.  The  diet  should  be  light  or  fluid,  avoiding  tea  and  coffee,  which  excite 
the  heart.    Alcohol  may  be  given  in  sepsis. 

4.  Local  Antiphlogistic  Measures. — An  ample  ice-bag  upon  the  pre- 
cordium  quiets  and  regulates  the  heart-rate,  relieves  palpitation  and 
pain  and  is  often  the  best  cardiant  and  sedative.  No  drug  quiets  the 
heart  like  opium.  A  Spanish-fly  blister,  as  large  as  the  hand,  often 
not  only  relieves  pain  but  stimulates  resorption. 

5.  Causal  therapy,  as  salicylates,  in  the  rheumatic  form. 

6.  Heart  stimulation  is  indicated  when  the  pulse  is  irregular,  fast  or 
small,  due  to  early  cardiac  irritation  or  to  later  mechanical  compression 
by  the  exudate.  Strychnine,  coffee  and  camphor  operate  more  quickly 
than  digitalis  or  may  be  used  to  follow  up  its  action.  Cardiac  depressants 
are  obviously  injurious. 

7.  In  treatment  of  the  fever,  hydrotherapy  is  preferable. 

8.  Compression  symptoms,  such  as  dyspnea  and  vomiting,  are  met  by 
the  judicious  use  of  morphine  hypodermically.  When  the  face  is 
pallid  the  heart  is  compressed  by  the  exudate  and  tapping  is  indicated. 
Tardy  resorption  of  large  exudates  or  sudden  or  severe  symptoms  there- 
from necessitate  tapping  of  the  pericardial  sac,  under  general  aseptic 
precautions.  The  puncture  is  made  in  the  fifth  left  (or  right)  interspace 
about  an  inch  from  the  sternum,  where  the  sac  is  not  covered  by  the 
pleura.  Gentleness  in  passing  the  trocar  enables  us  to  feel  the  giving  way 
of  the  parietal  pericardium  and  to  avoid  cardiac  trauma.  Removal  of 
a  small  quantity  frequently  provokes  absorption  by  relaxation  of  the 
vessels  in  the  tense  pericardium.  The  fluid  is  withdrawn  very  gradually 
by  the  gravity  or  siphon  method  (see  Pleurisy).  Sudden  or  extreme 
cardiac  embarrassment  may  necessitate  free  venesection. 

9.  Delayed  absorption  is  treated  by  potassium  iodide  gr.  x-xx,  by 
diuretin  60  to  90  gr.  per  diem,  and  by  small  doses  of  calomel  followed 


I 


PERICARDITIS  389 

by  salines.  Hot  packs,  alcohol  sweats  and  pilocarpine  should  be  entirely 
avoided  lest  collapse  occur. 

10.  Early  'pericardiotomy  is  indicated  in  suppurative  or  putrid  forms. 
About  one-half  of  the  cases  recover. 

Adhesive  Pericarditis. — Pericardial  Concretion  {Synechia);  Cicatricial 
{Callous)  Mediastinopericarditis. — Pericarditic  adhesions  within  the  sac 
or  more  extensive  bands  to  the  chest  wall,  pleura  or  spine  develop  in  41 
per  cent,  of  cases  of  pericarditis  and  are  found  in  6  per  cent,  of  autopsies. 
In  one  group  of  cases,  complete  obliteration  of  the  sac  may  occur  with 
absolute  clinical  latency;  the  heart  may  beat  itself  loose  from  fresh  or 
lax  adhesions,  especially  about  the  apex.  In  a  second  group,  there  are 
undistinctive  evidences  of  cardiac  insufficiency.  In  a  third  series,  dis- 
tinctive physical  signs  exist.  Adhesions  most  frequently  follow  serofibrin- 
ous pericarditis.  A  clear  history  or  the  actual  observation  of  a  previous 
pericarditis  is  a  strong  point  in  the  diagnosis. 

Symptoms. — 1.  Cardiac  insufficiency  is  caused  more  often  by  dila- 
tation or  atrophy  than  by  pressure  on  the  coronary  arteries  or  myocardial 
fibrosis.  While  severe  heart  symptoms  without  valvular  disease  in 
advanced  life  are  indicative  of  myocardial  degeneration,  in  the  young 
they  suggest  pericardial  adhesions  (Wilks) .  Failure  of  the  right  ventricle, 
without  valvular,  renal  or  pulmonary  disease,  or  sudden  decompensation 
in  valvular  lesions,  directs  attention  to  possible  pericardial  adhesions. 
Weiss  and  Pick  described  an  isolated  ascites,  associated  with  enlarged 
liver;  it  is  probably  due  to  inflammatory  extension  along  the  vessels 
from  the  pericardium  to  the  peritoneum.  Sudden  death  is  sometimes 
due  to  pericardial  synechise. 

2.  Systolic  Reteaction  of  the  Interspaces  at  the  Apex. — This 
may  occur  even  with  slight  basal  adhesions  which  hinder  the  systolic 
descent  of  the  heart,  while  diffuse  adhesions  other  than  basal  often  pro- 
duce no  symptoms.  It  is  especially  significant  when  the  normal  systolic 
protrusion  gradually  is  replaced  after  pericarditis  by  systolic  retraction 
(for  retraction  of  the  apex  also  occurs  in  other  conditions,  and  is  merely 
an  expression  of  impaired  locomotion  of  the  heart  and  lack  of  space  at 
the  apex).  It  is  best  seen  on  deep  inspiration  and  disappears  when  the 
heart  grows  weak. 

3.  Retraction  of  the  sternum,  epigastrium,  diaphragm  and  lower 
chest  wall  may  be  observed  when  adhesions  also  exist  outside  of  the  peri- 
cardium as  an  indurative  mediastinitis,  which  attaches  the  heart  ante- 
riorly to  the  chest  wall  and  posteriorly  to  the  spine,  and  necessitates 
retraction,  until  cardiac  weakness  develops  (Skoda).  Broadbent's  sign 
is  a  systolic  retraction  of  the  eleventh  and  twelfth  ribs  posteriorly. 

4.  The  diastolic  recoil  of  the  diaphragm  and  chest  wall  which  are 
retracted  in  the  systole,  is  recognized  by  palpation  and  by  auscultation 
as  a  dull  vibration. 

5.  Diastolic  collapse  of  the  cervical  veins  is  of  great  diag- 
nostic value,  and  is  due  to  their  aspiration  by  the  heart;  it  may  pro- 
duce diastolic  pallor  of  the  face. 

6.  The  Pulsus  Paradoxus. — The  pulsus  paradoxus,  a  pulse  inter- 
mitting with   inspiration,  strongly   suggests   cicatricial   mediastinoperi- 


390  DISEASES  OF   THE  PERICARDIUM 

carditis,  particularly  with  the  previously  mentioned  signs.  In  mediastino- 
pericarditis,  inspiratory  stretching  of  the  great  vessels  by  well-attached 
mediastinal  adhesions,  shuts  off  the  pulse.  Sometimes  observed  to  a 
moderate  degree  physiologically,  it  is  pathognomonic  when  (i)  it  appears 
without  forced  inspiration,  (ii)  when  the  pulse  is  completely  suspended 
by  inspiration,  (iii)  when  the  heart's  action  is  strong  and  regular  and 
(iv)  when  it  is  combined  with  inspiratory  swelling  of  the  cervical  veins 
{v.  i.).  Slowing  of  the  pulse  during  inspiration  is  explained  as  irritation 
of  the  vagus  by  the  mediastinal  connective  tissue. 

7.  Inspiratory  swelling  of  the  neck  veins  (Kussmaul),  which 
normally  collapse  during  inspiration,  is  due  to  mediastinal  bands,  which, 
on  inspiration,  interrupt  the  return  venous  flow.  Cyanosis  may  occur 
with  each  inspiration. 

8.  Other  signs  are  fixation  of  the  heart  by  adhesions,  which  gives 
no  change  of  dulness  by  change  of  posture;  absence  of  respiratory 
excursion  over  the  heart;  decrease  of  Traube's  semilunar  space  by  pleural 
adhesions;  decreased  movement  of  the  left  half  of  the  epigastrium 
(diaphragmatic  adhesion  to  heart) ;  cyanosis  and  dyspnea  due  to  adhe- 
sions with  the  diaphragm  impeding  respiration;    expiratory  weakening 


E  fi 

Fig.  27. — Pulsus  paradoxus  (Kussmaul);    E,  beginning  of  expiration,  and  .7,  of  inspiration. 

of  the  apex  by  pleural  adhesions;  weak  right  heart  with  no  accentuation 
of  the  second  pulmonic  tone;  loud,  even  musical,  murmurs,  especially 
in  the  aged ;  systolic  emptying  of  the  veins  of  the  thorax  due  to  systolic 
dilatation  of  the  internal  mammary  veins;  a  rumbling  presystolic  mur- 
mur at  the  apex,  especially  in  children,  without  signs  of  mitral  stenosis; 
precordial  creaking  when  the  patient  moves  the  arm;  and  other  mediastinal 
symptoms,  e.  g.,  left  recurrent  laryngeal  paralysis,  venous  thrombosis  in 
arm,  etc. 

Diagnosis. — In  the  diagnosis,  two  groups  of  symptoms  are  observed; 
first,  the  myocardial  (dilatation,  hypertrophy,  relative  tricuspid  insuf- 
ficiency); and  second,  the  mediastinal  (pulsus  paradoxus,  etc.).  (See 
Pick's  Pericarditic  Pseudocirrhosis,  under  Diagnosis  of  Hepatic 
Cirrhosis.) 

Prognosis. — The  prognosis  depends  upon  the  condition  of  the  myo- 
cardium. Cardiac  concretion  is  the  usual  cause  of  heart  failure  in  juvenile 
rheumatic  cardiopathies. 

Treatment. — The  treatment  is  identical  with  that  of  valvular  disease 
or  myocardial  insufficiency.  Brauer  advocates  surgical  solution  of  the 
adhesions  (cardiolysis),  conditional  on  the  myocardium  being  strong; 
28  operations  are  reported  (1910). 


HYDROPERICARDIUM  391 


PNEUMOPERICARDIUM. 


Gas  or  air  in  the  pericardium.  But  38  cases  were  collected  in  1904 
by  W.  B.  James,  from  whom  the  figures  below  were  taken. 

Etiology. — It  results  from  (a)  trauma  (18  cases),  such  as  perforating 
wounds,  crushing  of  the  ribs  or  sternum;  (6)  perforating  processes  from 
cavities  or  viscera  containing  air  or  gas  (15  cases);  pulmonary  cavities; 
gangrene,  pneumothorax,  esophageal  or  gastric  ulcer,  liver  abscess  or 
caseated  bronchial  'glands.  The  attendant  effusion  may  be  ichorous, 
hemorrhagic,  purulent  (pyopneumopericardium),  or  more  rarely  serous 
(hydropneumopericardium).  (c)  Exceptionally  gas  has  been  observed 
without  solution  of  continuity,  due  to  the  Bacillus  aerogenes  encapsulatus. 

Diagnosis. — On  inspection,  there  is  precordial  bulging  and  absence  of 
the  apex  beat,  though  it  may  reappear  upon  leaning  forward.  On  palpa- 
tion, the  vocal  fremitus  about  the  heart  and  the  apex  beat  are  gone,  fric- 
tion and  occasionally  splashing,  churning,  gurgling  sounds  may  be  felt. 
On  percussion,  when  the  patient  is  sitting,  a  tympanitic,  cracked-pot, 
or  even  metallic  note  is  obtained  above  or  over  the  entire  heart,  especially 
when  percussion  is  made  with  the  plessimeter  and  the  hard  part  of  the 
percussion  hammer.  The  tympanitic  note  varies  during  the  systole  and 
diastole;  it  becomes  higher  in  the  erect  posture  and  varies  with  the 
amount  of  exudation.  The  change  in  note  on  change  of  posture  and 
the  condition  of  the  apex  depend  upon  hydrostatic  laws,  as  is  the  case 
in  pneumothorax.  The  lung  is  compressed.  On  auscultation,  the  heart 
tones  vary  with  the  fluid,  being  loud  if  there  is  no  great  effusion,  and 
usually  metallic  or  musical,  like  the  sound  from  a  zither.  The  same  is 
true  of  the  quality  of  the  friction  (for  pericarditis  is  invariably  present). 
The  tones,  the  metallic  tinkling  (in  63  per  cent.)  or  splashing,  the  falling- 
drop  sound,  the  mill-wheel  churning  (in  50  per  cent.)  and  succussion  may 
keep  the  patient  awake  and  may  be  heard  in  an  adjacent  room,  as  in 
cases  of  Stokes,  Laennec  and  Graves. 

Differentiation  is  required  from  cavities,  encapsulated  pyopneu- 
mothorax near  the  heart  and  distention  of  the  stomach  imparting  a 
metallic  note  to  the  heart  tones.  Consideration  of  the  heart  dulness 
and  apex  beat  renders  the  diagnosis  easy;  in  James's  series  all  but  6  were 
recognized. 

Prognosis. — Death  occurs  in  70  per  cent,  of  the  cases,  usually  within 
two  weeks,  from  the  inherently  fatal  causal  disease  and  from  cardiac 
insufficiency;  traumatic  cases  are  more  favorable. 

Treatment. — Puncture  to  void  the  gas,  and  operation  for  putrid  or 
purulent  processes  are  indicated.    (See  Pericarditis.) 


HYDROPERICARDIUM    (HYDROPS    PERICARDII). 

Hydropericardium  is  secondary  to  circulatory  disturbances,  as  heart  or 
pulmonary  lesions,  or,  infrequently,  local  obstruction  in  the  pericardial 
veins;  or  cachectic  conditions  producing  transudation,  as  Bright's  disease 
or  carcinoma. 


392  DISEASES  OF   THE  ARTERIES 

Symptoms.^They  are  much  the  same  as  in  pericarditis,  except  that 
friction  is  absent. j  The  heart  region  is  sometimes  prominent,  the  apex 
beat  is  lost,  the  heart  tones  are  distant,  the  fluid  changes  with  change 
of  posture  and  the  duhiess  is  clearly  trapezoidal  since  no  adhesions  exist. 
In  most  autopsies  a  small  amount  of  fluid  is  found  which  transudes 
during  the  death  agony  or  after  death.  In  hydropericardium,  the  fluid  is 
yellowish-green,  and  is  sometimes  slightly  tinged  with  blood.  Evidences 
of  inflammation  are  absent;  the  fluid  is  alkaline,  contains  some  albumin, 
sugar  and  urea,  and  is  of  low  specific  gravity.  Chyle-like  efi^usions 
(chylopericardium)  are  very  rarely  seen. 

Diagnosis. — The  signs  of  fluid  are  the  same  as  in  pericarditis,  but 
there  is  no  temperature,  tenderness  or  friction.  Dilatation  of  the  heart 
causes  the  most  frequent  diagnostic  confusion  (q.  v.  for  differentiation). 
The  etiological  diagnosis  is  important,  as  finding  a  cardiac  or  renal  lesion. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  depend 
wholly  on  the  cause.  Cardiac  stimulants,  blisters  over  the  heart,  laxa- 
tives, etc.,  are  indicated. 

HEMOPERICARDIUM. 

Blood  tinges  the  exudate  in  certain  forms  of  pericarditis.  A  large 
quantity  of  blood  may  escape  into  the  sac  in  trauma  of  the  heart  or  of 
the  sac,  rupture  of  the  heart  {q.  v.)  or  of  aneurysms  {q.  v.). 

The  symptoms  and  physical  signs  relate  to  (a)  the  acute  anemia  with 
pallor,  syncope  and  rapid  pulse,  which  usually  ends,  in  a  few  hours  or 
days,  in  death;  (6)  signs  of  fluid  in  the  pericardial  sac.  The  procjnosis 
is  favorable  only  in  the  traumatic  cases;  death  may  be  postponed  eleven 
days.  The  treatment  is  expectant;  the  heart  should  be  stimulated  and 
salt  solution  infused. 


DISEASES  OF  THE  ARTERIES. 

ARTERIOSCLEROSIS. 

Synonyms. — Atheroma,  arteriocapillary  fibrosis  (Gull  and  Sutton), 
endarteritis  deformans  (Virchow),  angiosclerosis  (Thoma). 

Definition. — A  regressive  change,  evidenced  first  by  malnutrition  in 
the  walls  of  the  large  or  small  vessels  and  later  by  compensatory  thick- 
ening, either  localized  or  diffuse.     Morgagni  recognized  atheroma. 

Etiology. — 1.  Age. — Arteriosclerosis  is  the  essential  element  in  senile 
involution,  although  some  individuals  attain  their  hundredth  year  with 
no  arterial  change.  Cazalis  said,  "A  man  is  as  old  as  his  arteries,"  and 
Peter  spoke  of  "the  vital  rusting."  Though  usually  found  after  the  fiftieth 
year,  hereditary  influences,  syphilis  or  the  acute  infections  may  develop 
hard  arteries  before  the  fortieth  year,  in  adolescence  or  even  in  infancy. 
Chiari  found  it  in  27  per  cent,  of  those  under  twenty-five  3'ears,  and 
Fremont  Smith  collected  144  cases  in  children. 


ARTERIOSCLEROSIS  393 

2.  Sex. — Eighty  per  cent,  of  cases  occur  in  men,  from  causes  enu- 
merated below.  In  women  it  usually  occurs  a  decade  later.  In  factory 
women  Jusserand  found  a  larger  percentage  than  in  men. 

3.  Arterial  Poisons. — Chronic  alcoholism  causes  25  per  cent,  of  all 
cases;  lead,  coffee,  tea  and  tobacco  (affecting  the  coronary  vessels  and 
those  of  the  legs)  are  causative  factors.  Angiosclerosis  has  been  pro- 
duced experimentally  by  adrenalin. 

4.  Overwork  is  second  in  importance  only  to  alcohol.  Physical 
exertion  brings  one-third  of  the  blood  to  the  muscles,  thus  lowering 
the  tension  in  other  vessels  (v.  i.  Thoma's  Theory). 

5.  Poisons  Prodlx'ed  by  Perverted  Metabolism. — Interstitial  neph- 
ritis bears  a  threefold  relation  to  arteriosclerosis:  (a)  It  results  from 
diffuse  arterial  hardening;  (5)  it  raises  arterial  pressure  mechanically 
(Traube)  by  increased  peripheral  resistance  in  the  arterioles,  or  by 
alteration  in  the  quality  of  the  blood  (Bright);  (c)  both  processes  are 
coordinate  to  a  common  cause.  Gout,  diabetes,  high  living,  overeating  and 
obesity  come  under  this  head. 

6.  Specific  Infections. — Syphilis  causes  but  12  per  cent,  of  cases. 
Tuberculosis  (in  16  per  cent.),  typhoid,  rheumatism,  influenza,  scarlatina 
and  other  infections  have  a  direct  bearing  on  vascular  sclerosis;  Oppen- 
heimer  described  arteriosclerosis  in  children  nine  and  ten  years  old,  due 
to  acute  infections  (v.  s.). 

7.  Other  Causes. — Nervous  factors,  as  worry,  high  tension  and 
ambition  are  important.  Excessive  brain  effort  tends  toward  cerebral 
localization,  precisely  as  digestive  excesses  may  develop  changes  in  the 
mesenteric  vessels,  as  working  with  the  arms,  as  in  butchers,  may  develop 
changes  in  the  brachials,  and  as  excessive  walking  may  produce  arterio- 
sclerosis in  the  femorals. 

Pathogenesis  and  Pathology. — (.4)  Thoma  considers  angiosclerosis  a 
compensatory  process;  to  restore  the  caliber  of  widened  vessels,  the 
tunica  media  contracts,  or  when  it  cannot  contract,  the  subendothelial 
connective  tissue  increases  in  thickness.  Thus  in  the  fetus  there  is  no 
connective  tissue  in  the  tunica  intima,  but  it  appears  when  the  fetal 
circulation  changes  at  birth,  new  areas  of  circulation  being  opened  up. 
All  bloodvessels  have  a  nervous  supply  ending  in  the  Vater-Pacini  bodies. 
They  respond  to  persistent  low  pressure  or  dilatation,  by  increased  pro- 
liferation of  the  connective  tissue.  (J5)  Others  regard  arteriosclerosis  as 
due  to  inflammation  in  the  nutrient  vessels,  the  vasa  vasorum,  leading  to 
growth  of  connective  tissue,  i.  e.,  mesarteritis  and  periarteritis  (Huchard, 
Koster).  Arteriosclerosis  in  vessels  with  no  vasa  vasorum  must  be  simply 
degenerative. 

Conceptions  of  its  morbid  anatomy  differ  widely,  atheroma  of  the 
aorta  and  endarteritis  or  arteriocapillary  fibrosis  being  sometimes  de- 
scribed under  separate  headings,  but  the  difference  is  rather  anatomical 
than  pathological.  Large  vessels,  as  the  carotid,  contain  more  elastic 
than  muscular  tissue,  but  the  small  vessels  are  largely  muscular.  Two 
main  forms  are  distinguished,  the  diffuse  and  the  nodular.  Without  dis- 
tinction as  to  form,  Rokitansky  found  that  arteriosclerosis  occurred  in 
the  following  order  of  frequency:  ascending  aorta,  arch,  thoracic,  abdom- 


394  DISEASES  OF   THE  ARTERIES 

inal  aorta,  splenic,  iliac,  femoral,  coronary  (next  after  the  aorta,  accord- 
ing to  Huchard  and  Sansom),  cerebral,  brachial  and  carotid  arteries.  It 
is  rare  in  the  gastric,  mesenteric  and  hepatic  vessels  and  least  frequent 
in  the  pulmonary  trunk.    Bergmann  found  the  two  varieties  as  follows: 

Diffuse  form.  Xodular  variety. 

Radial 89  per  cent.  2  per  cent. 

Ulnar 88          "  8  " 

Tibial 87         "  8  " 

Popliteal        64          "  25 

Splenic 64          "  17  " 

Femoral 58         "  14  " 

Axillary 53          "  16  " 

External  iliac 49         -"  15  " 

Brachial 49          "  9  " 

Subclavian 45          "  43  " 

External  carotid 44          "  22  " 

Cerebral 40          "  43  " 

Internal  carotid        ........  28         "  60  " 

Ascending  aorta 19         "  56  " 

Common  carotid 10         "  69  " 

Abdominal  aorta 0          "  75  " 

(Both  forms  may  coexist  in  the  same  vessels.) 

It  will  be  noted  that  where  the  diffuse  variety  is  most  frequent  the 
nodular  form  is  least  observed  and  that  the  converse  is  true.  The  diffuse 
form  is  most  frequent  in  the  extremities  where  arterial  tension  is  most 
variable  and  more  collateral  circulation  prevails;  the  nodose  form  is 
most  common  in  the  aorta,  its  primary  branches  and  the  circle  of  Willis, 
where  arterial  pressure  varies  greatly. 

To  the  nalced  eye  the  intima  may  be  normal  and  smooth  but  most 
often  is  uneven  and  thickened.  Small,  gelatinous  or  yellowish,  fatty 
areas  are  seen  which  though  at  first  circumscribed,  often  fuse  into  large 
plaques;  they  occur  where  arterial  pressure  is  greatest,  as  in  the  aortic 
arch  (see  Syphilis  and  Axeurysm),  or  where  the  vessel  divides  or  gives 
off  branches,  as  the  subclavian  or  intercostal  branches.  The  plaques 
of  atheroma  or  nodular  arteriosclerosis  represent  nature's  effort  to  fill 
out  areas  of  degeneration  and  dilatation  and  thus  even  the  caliber  of  the 
vessel.  Microscopically  the  intima  may  be  increased  three-  or  fourfold 
from  swelling,  increase  of  connective-tissue  and  round-cell  infiltration. 
Granular  detritus,  fatty  needles  and  cholesterin  plates  are  seen  in  the 
atheroma  plaques,  a  name  indicating  their  pulpy,  grumous  appearance. 
An  atheromatous  area  rupturing  into  the  lumen  produces  the  atheromatous 
idcer,  which  may  cause  embolism,  thrombosis  or  occlusion.  Deposit  of 
lime  in  these  areas  leads  to  calcification  or  produces  rough  areas  in  the 
aorta  which  break  on  manipulation  or  may  cut  the  finger.  The  lumen  of  the 
smaller  vessels  is  often  decreased  or  obliterated  (endarteritis  obliterans) ; 
their  middle  and  outer  coats  at  times  are  thickened  by  hyaline  degenera- 
tion and  fibrous  tissue;  the  muscular  coat  may  waste  and  all  elastic 
tissue  may  disappear;  the  essential  changes  are  in  the  elastic  tunic. 
In  the  larger  vessels  dilatation  may  develop  where  thickening  of  the 
intima  fails  to  protect  the  vessel  wall. 

The  general  results  of  arteriosclerosis  are  (1)  vascular  inelasticity, 
deformity,  tortuosity,  obliteration,  and  high  arterial  tension,  and  (2) 
visceral  alterations  in  the  heart,  brain,  etc.  {v.  ?'.). 


ARTERIOSCLEROSIS  395 

The  rare  sclerosis  of  the  'pulmonary  artery  occurs  in  mitral  lesions  and 
emphysema;  pulmonary  atheroma  may  occur  alone,  sometimes  with 
aneurysmatic  dilatation  of  its  branches  and  with  pulmonary  regurgitation. 

Thoma's  angiosclerosis  includes  'pldehosclerosis ,  which  frequently 
accompanies  arteriosclerosis  and  sometimes  occurs  independently,  in  the 
lower  extremities,  lung  and  portal  tributaries  in  cases  of  liver  cirrhosis  or 
pylephlebitis. 

Symptoms  and  Diagnosis. — In  diffuse  forms  the  process  may  be  latent. 
The  clinical  picture  is  extremely  variable. 

1.  The  'peripheral  arteries  may  be  involved,  with  or  without  changes 
in  the  aorta,  heart,  brain  and  kidneys.  The  small  arteries  appear  tortuous, 
pulsating  and  lengthened,  as  in  the  temporals  or  brachials  when  the 
elbow  is  flexed  and  the  arm  is  rotated  outward.     With  the  finger,  which 


Fig.  28. — Pulse  tracing  in  arteriosclerosis. 

no  instrument  can  totally  replace,  we  distinguish  between  hardness  of  the 
vessel  walls  and  increased  arterial  tension,  although  varying  degrees  of 
both  conditions  usually  occur  together.  Normal  blood-pressure  does  not 
mean  a  normal  movement  of  the  blood  since  accommodative  vascular 
contraction  may  follow  poor  vascular  filling;  a  large  artery  does  not 
necessarily  mean  a  strong  pulse  nor  does  a  small  artery  always  indicate 
a  weak  pulse.  Pressing  on  the  radial  with  one  finger  should  obliterate 
the  pulse  beyond  that  point  if  the  arteries  are  not  sclerotic,  unless  there 
is  an  anastomotic  or  recurrent  pulse  from  the  ulnar  to  the  radial  vessel; 
this  source  of  error  is  easily  eliminated  by  simultaneous  pressure  on  the 
ulnar  vessel.  The  wall  of  the  artery  is  hard,  often  uneven  or  nodular, 
and  the  serial  atheromatous  plaques  sometimes  feel  like  a  rosary.     In 


Fig.  29. — Pulse  tracing  in  extreme  arteriosclerosis  (Sahli). 

extreme  instances  the  vessel  feels  calcareous— the  "pipe-stem  artery." 
The  Roentgen  rays  clearly  show  the  arterial  change.  The  pidse  is  hard 
{pulsus  durus),  retarded  {pulsus  tardus)  or  slow  {pidsus  rarus);  it  rises 
slowly  and  is  long  maintained  {p.  rotundus),  the  vessel  is  firm  between 
the  pulse  beats,  the  elastic  wave  is  lessened  or  absent,  the  tracing  has  a 
rounded  or  flat  top,  and  the  two  radials  may  differ  {pulsus  differens). 
In  vessel  obliteration  or  absolutely  rigid  walls  the  pulse  cannot  be  felt. 
Slight  pressure  on  the  vessels  often  elicits  a  systolic  murmur.  The  right 
radial  is  normally  larger  and  more  often  shows  changes  than  the  left. 
Changes  may  occur  in  internal  vessels  without  change  in  the  radials  (and 
conversely) . 

Increased  arterial  tension  is  a  symptom  only;    barely  one-half  of  the 
arteriosclerotics  show  hypertension.    The  normal  tension  ranges  between 


396  DISEASES  OF   THE  ARTERIES 

110  and  140  mm.,  any  permanent  register  over  160  indicating  hyperten- 
sion (excitement  may  raise  the  reading  10  to  20  points,  temporarily). 
The  causes  of  high  tension  are:  (1)  Toxins  injuring  the  vessel  walls 
(high  living,  sedentary  life,  intestinal  putrefaction  or  tobacco);  (2) 
causes  raising  blood-pressure  without  vascular  injury  (the  toxemia  of 
pregnancy);  (3)  local  diseases,  as  nephritis,  diseases  of  the  brain,  abdom- 
inal vessels  or  splanchnic  circuit;  (4)  profound  neurasthenia;  and  (5) 
arteriosclerosis. .  A  pressure  of  over  160  indicates  nephritis  in  70  and 
of  over  200  in  100  per  cent,  of  cases.  In  few  cases,  hypertension — due  to 
vascular  spasm — is  apparently  independent  of  arteriosclerosis  and 
nephritis.  In  determining  blood-pressure  instrumentally,  we  regard  the 
systolic  pressiu-e  (the  maximiun  pressure,  corresponding  to  the  intra- 
ventricular pressure);  the  diastolic  pressure  (the  minimal  pressure, 
corresponding  to  the  peripheral  resistance  in  the  arterioles);  and  the 
pulse  pressure  fthe  difference  between  the  systolic  and  diastolic  and 
normally  50  per  cent,  of  the  latter).  Auscultatory  estimation  (Korotkow) 
gives  the  most  accurate  results.  If  the  arm  band  is  inflated  to  a  point 
above  the  maximal  pressiu-e  and  the  bell  of  a  stethoscope  is  placed  over 
the  artery  at  the  bend  of  the  elbow,  nothing  is  heard.  As  the  pressure  is 
slowly  allowed  to  fall  a  systolic,  knocking  sound  is  heard  over  the  artery 
as  soon  as  the  maximal  pressure  is  reached.  This  sound  (or  first  phase) 
is  due  to  the  sudden  distention  of  the  walls  of  the  empty  artery  by  the 
first  jets  of  blood  that  pass  below  the  occluding  arm  band.  As  the 
pressure  falls,  this  knocking  sound  grows  louder,  is  then  often  replaced  by 
a  murmur  (second  phase),  which  again  gives  place  to  a  clear,  knocking 
soimd  (third  phase)  similar  to  the  first.  This  last  sound  then  suddenly 
becomes  dull  (fourth  phase;  and,  after  a  further  faU  of  a  centimeter  or 
so,  ceases  entirely  (fifth  phase).  The  first  and  fourth  phases  are  most 
important,  indicating  the  systolic  and  diastolic  pressure,  respectively, 
and  the  mercury  column  is  watched  for  the  record  at  these  phases.  If 
the  third  phase  is  loud,  long  and  clear,  the  heart  is  strong;  if  weak, 
there  is  decompensation. 

2.  Heart  Changes. — ia)  Simple  hypertrophy  of  the  left  ventricle  may 
occur,  with  hea%dng  apex,  loud  second  aortic  tone,  tense  pulse  and  thick- 
ening of  the  arteries.  Some  "consensual"  right-heart  hypertrophy  is 
common  because  of  anastomosis  between  the  ventricular  muscular  fibers 
or  because  of  pulmonary  stasis.  The  heart  is  not  hypertrophied  in  the 
majority  of  cases;  it  does  not  necessarily  follow  arteriosclerosis  in  the 
extremities  or  brain,  but  most  often  occurs  when  the  splanchnic  vessels 
or  the  aorta  are  sclerosed.  The  apex  may  sink  downward  and  to  the  left 
from  relaxation  and  lengthening  of  the  aorta,  (b)  Hypertrophy  plus 
dilatation;  with  heart  insufficiency,  dyspnea,  scanty  urine  and  hydro- 
thorax  are  common;  a  systolic  murmiu"  often  leads  to  a  \\Tong  diagnosis 
of  mitral  insufficiency.  Interstitial  nephritis  iv.  s.)  is  the  commonest 
cause  of  the  hypertension,  hypertrophy  and  dilatation.  Cardiac  weak- 
ness may  accompany  a  blood-pressure  of  200  to  300  mm.  In  high  arterial 
tension  a  double  impulse  may  be  felt  and  seen  at  the  apex,  which  precedes 
cardiac  weakness.  Edema  is  not  frequent.  Gallop-rhythm  points  to 
coronarv  or  renal  disease.     The  heart  muscle  shows  various  changes 


ARTERIOSCLEROSIS  397 

since  arteriosclerosis  is  prone  to  starve  the  myocardium;  they  are  atrophy, 
myocarditis,  fatty  heart,  myofibrosis,  myomalacia  cordis,  the  cor  renale, 
heart  aneurysm,  angina  pectoris,  heart-block,  Adams-Stokes's  syndrome, 
coronary  embolism,  cardiac  asthma  and  arrhythmia;  these  lesions  fall 
under  the  two  forms  of  visceral  sclerosis:  (i)  inflammatory,  occurring 
about  the  vessels,  and  (ii)  dystrophic  sclerosis,  often  somewhat  distant 
from  the  vessel  involved. 

3.  In  the  aorta,  dilatation  may  give  dulness  in  the  second  (and  third) 
right  intercostal  spaces,  confirmed  by  the  fluoroscope;  in  the  jugulum  or 
abdomen  may  be  felt  the  aorta,  plaques  or  even  crackling;  the  sub- 
clavian or  innominate  arteries  may  be  felt  even  through  their  entire 
length.  The  normal  aorta  propels  the  blood  onward  after  the  aortic 
valves  close;  if  the  aorta  loses  its  tone  the  peripheral  vessels  receive 
inadequate  blood,  depending  wholly  on  the  ventricular  systole,  giving 
perhaps  a  pulsus  celer.  A  short  systolic  murmur  over  the  aorta  often 
results  from  atheroma  or  dilatation,  and  the  second  aortic  tone  is  then 
accentuated  and  metallic.  Its  vibration  may  sometimes  be  felt;  when 
emphysema  is  present  it  is  best  heard  in  the  jugulum.  The  accentuation 
may  be  caused  by  increased  tension,  widening  or  rigidity  of  the  aorta. 
The  murmur  and  sharp  tone  are  often  heard  in  the  neck  and  back,  and 
the  's^Titer  has  heard  the  accentuation  only  in  the  neck.  Atheroma  may, 
by  downward  extension,  cause  aortic  stenosis  or  regurgitation. 

4.  Renal  findings  are  next  in  frequency.  The  kidneys  are  often  con- 
tracted (the  senile  arteriosclerotic  and  the  genuine  contracted  kidney). 
The  renal  findings  are  probably  most  often  primary  (see  Interstitial 
Nephritis).  The  urine  may  increase  as  a  result  of  increased  blood- 
pressure  or  decrease  from  asystole. 

5 .  Brain  symptoms  rank  next  in  importance.  Syncope,  vertigo,  headache, 
tinnitus,  neurasthenic  symptoms,  trar.sient  aphasia  or  hemiplegia  result 
from  transient  ischemia.  Brain  hemorrhage  and  miliary  aneurysms  are 
frequent  sequences;  encephalomalacia  results  from  cerebral  embolism  or 
thrombosis.  Brain  atrophy,  depressive  conditions,  the  lacunar  sclerosis 
of  Grasset  and  Marie,  epileptic  seizures  and  the  Adams-Stokes's  triad 
may  be  attributed  to  cerebral  atheroma.  Vascular  brain  lesions  occur 
fairly  often  in  cases  which  show  arteriosclerosis  in  the  extremities  and 
temporal  vessels,  though  sclerosis  of  the  aorta,  coronary  or  splanchnic 
vessels  occurs  more  often  without  peripheral  angiosclerosis.  Most 
instances  of  myelitis,  so-called,  are  not  inflammation  but  arterial  ischemia 
with  myelomalacia. 

Charcot's  claudication  intermittente  (Erb's  dysbasia  intermittens  angio- 
sclerotica;  intermittent  limping;  angina  cruris)  is  chiefly  due  (a)  to 
atheroma  in  the  abdominal  aorta  and  its  branches  in  the  limbs;  it  is 
seen  in  abdominal  aneurysm  in  the  horse.  It  appears  also  to  result  (6) 
from  vessel  spasm  or  (c)  rarely  atheroma  in  the  spinal  vessels.  Erb, 
reviewing  159  cases  found  that  94  per  cent,  were  in  men  over  forty  years 
of  age;  33  per  cent,  were  Jews;  syphilis  was  causal  in  23  per  cent.; 
half  were  enormous,  and  half,  moderate  smokers;  most  cases  developed 
in  the  upper  classes.  Pain,  paresthesise  and  sometimes  local .  cyanosis 
occur  in  the  legs,  which  "  give  way"  after  moderate  exertion.    The  dorsalis 


398  DISEASES  OF   THE  ARTERIES 

pedis  (sometimes  also  the  tibial  and  femoral  vessels)  usually  cannot  be 
felt.  Analogous  changes  occur  in  the  arms,  brain,  heart,  intestine, 
kidney  and  eye.  Brooks  reported  an  arteriosclerotic  with  the  picture 
of  myasthenia  gravis. 

Some  vasomotor  neuroses — as  erythromelalgia,  Reynaud's  disease, 
acroparesthesia — and  some  neuritides  and  neuralgias  are  occasionally 
associated  with  angiosclerosis;    sclerotic  vessels  are  prone  to  spasm. 

6.  The  g astro-intestinal  symptoms  rank  next  in  frequency.  Cases  are 
described  of  dyspepsia,  round  ulcer,  arteriosclerotic  gastritis,  gastro- 
intestinal hemorrhages,  intestinal  perforation  and  ulceration.  Some 
cases  resemble  gastric  cancer.  Severe  abdominal  pain  (angina  abdominis) 
is  due  to  local  anemia  (intermittent  claudication  of  the  abdominal  vessels, 
intermittent  dysperistalsis) ;  Pal  thinks  spasm  occurs  in  the  mesenteric 
and  gastric  vessels;  it  develops  in  two  or  three  hours  after  eating,  and  is 
often  accompanied  by  distention  and  dyspnea.  Proctitis,  piles  and  blood 
in  the  stools  are  not  uncommon.  Abdominal  angina  is  often  associated 
with  angina  pectoris  and  angina  cruris. 

7.  The  retinal  vessels  are  not  infrequently  embolized,  narrowed  or 
aneurysmatic,  which  leads  to  softening,  hemorrhage  and  exudation. 
As  a  rule,  retinal  is  associated  with  cerebral  atheroma. 

8.  In  the  respiratory  tract,  emphysema  and  bronchitis  are  very  com- 
monly coincident  or  consecutive.  Hemoptysis  is  rarely  referable  to 
atheroma  of  the  pulmonary  arterioles. 

9.  Perijjheral  vessels;  gangrene  results  from  obliterating  endarteritis; 
44  out  of  81  cases  of  gangrene  of  the  legs  in  von  Eiselsberg's  Clinic  were 
arteriosclerotic.  Thrombosis  or  embolism  may  occur  in  the  aorta, 
cerebral  or  other  arteries. 

10.  The  general  nutrition  varies.  Some  writers  distinguish  between 
a  plethoric  and  an  anemic  type.  French  writers  speak  of  a  eachexie  arter- 
ielle,  in  which  the  pallor  is  distinguished  from  the  dusky  anemia  of  cardiac 
disease,  but  the  anemia  is  more  apparent  than  real. 

Early  Diagnosis. — Early  symptoms  are  local  disturbances  in  circulation 
and  may  only  appear  after  exertion  in  cold  weather,  excitement,  or  mild 
infections  as  "bronchitis,"  which  results  from  simple  stasis,  and  responds 
only  to  cardiac  therapy.  The  patient  tires  more  easily  and  the  arterial 
tension  may  rise;  slight  edema  of  ankles  or  epistaxis  is  suggestive. 
Early  nervous  symptoms  are  headache,  irritability,  emotivity,  somnolence, 
difficulty  in  concentration  or  in  undertaking  new  work,  vertigo,  neuralgias, 
insomnia,  or  neurasthenia  appearing  for  the  first  time  after  forty  years 
of  age.  Arteriosclerotic  "rheumatoid"  pains  may  be  early  symptoms. 
A  slight  albuminuria  always  should  attract  attention.  Ocular  and 
vasomotor  disturbances  may  characterize  the  insidious  onset.  The 
above  symptoms  are  important  since  successful  therapy  depends  on  the 
early  recognition  of  what  Huchard  terms  the  "presclerotic"  symptoms. 

Prognosis. — The  process  is  frequently  latent  until  it  is  far  advanced. 
Its  early  stage  may  remain  stationary  for  a  long  period,  but  there  is 
constant  danger  of  apoplexy,  angina  pectoris,  myocardial  paralysis  or 
uremia.  When  a  mitral  murmur  develops,  there  appears  every  sign  of 
failing  tonicity  and  contractility;   when  stasis  predominates  anginal  at- 


ARTERIOSCLEROSIS  399 

tacks  cease.  Many  deaths  attributed  to  acute  infections  are  deaths 
from  arteriosclerosis.  A  patient  may  Uve  years  with  a  tension  of  180  to 
200  mm.,  asthma  or  alternating  pulse;  he  may  work  with  great  energy 
for  years,  until  the  end  comes — often  very  suddenly.  The  writer  observed 
a  blood-pressure  of  315,  with  which  the  patient  worked  a  year.  The 
prognosis  is  most  favorable  in  angiosclerosis  of  the  peripheral  vessels. 
A  slow  pulse  is  less  favorable  than  arrhythmia  and  moderate  increase  in 
rate;  the  extra-systole  is  not  unfavorable,  whereas  fibrillation  is  always 
menacing. 

Treatment. — L  Fropliylaxis  concerns  the  etiological  factors  and  the 
patient's  mode  of  life.  Alcohol  and  tobacco  should  be  forbidden,  mercury 
and  iodides  given  in  syphilis,  the  diet  regulated  in  diabetes,  colchicum 
given  in  gout,  etc.  Overwork  and  excitement  are  to  be  avoided.  In 
early  cases  the  process  may  sometimes  be  arrested. 

II.  Hygienic  and  dietetic  measures  are  along  lines  recommended  in 
chronic  nephritis,  though  in  general  less  strict.  In  some  instances, 
mental  rest  or  moderation,  rest  in  bed  and  a  low  diet  restore  health, 
lower  blood-pressure  and  revive  the  heart.  To  start  with,  the  Karell 
diet  is  excellent,  later  carbohydrates,  fats,  fruits  and  vegetables  are  given, 
but  the  quantity  of  the  intake  is  closely  watched.  Soups,  gravies  or 
meat  rich  in  purin  bodies  are  prohibited;  later  some  meat,  especially 
boiled,  may  be  allowed.  The  salt-intake  may  require  regulation.  If  the 
patient  is  able  to  resume  work,  exercise  is  adapted  to  his  strength  and 
to  the  effects  upon  the  blood-pressure,  but  long  hours  of  sleep,  and  keep- 
ing the  patient  abed  longer  than  the  sleeping  hours,  are  most  effective. 
Daily,  prolonged  warm  baths  and  moderate  sweats  are  excellent.  Mas- 
sage, a  loarm  climate,  iMSsive  exercise  and  the  Schott  method  of  treatment 
may  be  employed  (page  323).  Skoda  employed  hot  hand-  and  foot-baths 
to  reduce  peripheral  resistance.    Saline  laxatives  may  reduce  hypertension. 

III.  Drugs. — Iodide  of  potash  is  generally  advised — 15  to  30  grains 
daily  for  twenty  days;  then  during  a  ten-day  intermission,  nitroglycerin 
is  used  (see  pages  227  and  335).  In  a  non-syphilitic  series  of  personally 
observed  cases  the  walls  of  the  nodular,  hard  vessels  distinctly  improved 
with  administration  of  iodides.  Rhomberg  thinks  that  iodides  operate 
less  by  vasodilatation  than  by  decreasing  the  viscosity  of  the  blood,  and 
others  believe  that  they  stimulate  the  thyroid  gland  and  Krehl  warns 
against  the  symptoms  of  hyperthyroidism  which  iodides  may  elicit,  as  loss 
of  weight  (even  resembling  cachexia),  nervousness  and  fever.  Iodides  are 
particularly  indicated  in  arteriosclerotics  with  bronchitis. 

Hypertension  is  pathological,  yet  clearly  conservative;  with  some 
clinicians  200  mm.  is  an  indication  for  drugs,  yet  here  or  with  even  higher 
figures,  it  is  best  to  consider  how  the  heart  functionates.  Vasodilators 
must  not  he  u^ed  indiscriminately.  Nitroglycerin  gr.  -^  is  equivalent  to 
TUiij  of  spiritus  glycerylis  nitratis,  gr.  j  sodium  nitrite  or  gr.  iss  erythrol 
tetranitrite.  Nitroglycerin  acts  for  thirty  minutes,  nitrite  of  arayl  for 
seven,  sod.  nitrite  for  sixty  and  erythrol  for  one  hundred  and  twenty 
minutes.  The  amyl  pearls  should  be  protected  from  the  light,  the  spirits 
should  not  be  diluted,  as  it  thus  deteriorates  rapidly  and  the  erythrol 
should  be  chocolate-coated.    Nitroglycerin,  if  it  initially  reduces  blood- 


400  DISEASES  OF   THE  ARTERIES 

pressure,  is  not  apt  to  maintain  the  lowered  pressure,  whereas  sod.  nitrite 
is  more  likely  to  maintain  it,  with  repeated  doses ;  nitroglycerin  operates 
very  rapidly  when  simply  placed  under  the  tongue.  Erythrol  is  prone  to 
produce  violent  headache.  Hewlett  proved  that  amyl  nitrite  not  only 
dilates  the  vessels  but  stimulates  the  heart.  Vaquez  employs  spts. 
tietheris  nitrosi,  5ss-j,  over  a  protracted  period.  Lauder  Brunton  em- 
ploys pot.  nitrate  and  bicarb.,  aa  gr.  x  and  sod.  nitrite  gr.  j  in  a  full 
glass  of  water.  These  remedies  may  produce  a  distinct  fall  of  blood- 
pressure  and  yet  they  seem*  also  to  benefit  in  some  other  way,  possibly 
by  reducing  pressure  or  spasm  locally,  e.  g.,  in  the  coronary  vessels.  In 
considering  their  action,  one  must  remember  that  spontaneous  reduction 
of  pressure  may  occur. 

Chloral  hydrate,  gr.  v-x,  often  operates  better  than  nitroglycerin, 
in  pain,  high  tension,  insomnia  and  nervousness  (combined  with  bro- 
mides). Chloral  operated  very  successfully  in  one  case  with  pressure 
of  315  mm.  in  which  nitroglycerin  always  induced  delirium.  Coffee 
may  relieve  anginal  and  abdominal  pains.  Venesection,  iron  and  digiialis 
are  indicated  when  the  heart  muscle  weakens.  Huchard  advises  the 
following  pill: 

I^ — Sodii  iodidi 5j 

Sparteinse  sulphatis gr.  xv 

Pulv.  glycyrrhizse •      .      .      .      q.  s. 

M.  et  fac  in  pil.  no.  xl. 

S. — One  after  meals. 

Rest  is  more  efficacious  than  are  cardiants.  Morphine  is  a  valuable 
nervous  sedative,  tonic  and  possibly  a  vasodepressant  for  severe  cases  of 
cardiac  asthma,  but  must  be  used  with  great  care. 

ANEURYSM. 

Definition. — A  dilatation,  usually  localized  and  sac-like,  of  an  artery. 
Aneurysm  was  described  by  Galen,  Vesalius  who  made  the  first  diagnosis, 
Pare,  Lancisi  and  Morgagni. 

Etiology. — (a)  Syphilis  is  the  most  important  cause;  it  was  estimated 
at  80  and  100  per  cent.  The  Wassermann  reaction  proves  that  the 
relationship  between  syphilis  and  aneurysm  is  as  well  established  as  that 
between  syphilis  and  locomotor  ataxia.  Lancisi,  in  1728,  first  recognized 
"venereal  aneurysm",  (h)  Trauma  is  an  overestimated  factor.  Sudden 
effort  with  weakened  aorta  may  induce  partial  rupture  of  the  aorta  with 
consecutive  aneurysm,  (c)  Sex:  aneurysm  is  from  two  to  eight  times  as 
frequent  in  males  as  in  females,  (d)  Age:  the  old  statement  is  still 
valid  that  aneurysm  occurs  before  and  arteriosclerosis  after  the  fiftieth 
year;  80  cases  under  twenty  years  of  age  were  collected  by  Le  Boutillier 
(1903).  (e)  Embolic  and  mycotic  aneurysms  are  usually  small  and  may  be 
multiple  in  the  small  vessels.  Lewis  and  Schrager  collected  97  cases 
(1909).  (/)  The  traction  aneurysm  at  the  ductus  arteriosus  Botalli  is  rare. 
{g)  The  arrosion  aneurysm,  in  which  the  inner  coats  bulge  out  when 
the  adventitia  is  eroded,  occurs  largely  in  tuberculous  cavities.  The 
"aneurysmal  diathesis"  is  spoken  of  by  older  WTiters;  Pelletier  found 
63  in  one  case.     Multiple  aneurysms  of  the  arch  are  clearly  syphilitic. 


ANEURYSM  401 

Pathology. — The  varieties  are:  (a)  True  aneurysm,  in  which  the  sac 
consists  of  one  or  more  coats,  very  rarely  all  three  arterial  coats.  The  sac 
is  usually  (i)  fusiform  and  diffuse,  or  (ii)  sacculated  and  circumscribed. 
(b)  False  aneurysm,  in  which  all  the  coats  rupture,  or  in  which  one  coat 
ruptures  through  the  others,  like  a  hernia.  These  are  circumscribed  or 
diffuse,  especially  in  the  transverse  arch  and  abdominal  aorta,  (c)  Dis- 
secting aneurysm,  wherein  the  intima  of  the  vessel  ruptures  and  the  blood 
channels  down  the  vessel  between  the  intima  and  media  or  between  the 
layers  of  the  latter;  it  is  a  partial  rupture.  The  rupture  back  into  the 
aorta  is  an  attempt  of  nature  toward  recovery ;  the  patient  may  live  for 
years,  (d)  Varicose  aneurysm,  wherein  the  sac  ruptures  into,  e.  g., 
the  innominate  vein  or  cava;  this  form  is  also  called  arteriovenous,  or 
aneurysmal  varix  when  the  main  change  is  in  the  vein. 

x4theroma  occurs  very  frequently  in  comparison  with  aneurysm;  and 
the  pathology  of  aneurysm  is  that  of  syphilitic  mesaortitis;  at  the  roof  of 
the  aorta,  fleshy  nodes  develop  in  the  media  and  adventitia;  about  the 
vasavasorum,  cellular  infiltration  occurs  which  later  necroses;  cicatrization, 
shrinking  or  dilatation  results;  that  these  lesions  are  luetic,  is  attested  by 
the  history,  presence  of  spirochetes  (Reuter,  Benda)  and  by  the  positive 
Wassermann  reaction  in  66  to  85  per  cent.  (v.  pages  208  and  219).  In 
the  sac,  thrombi  form  from  the  roughened  intima  and  slowed  circula- 
tion and  to  a  small  extent  guard  against  extension  and  rupture.  Aneu- 
rysm occurs  at  those  points  in  the  aorta  on  which  the  blood  stream 
impacts  most  strongly;  59  per  cent,  of  thoracic  aneurysms  occur  on  the 
anterior  surface  of  the  ascending  aorta,  29  per  cent,  on  the  convexity 
of  the  arch  and  12  per  cent,  on  the  posterior  surface  of  the  descending 
segment.  Aneurysm  of  the  pulmonary  artery  occurs  in  but  0.4  per 
cent. 

Symptoms. — Bramwell  distinguishes  three  classes  of  cases:  (a)  Those 
which  are  entirely  latent,  and  become  manifest  only  by  rupture  or  at  the 
autopsy.  (6)  Those  presenting  symptoms  of  intrathoracic  pressure  but 
without  physical  signs,  (c)  Those  signalized  by  distinct  physical  signs, 
e.  g.,  by  pulsating  expansile  tumor. 

The  Subjective  Evidences  of  Aneurysm. — A  disproportionate 
value  attaches  to  the  symptoms,  because  of  its  frequent  latency  or  the 
variability  or  disappearance  of  its  signs  when  the  aneurysm  changes  the 
direction  of  its  growth. 

1.  Fain. — Pain  is  either  intrinsic,  resulting  from  aortitis,  localized,  and 
dull  or  aching  in  character;  or  it  is  extrinsic,  resulting  from  pressure  on 
nerve  trunks,  especially  in  deep-seated  tumors,  or  from  the  weight  of  the 
aneurysm,  as  illustrated  by  Stokes's  case  in  which  pain  was  relieved 
by  the  use  of  crutches.  Fain  in  the  majority  of  cases  is  the  first,  the  most 
notable,  and  most  enduring  symptom.  It  is  often  alleviated  by  iodides, 
which  is  suggestive  of  aneurysm;  it  is  usually  paroxysmal,  lancinating 
or  boring  in  character  (when,  for  instance,  the  spine  is  eroded);  it  is 
augmented  by  movement,  but  may  cease  when  the  part  compressed  is 
entirely  eroded.  The  pain  is  local  or  is  reflected  into  the  brachial  plexus, 
arm,  neck  or  may  cause  numbness  and  paresis  of  the  arm.  Inter- 
costal neuralgia  is  always  suggestive  of  aneurysm.  Though  more  usual 
2G 


402  DISEASES  OF   THE  ARTERIES 

anteriorly,  pain  is  sometimes  felt  in  the  interscapular  region.     Anginal 
pain  follows  involvement  of  the  cardiac  plexus. 

2.  Dysjmea. — Dyspnea  is  frequently  out  of  all  'proyortion  to  the  findings. 
It  is  due  to  compression  by  the  aneurysm  of  the  heart,  vagus  or  phrenic 
nerve,  trachea,  bronchi,  lungs  or  pulmonary  artery;  or  to  compression 
of  the  plexus  cardiacus  or  pulmonicus,  producing  bronchial  spasm,  and 
laryngeal  spasm  or  paralysis.  Dyspnea  may  occur  with  change  of  posture; 
it  is  paroxysmal  and  may  subside  entirely. 

3.  Cough. — Cough  is  one  of  its  least  distinctive  features.  It  results 
from  pressure  on  the  air  passages,  vagus  irritation,  bronchitis  or  laryngeal 
involvement.  It  is  often  unproductive.  Like  all  other  eccentric  pressure 
symptoms,  it  varies  with  the  size  and  direction  of  the  aneurysm,  and  it 
is  paroxysmal  (Morgagni). 

4.  Difficult  sivalloiving  results  from  direct  compression,  from  pressure 
on  the  recurrent  laryngeal  nerve,  inducing  esophageal  spasm,  or  most 
often  from  adhesions  between  the  aneurysm  and  esophagus.  It  occurs 
particularly  in  low^  aneurysms  of  the  "recurrent  type"  (v.  page  404).  One 
of  the  earliest  aneurysms  reported  by  Stokes  was  the  size  of  an  egg,  and 
produced  pain,  dysphagia  and  compression  of  the  left  bronchus,  with 
rupture  into  the  latter.  Dysphagia  may  be  intermittent  or  present  only 
in  one  posture.  Its  infrequency  is  explained  by  the  ready  lateral  luxation 
of  the  esophagus.  The  danger  of  sounding  the  esophagus  is  well  known; 
lethal  hemorrhages  have  occurred  in  the  physician's  consultation  room. 

5.  Compression  of  the  vagus  results  in  asthma,  laryngeal  spasm,  vomit- 
ing, stenocardiac  attacks,  hiccough  or  dysphagia. 

The  Physical  Signs  of  Aneurysm. — 1.  Inspection. — Stokes  described 
two  distinct  areas  of  pulsation  in  the  chest,  "like  two  separate  hearts," 
most  significant  when  the  cardiac  impulse  is  the  weaker.  Inspection  is 
most  advantageously  made  with  the  eye  just  below  the  level  of  the 
shoulder  and  near  the  chest.  The  typical  expansile  pulsation  is  best 
detected  in  superficial  thin-walled  aneurysmata  in  the  ascending  arch, 
or  those  presenting  in  the  jugulum;  pulsation  is  less  a  question  of  size 
than  location.  Visible  pulsation  may  be  absent  even  in  the  largest 
varieties;  deeply  situated  aneurysms  give  diffuse  or  no  pulsation.  Throb- 
bing over  the  aorta  is  least  important  when  there  is  also  marked  arterial 
pulsation  (aortic  regurgitation).  The  pulsation  must  be  expansile  to 
establish  a  diagnosis;  the  author  saw  one  case  with  an  expanding  throb- 
bing aorta  and  dulness  over  the  arch  which  was  due  to  massive  callous 
connective  tissue  involving  the  pleura  and  pericardium.  Another  in- 
stance was  observed  in  pernicious  anemia;  the  hands  placed  over  the 
left  side  of  the  chest,  as  well  as  near  the  spine  were  lifted  w^idely  apart, 
and  the  expansile  pulsation  was  seen  at  a  distance  of  forty  feet;  the 
autopsy  revealed  no  aneurysm.  Pulsation  lent  to  a  tumor,  a  collapsed 
lung,  the  liver  or  a  pleural  exudate  is  readily  distinguished. 

2.  Palpation. — Pulsation  felt  slightly  later  than  the  heart  shock,  is 
more  obvious  the  slower  the  heart  rate  becomes.  The  e.xjmnsile  pidsa- 
tion  is  more  easily  detected  by  the  fingers  than  by  the  eye.  Palpation  may 
reveal  remittent  tension  of  the  sac,  tenderness  on  deeper  pressure,  resist- 
ance caused  bv  lamellated  thrombi  and,  in  rare  cases,  fluctuation  of  the 


ANEURYSM  403 

tumor  during  diastole.  Pulsation  in  a  deeply  situated  aneurysm  is  best 
elicited  by  placing  one  hand  anteriorly  and  the  other  posteriorly  on  the 
chest.  A  thrill  may  be  felt  which  is  most  commonly  systolic.  A  diastolic 
shock  sometimes  occurs  over  the  jugulum  and  aortic  area  (Lancisi),  due 
to  retraction  of  the  hypertrophic  aorta  near  the  heart. 

3.  Percussion. —  Dulness  is  significant  only  when  it  is  present  to  one 
side  of  the  sternum,  but  not  when  confined  to  the  sternum.  Dulness  in 
the  left  interscapular  region  is  less  valuable,  because  of  the  thickness  of 
the  chest  wall.  The  dulness  may  so  merge  with  that  of  the  spine,  heart, 
liver  or  spleen  that  no  certain  statement  can  be  made.  Aneurysms  are 
often  obscured  by  an  emphysema,  or  they  may  grow  from  a  deep  origin 
into  the  lung  substance.  Dulness  ceasing  or  shifting  to  another  place, 
almost  certainly  indicates  aneurysm.  It  is  inexplicable  that  aneurysms 
often  press  upon  relatively  unyielding  structures,  while  the  softer  parts 
in  their  immediate  vicinity,  as  the  lungs,  are  less  compressed. 

4.  xiuscultation  is  frequently  negative,  even  in  large  sacs — explained 
by  thrombi  in  the  sac  and  weak  heart  action.  Tivo  clear  tones  are  most 
frequently  heard;  the  second  circumscribed  tone  is  pathognomonic  of 
aneurysm  especially  of  the  ascending  arch,  and  originates  in  the  aneurysm 
itself  (not  in  the  closure  of  the  aortic  cusps).  The  frequent  systolic  mur- 
mur is  blowing,  roaring  or  scraping;  it  is  due  to  vibrations  in  the  aortic 
wall,  to  entrance  or  exit  of  blood  from  the  sac,  to  blood  currents,  thrombi, 
or  more  rarely  to  pressure  of  the  sac  upon  the  aorta  itself. 

The  less  frequent  diastolic  murmur  is  probably  caused  by  (relative) 
aortic  insufficiency,  whien  the  aneurysm  lies  in  the  first  part  of  the  aorta. 
It  may  be  due  to  folds  in  the  aorta  or  to  dissection  of  the  aneurysm  into 
the  sinus  Valsalvae.  A  continuous  murmur  is  rare.  Of  132  cases  only  12 
presented  a  systolic  murmur,  25  gave  systolic  and  diastolic  murmurs,  and 
in  6,  diastolic  murmurs  alone  were  found  (Sansom).  Douglas  Powell 
detected  murmurs  in  about  half  of  his  cases  of  sacculated  aneurysms. 

The  Heart. — Its  position  varies  with  the  size  and  location  of  the 
aneurysm,  (a)  Large  aneurysms  of  the  ascending  aorta  not  only  depress 
it,  but  cause  such  axial  rotation  that  the  left  lies  lower  than  the  right 
ventricle;  this  type  may  cause  pressure  atrophy  of  the  right  ventricle. 
(6)  Aneurysm  of  the  undersurface  of  the  arch  may  dislocate  the  heart  to 
the  median  line,  (c)  Aneurysm  of  the  descending  segment  may  flatten  the 
heart  against  the  chest  wall,  simulating  mitral  regurgitation,  {d)  Second- 
ary aneurysmatic  outgrowths  from  the  chief  aneurysm  complicate  the 
physical  findings;  and  sometimes  attain  incredible  proportions,  {e)  In  un- 
complicated cases  myocardial  alteration  is  entirely  accidental.  The  most 
violent  aneurysmal  pulsation  Stokes  ever  witnessed  occurred  with  marked 
myocardial  atrophy.  Failure  of  the  heart  to  hypertrophy  is  explained  by 
coronary  disease  or  compression  of  the  pulmonary  artery,  thereby  decreas- 
ing the  flow  of  blood  to  the  left  heart  and  coronary  arteries;  compression 
of  the  pulmonary  arter}^  may  cause  relative  tricuspid  regurgitation  or 
pulmonary  insufficiency.  Hypertrophy  of  the  left  ventricle  bears  an  inti- 
mate relation  to  aortic  leakage ;  it  may  in  rare  cases  result  from  aneurysm 
involving  the  entire  periphery  of  the  aorta.  Stokes's  early  observations 
recount  every  symptom  of  aneurysm. 


404  DISEASES  OF   THE  ARTERIES 

The  Vessels. — The  yulsus  differens  is  frequently  physiological,  and 
the  right  radial  is  normally  larger  than  the  left,  whence  if  the  right 
radial  pulse  is  smaller,  it  means  more  than  if  the  left  were  slightly  smaller. 
When  the  radials  differ,  it  is  advisable  to  compare  the  brachials.  When 
one  radial  is  small,  its  fellow  ulnar  is  often  vicariously  larger.  A  pulse 
may  grow  smaller  and  later  return  to  its  normal  size,  due  to  change  in 
the  size  and  the  direction  of  the  aneurysm.  Asymmetrical  blood-pressures 
may  be  due  to  other  causes  than  aneurysm,  as  atheroma,  coagula,  em- 
bolism or  reduction  of  the  lumen  of  a  vessel  by  the  dragging  of  the  aneu- 
rysm or  compression  of  the  aorta  by  a  sac  between  it  and  the  spine. 
Changes  are  observed  most  often  in  the  carotid  and  subclavian  vessels. 
The  'pulsus  paradoxus  and  capillary  pulsation  may  occur  with  large 
aneurysm.  Retardation  of  the  pulse  occurs  especially  in  fusiform  aneu- 
rysms. An  aneurysm  sometimes  may  be  localized  by  regarding  the 
vessels  altered.  If  pressure  is  exerted  upon  the  superior  cava,  dropsy  of 
the.  upper  portion  of  the  body,  of  one  or  both  arms,  swelling  of  the  face 
and  of  the  tongue,  sometimes  exophthalmos  and  a  "brawny"  or  "collar- 
like"  distention  of  the  neck  occur.  Obstruction  above  the  azygos  vein 
causes  lividity  and  edema  which  are  confined  to  the  head  and  arms;  when 
it  occurs  below  that  vessel  the  chest  is  also  congested.  The  innominate 
and  azygos  veins  or  the  vense  cavse  may  be  obliterated.  Rupture  into 
the  superior  cava  is  attended  by  cyanosis,  and  a  continuous  bruit  (also 
heard  in  vascular  sarcomata  or  aneurysms  rupturing  into  the  pulmonary 
artery  or  right  ventricle.)  In  Ewart's  case  (not  suspected  during  life) 
phlebotomy  was  performed,  and  bright-colored  blood  escaped  in  jets. 

The  Respiratory  Tract. —  Tracheal  tugging,  described  by  Oliver 
and  Cardarelli  simultaneously,  is  elicited  by  lifting  the  larynx  with 
the  fingers;  a  tugging  sensation  in  the  trachea  is  then  felt  with  each 
systole;  this  symptom  occurs  also  in  left  ventricle  hypertrophy  and 
in  tracheal  adhesions. 

Tracheal  pulsation  may  be  demonstrated  by  the  laryngoscope  in  many 
aneurysms.  The  examination  should  be  made  by  direct  sunlight,  and 
the  observer  should  sit  before  the  standing  patient.  It  also  occurs 
in  tumors  which  compress  the  trachea,  and  physiologically.  A  short 
systolic  murmur  can  sometimes  be  heard  over  the  trachea  when  the 
patient  breathes  quietly  with  the  mouth   open. 

Recurrent  laryngeal  paralysis  was  first  described  by  jNIorgagni  and 
Todd  was  the  first  to  note  laryngeal  muscular  atrophy.  Unilateral 
paralysis  with  the  cadaveric  position  of  the  vocal  cords,  in  the  absence 
of  other  causes,  is  indicative  of  intrathoracic  aneurysm,  neoplasm  or 
mitral  stenosis.  The  cough  is  hoarse,  clanging  or  brazen.  It  is  a  par- 
alytic cough,  i.  e.,  an  imperfect  expiration  which  lacks  forcible  closure 
of  the  glottis  observed  in  ordinary  coughing;  it  was  called  the  bovine 
cough  by  Wyllie,  from  the  fact  that  cattle  have  no  false  cords  whose 
closure  is  an  important  mechanism  in  coughing.  The  right  recurrent 
laryngeal  nerve,  curving  around  the  subclavian  artery,  does  not  enter 
the  thorax,  and  is  therefore  seldom  involved;  whereas  the  left  recurrent 
nerve  passes  into  the  chest  and  curves  between  the  aorta  and  left  bronchus ; 
Dieulafoy  described  a  "recurrent  type  of  aneurysm,"  which  is  usually 


ANEURYSM 


405 


small,  syphilitic  in  origin,  often  multiple,  invohes  the  left  recurrent 
nerve,  and  causes  spasm  of  the  larynx,  due  to  recurrent  laryngeal  irrita- 
tion contracting  the  posterior  transverse  arytenoid  muscle  and  inducing 
dyspnea  and  inspiratory  stridor.  Irritation  of  other  vagus  branches 
induces  spasmodic  dysphagia,  anginal  pain,  etc. 

Lung  Symptoms. — Stenosis  of  the  right  bronchus  is  less  frequent 
than  that  of  the  left,  which  lies  nearer  the  aortic  arch.  The  lung  moves 
less  freely  than  normal;  it  suffers  inspiratory  retraction,  and  the  breath 

sounds  and  fremitus  are  dimin- 
ished; at  times  air  may  escape 
only  during  the  diastole.  A  short 
note  elicited  over  the  left  upper 
lobe  may  arouse  suspicion  of  the 
"recurrent  type." 

Rokitansky's  dictum  that  large 
aneurysms  are  almost  never  asso- 


FiG.  30.— Dieulafoy's  diagram  of  the  region 
in  which  he  describes  his  "recurrent  type" 
of  aneurysm;  posterior  view.  A,  aorta,  in 
contact  -with  the  trachea  and  left  bronchus; 
L,  larynx  (seen  from  behind) ;  p,  left  and  p', 
right  vagus;  r,  left  recurrent  laryngeal  nerve, 
passing  under  the  aorta,  and  r',  right  recur- 
rent, in  relation  to  the  subclavian  artery. 


Fig.  31.— Dieulafoy— I-VII,  multiple 
syphilitic  aneurysms. 


ciated  with  jjuhnonary  tuberculosis,  was  disproved  by  Stokes;  tuberculosis 
results  in  13  per  cent,  of  cases  of  aneurysm  from  compression  of  the 
pulmonary  artery  or  decreased  lung  excursion. 

Bronchiectasis,  hronchorrhea  and  suppuration  of  the  lung  are  well  called 
"aneurysmal  phthisis"  by  Osier  and  Ross.  Pulmonary  retraction  is 
observed  from  compression  or  adhesions.  Pleurisy  with  effusion  may 
complicate  and  entirely  obscure  an  aneurysm.  Gangrene  of  the  limg  or 
bronchial  mucosa  occurs  from  compression  of  the  nutrient  artery  of  the 


406  DISEASES  OF   THE  ARTERIES 

lung  or  stagnation  of  mucus;  it  may  produce  subcutaneous  emphysema. 
Pulmonary  hemorrhage  may  occur  from  gross  rupture  into  a  large  tube, 
from  mere  granulations  in  a  compressed  tube,  or  from  an  aneurysm 
slowly  leaking  into  the  parenchyma  of  the  lung.  The  hemorrhage 
may  be  continuous,  premonitory  or  fatal;  it  may  be  seen  as  flecks  in 
the  sputum,  as  rusty  sputum,  as  prune-juice  expectoration,  as  pure  blood 
or  more  frequently  as  partly  coagulated  blood. 

Sympathetic  Symptoms. — The  pupils  are  often  involved;  myosis 
results  from  sympathetic  paralysis  and  high  blood-pressure,  and  mydriasis 
from  sympathetic  stimulation  and  low  blood-pressure.  Irregular,  im- 
mobile pupils,  absence  of  the  patellar  reflexes  and  tabes  compose  the 
Babinski  syndrome. 

Diagnosis. — The  clinical  signs  and  symptoms  are  most  variable  (Stokes). 
The  presence  of  an  aneurysm  should  be  suspected  when  marked  pain 
or  imroxysmal  dyspnea  occurs.  Variahility  of  physical  signs  is  suggestive 
of  aneurysm. 

Eaely  Diagnosis  of  Mes aortitis. — The  sole  therapeutic  hope  lies 
in  the  early  recognition  of  aortitis.  In  the  secondary  stage  of  lues, 
its  incipiency  is  marked  substernal  soreness,  slight  paroxysmal  dyspnea 
and  angina,  pulsation  of  the  cervical  vessels,  cardiac  hypertrophy, 
substernal  dulness  and  a  positive  Wassermann  reaction  in  85  per  cent, 
(Longcope  and  Donath). 

Diagnosis  of  Location. — 1.  Aneurysm  of  the  ascending  portion, 
called  "aneurysm  of  physical  signs,"  is  most  often  observed  in  the  first 
interspace  to  the  right  of  the  sternum,  which  is  often  eroded.  Luxa- 
tion of  the  heart  to  the  left,  radial  slowing,  compression  of  the  superior 
cava  and  pulmonary  artery  with  hypertrophy  of  the  right  ventricle, 
dyspnea  and  phthisis  occur.  Anginal  or  other  cardiac  symptoms  are 
frequent,  and  the  aneurysm,  however  small,  is  usually  rapidly  fatal  from 
rupture  into  the  pericardium,  pleura,  upper  cava  or  heart  chambers. 
Aneurysms  just  above  the  valves  tend  to  grow  downward  because  of  the 
reflux  of  blood  from  the  aorta,  whereas  those  located  higher  grow  upward 
because  of  impact  of  blood  from  the  left  ventricle.  Sympathetic  involve- 
ment is  common. 

2.  In  the  arch,  the  "aneurysm  of  symptoms"  is  observed  with  left 
recurrent  paralysis  or  spasm,  stridor,  pulsation  in  the  jugulum,  unusual 
prominence  or  luxation  of  the  sternal  ends  of  the  clavicles,  prominence 
of  the  subclavian  arteries,  dulness  to  the  left  of  the  sternum,  myosis, 
slowing  or  lessening  of  the  left  radial  pulse,  compression  of  veins,  par- 
ticularly the  left  innominate,  the  trachea,  thoracic  duct,  sympathetic 
ganglia,  bronchi  and  left  upper  lobe,  and  disturbance  in  the  brain  cir- 
culation (hemiplegia)  when  the  carotid  artery  is  occluded.  These 
aneurysms  usually  grow  backward. 

3.  In  the  descending  segment,  the  "aneurysm  of  latency"  is  most 
often  encountered.  If  there  are  symptoms,  pulsation  in  the  left  inter- 
scapular region,  slowing  of  the  femoral  pulse,  pressure  on  the  azygos  or 
hemiazygos,  pressure  on  the  spine  with  erosion  and  tenderness  to  touch, 
intercostal  neuralgia  (sometimes  with  recurrent  attacks  of  herpes  zoster) , 
stenosis  of  the  left  bronchus  or  esophagus,  pressure  upon  the  heart. 


ANEURYSM  407 

forcing  it  against  the  sternum,  and  increased  heart  rate  from  plexus 
pressure,  are  present.  The  a;-rays  alone  detect  aneurysms  lodged  in  the 
lung  substance;  pulsation  is  often  observed,  but  not  invariably.  Letulle 
in  three  years  detected  27  latent  aneurysms  by  the  .i--rays  alone. 

The  Wassermann  test  was  present  in  74  per  cent,  of  182  cases  (Long- 
cope),  and  in  92  per  cent,  in  those  under  forty  years  of  age  (Harris). 
To  illustrate  the  associations  of  aneurysm,  Chiari  found  that  59  per 
cent,  of  luetics  had  mesa-ortitis  syphilitica  and  Straub  found  84  per  cent, 
of  paretics  with  mesa-ortitis. 

Differentiation. — Differentiation  from  solid  tumors  is  determined 
by  their  propagated  non-expansile  pulsation,  their  more  rapid  develop- 
ment, leukocytosis,  adenopathy  and  cachexia.  In  aneurysm  the  lymph 
glands  are  rarely  enlarged.  Pain,  recurrent  paralysis  and  dysphagia 
are  common  to  all  tumors,  aneurysmatic  and  neoplastic.  .  Venous 
ectasia  is  more  common  in  tumor.  A  few  rare  instances  of  coincidence 
of  tumor  and  aneurysm  are  observed.  The  pulsation  in  carcinoma  is 
rarely  associated  with  a  diastolic  "back  stroke,"  which  is  frequent  in 
aneurysm.  An  unequal  pulse  suggests  aneurysm  or  atheroma.  The 
bruit  in  tumor  is  usually  systolic,  but  murmurs  are  frequently  absent 
in  aneurysm.  Tugging  is  present  in  both  but  more  common  in  the 
latter.  Aneurysm  runs  a  much  more  protracted  course  than  tumors. 
Exploratory  puncture,  the  .r-rays  and  diagnosis  ex  juvantihus  with 
mercury  and  iodides  are  of  differential  importance. 

Other  causes  for  pulsation,  such  as  a  dynamic  throbbing  (aortic  regur- 
gitation), throbbing  in  acute  aortitis,  pulsation  in  an  aorta  dislocated 
from  kyphosis,  and  pulsation  in  pneumonia,  anemias,  or  in  vascular 
tumor  of  the  lung  or  pleura,  are  usually  diflferentiated  when  all  symptoms 
and  signs  are  carefully  considered.  In  ijulsating  empyeraa  the  dulness 
is  usually  low  in  the  chest  and  largely  left-sided;  puncture  reveals  pus 
and  stops  the  pulsation. 

Prognosis. — Recovery  is  rare,  though  spontaneous  cure  is  possible 
by  compensatory  thickening  of  the  intima  or  by  organization  and  calci- 
fication of  thrombi  in  the  sac;  Adami  collected  39  cures.  The  course  is 
generally  two  years.  The  author  watched  for  twelve  years  a  blacksmith 
who  worked,  though  he  had  an  aneurysm  of  the  ascending  aorta,  which 
was  as  large  as  his  fist,  and  which  protruded  beyond  the  ribs.  The  size 
of  the  sac  is  of  no  prognostic  value.  Those  of  the  small  "recurrent 
type"  are  most  dangerous,  and  large  ones  may  be  protected  by  connective 
tissue. 

Mechanism  of  Death.— (a)  Rupture  occurs  in  75  per  cent.  of.  cases: 
20  per  cent,  into  the  left  and  13  per  cent,  into  the  right  pleura;  into 
the  left  bronchus  16;  into  the  pericardium  12;  into  the  left  lung  9; 
externally  6;  into  the  esophagus  5;  into  the  trachea  4  per  cent.;  (h) 
suffocation;  (c)  viarasmus;  (d)  intercurrent  disease;  (e)  embolism;  and 
(/)  brain  lesions.  Hemorrhage  usually  shortens  the  course,  but  in  one 
case  rupture  into  the  bronchus  occurred  five  years  before  death.  Another 
patient  suffered  external  rupture  of  the  sac;  he  collected  the  blood 
in  a  basin  and,  though  he  fainted  from  the  hemorrhage,  he  lived  four 
months,  only  to  die  of  typhus  fever.     Stokes  described  an  external 


408  DISEASES   OF   THE  ARTERIES 

rupture  in  whicli  the  pre.senee  of  mind  of  the  nur.-e.  in  -tuffing  some 
cloth  into  the  sac,  kept  the  patient  a.\r.'>-  v^r  >t  '■i.ij--irh-r;il)]f;  time. 

Treatment. — 1.  The  TufiU'II  treatment  ihjTe^  it"Ih  _M<ir_;i_-ni.  Albertini 
and  Valsalva,  "^-ithotit  the  \'ene-ection  recummeiided  by  A'alsalva,  /'.  e.. 
absolute  mental  and  physical  rest  for  several  months,  and  food  reduced 
to  the  mmimumL.  The  blood-pressure  is  greatly  lessened.  The  treatment 
is  of  value  only  in  cases  of  sacs  with  small  necks. 

2.  Iodides  were  given  prominence  by  Balfour,  though  used  first  by 
BouUlaud.  They  increase  the  secretions  but  do  not  inspissate  the  blood. 
It  is  questionable  whether  arterial  tension  and  dilatation  of  the  sac  are 
lessened;  it  is  certain  that  pain  is  alleviated.  T^venty  grams  are  given 
at  a  dose  (v.  page  399) .  Aside  from  relief  of  pain,  they  are  tiseless  in  fusi- 
form or  large  aneurysms  with  wide  communications. 

3.  Cold,  apphcations  may  relieve  pain  when  the  sac  is  superficial. 
Supports  may  relieve  the  pain  and  protect  against  rupture.  Calciimi 
chloride  does  not  promote  coagulation. 

4.  Gelatin  injections  (I  per  cent,  -olution  are  recommended  by  Lan- 
cereaux  to  produce  coagulation  in  the  sac ;  the  results  are  not  convincing. 
There  is  danger  of  embolism  and  tetanus  (q.  v.). 

5.  Electrolysis,  introduction  of  fine  ivire.  compression  and  surgical 
intervention  have  given  discouraging  results.  A  few  recoveries  are 
reported  but  one  cannot  help  comparing  their  small  number  with  the 
probably  equal  number  of  .spontaneous  recoveries  Borger,  in  19<Jij. 
compiled  19  cases  of  dissecting  aneurysms  of  the  aorta  which  recovered  . 
Fatal  thrombosis  or  total  embolism  of  the  aorta  may  occur. 

6.  Dyspnea  is  treated  as  in  cardiac  disease.  Venesection  may  afi'ord 
temporary'  relief,  and  morphine  is  finally  indicated.  Tracheotomy  may 
be  necessary  in  lar^mgeal  spasm  reflex  recurrent  irritation  but  the  actual 
compression  by  the  sac  is  usually  too  low  for  operative  interference. 
r)igitalis  is  at  all  times  contra-indicated. 

Abdominal  Aneurysm. — Constituting  .5  per  cent,  of  aneurysms  of  the 
aorta,  over  two-thirds  occur  in  the  upper  abdomen  and  40  per  cent, 
at  or  aboA'e  the  celiac  axis.  The  average  size  is  that  of  an  orange  and  the 
tumor  usually  develops  from  the  anterior  surface  of  the  vessel  and  grows 
do'omward.    INIost  are  false  aneury.sms. 

Symptoms  and  Signs.- — Four  per  cent,  of  abdominal  aneurysms  are 
latent  clinically;  a  good-sized  sac  may  be  hidden  under  the  arch  of  the 
diaphragm.  Pain  is  severe,  boring  and  constant  or  parox^'smal;  it 
may  lessen  after  hemorrhage  from  rupttire.  Indefinite  gastric  syrnpto?ns 
are  less  frequent  than  duodenal,  where  obstruction  and  hemorrhage  may 
occur.  Inspection  shows  pulsation  in  (:i.5.  expansile  pulsation  in  1.5  and 
tunioT  in  57  per  cent.  Palpation  may  elicit  the  expansile  pjulsation  and 
in  some  cases  a  thrill.  Percussion  may  reveal  dnlness  but  its  close 
relations  give  indefinite  findings:  the  diaphragm  bounds  the  aneurysm 
above;  the  kidney  to  the  left:  the  liver,  pancreas  and  kidney  to  the  right; 
and  the  stomach,  pancreas  and  colon  in  front.  The  tissues  about  the  sac 
thicken  and  produce  adhesion-.  On  aasr-uliafion.  a  si/stoUr-  -murmur 
obtains  in  .50  per  cent,  or  two  tones  are  heard:  a  diastolic  murmur  is 
sometimes  heard.     Piupture,  diffusion  by  di.-section,  great  thickening 


ANEURYSM  '       409 

of  the  sac  and  Tlirombus  formation  may  easily  obscure  all  auscultatory 
signs. 

Diagnosis. — In  Two-thirds  of  the  case<  an  incorrect  diagnosis  is  made. 

1.  ( _''  'MPEESSiox  SYMPTOMS,  gastric  and  duodenal,  may  suggest  ulcer  or 
cancer.  The  spine,  eroded  in  10  per  cent,  of  cases,  may  simulate  lumbago, 
myehtis.  Pott's  disease  and  spinal  tmnor.  Pulsation  should  be  searched 
for  along  the  spine.  The  affection  may  suggest  renal  colic,  kidney  tumor, 
perinephritis  or  psoas  abscess  fiuctuatmg  blood  from  ruptured  Press- 
tire  on  the  splenic  vein  may  provoke  much  splenic  enlargement.  The 
heart  is  rarely  compressed.  Retardation  or  absence  of  the  femoral  pulse 
and  dyspnea  may  be  of  value  in  differentiation. 

2.  Abdomexal  Pn^SATiox. — "Instead  of  being  your  first,  it  should 
be  your  last  idea  that  abdominal  pulsation  is  due  to  aneiu-ysm"  f -Jenner). 
Epigastric  puhafion  may  be  confused  ^vith  cardiac  h^-pertrophy.  Uver 
pulsation,  the  dynamic  pulsation  of  aortic  regurgitation,  the  pulsation  of 
acute  hemorrhage,  or  especially  nem-asthenic  pain  and  throbbing,  with 
thrills,  systoHc  and  even  diastohc  murmurs — P\.osenbach's  "intermit- 
tent dilataTion  of  the  aorta."  The  pulsation  must  be  distinctly  expansile 
(even  then  occasional  errors  are  made;  and  a  definite  sac  must  be  felt. 

3.  CoMMiJXiGATED  THEOBBiXG,  lent  to  a  tumor  of  the  stomach  hing 
on  the  aorta,  may  also  be  attended  by  a  systolic  murmur  but  the  differ- 
entiation is  usually  made  with  ease,  except  in  soft  neoplasms.  Tumors 
are  often  felt  to  better  advantage  in  the  genupectoral  attitude;  they 
are  more  movable,  more  often  produce  dilated  veins  and  ascites.  Ab- 
dominal aneurysms  may,  in  exceptional  cases,  be  movable.  Stokes 
held  that  tumors  developed  upward  and  aneurvsms  downward. 

-1.  (a  1  Aneurysms  of  the  celiac  axis  are  difficult  or  impossible  to  dis- 
tinguish. Over  2(1  cases  are  recorded.  They  are  often  traumatic  or 
emboUc  i mycotic),  ifci  Superior  i20  cases,  BacceUi,  1904)  or  inferior 
mesenteric  aneur^-sms  occur  most  frequently  in  children,  from  sepsis. 
(ci  Ch"er  20  cases  of  splenic  aneurysm  are  recorded.  The  spleen  is  often 
enlarged,  'dj  In  the  hepatic  artery  (40  cases.  RoUaod,  190S)  it  is 
induced  by  acute  infections  (73  per  cent.),  trauma,  embohsm  or  gall- 
stones; 41  per  cent,  develop  in  the  main  trunk  and  2.5  per  cent,  in  its 
right  branch;  in  but  1  case  did  it  develop  in  the  artery  of  the  cystic 
duct.  Pain  71  per  cent.  .  hemorrhage  '5S  per  cent.),  icterus  (63  per 
cent. J,  vomiting  and  large  spleen  have  been  noted;  in  79  per  cent,  rupture 
occurred  (in  10  cases  into  the  peritoneum);  they  never  pulsate;  but  once 
was  there  a  systolic  murmur;  Kehr  operated  successfully,  (e)  Over  10 
aneiu-ysms  of  the  coronary  artery  of  the  stomach  are  recorded,  [f)  Renal 
aneurysm  is  rare   26  cases.  Skillem,  1906;  in  3  operation  was  successful). 

Prognosis. — The  clinical  course  averages  one  to  three  years.  Rupture 
occiu's  in  70  per  cent.:  33  per  cent,  into  the  peritoneum;  16  per  cent,  into 
the  pleura;  7  per  cent,  into  the  duodenum;  and  7  per  cent,  into  the  retro- 
peritoneal tissue.   Death  does  not  necessarily  nor  at  once  follow  rupttu-e. 

Treatment. — Treatment  is  as  in  the  thoracic  type.  From  its  acces- 
sibility, operative  procedures  are  more  common  and  somewhat  more 
successful.  Continued  compression  of  the  aorta  has  benefited  cases 
of  aneurvsm  located  low  in  the  abdomen. 


410  DISEASES  OF   THE  ARTERIES 

ACUTE  AORTITIS  AND  ARTERITIS. 

These  are  rare  lesions,  occurring  in  the  aorta  and  associated  with 
syphihs  (v.  page  208),  aneurysm  (v.  page  401),  sepsis,  endocarditis,  or 
in  the  peripheral  vessels  after  influenza  or  other  infections. 

Of  periarieritis  nodosa  (Kussmaul  and  ]Maier,  1866),  or  "arteritis  pro- 
liferans  nodosa,"  only  26  cases  have  been  published;  it  consists  of  local- 
ized proliferation  and  round-cell  infiltration  of  the  intima,  with  its 
rupture  through  the  other  coats,  and  leads  to  thrombosis  or  aneurysm. 
It  is  probably  an  infection.  It  occurs  largely  in  men  between  twenty 
and  thirty-five  years  of  age.  The  nodes  are  seen  in  the  vessels  of  the 
muscles,  heart,  kidney,  intestines  and  skin;  they  produce  hydrops, 
muscular  pains,  nephritis,  convulsions,  paralysis,  vomiting,  diarrhea, 
alimentary  hemorrhage,  epigastric  pain,  low  temperature  and  a  rapid 
pulse.  The  affection  is  fatal  within  six  to  twelve  weeks  and  is  usually 
mistaken  for  typhoid  or  meningitis.  In  one-quarter  of  the  cases  syphilis 
was  an  antecedent  and  one  patient  recovered  under  mercury. 

RUPTURE  OF  THE  AORTA. 

Rupture  results  from  trauma,  endarteritis  or  narrow  aorta.  But  6 
cases  of  rupture  of  a  sound  aorta  are  known  and  only  48  cases  of  spon- 
taneous rupture.  All  coats  may  be  ruptured,  usually  transversely.  If 
the  rupture  is  partial,  the  resulting  aneurysm  may  dissect  even  to  the 
popliteal  arteries.  It  most  often  occurs  in  the  first  segment  when  hemo- 
pericardium  results,  or  into  the  lung,  mediastinum  or  retroperitoneal 
connective  tissue.  The  symptoms  are  sudden  pain,  a  sense  of  "some- 
thing ruptured"  and  acute  anemia;  sudden  death  is  usual,  though 
patients  with  dissecting  aneurysm  may  live  eleven  years  or  even  recover. 

Embolism  of  the  aorta  is  due  to  impaction  of  atheromatous  plaques, 
tumor  tissue,  echinococcus  cysts,  endocarditic  plugs  or  ordinary  thrombi. 
It  is  very  uncommon.  Sudden  death  results  if  embolism  occurs  in  the 
first  part  of  the  vessel.  If  it  occurs  near  the  iliacs,  collateral  circulation 
is  possible.  There  are  pain  and  stiffness  in  the  legs,  sensory  disturbances, 
paresis  and  contractures  from  anemia  of  the  spinal  cord.  The  femoral 
pulsation  is  absent.  The  bladder  and  rectum  are  disturbed.  Hemorrhage 
from  the  stomach,  bowels  and  kidneys  has  been  observed.  The  clot 
may  back  up  toward  the  heart  or  it  may  resorb.  The  prognosis  is  bad 
and  the  treatment  is  symptomatic.  Thrombosis  results  from  infections, 
weak  heart,  aneurysm,  atheroma  or  compression,  mostly  in  the  transverse 
arch  or  abdominal  aorta  at  its  division.  Its  pain,  paraplegia  or  anes- 
thesia is  sometimes  confused  with  spinal  cord  disease.  If  gradual, 
collateral  circulation  may  be  established. 


SECTION  III. 

DISEASES  OF  THE  EESPIRATOEY 
TRACT. 


DISEASES  OF  THE  NOSE. 


ACUTE  RHINITIS,  CORYZA. 

Definition. — An  acute  nasal  infection. 

Etiology.  —  (a)  It  is  an  independent  infection,  sometimes  epidemic 
in  the  spring  and  fall;  cold  is  only  a  predisposing  factor.  The  most 
common  organisms  are  the  ^Micrococcus  catarrhalis,  ^Micrococcus  para- 
tetragenus,  Bacillus  septus,  Bacillus  Friedlander,  and  probably  the 
Bacillus  influenzae  and  pneumococcus;  80  per  cent,  of  cultures  are  nega- 
tive, (b)  It  is  a  concomitant  of  various  infections,  notably  of  influenza, 
measles,  pertussis,  etc.  (c)  Toxic  factors,  as  iodides,  bromides,  ipecac  dust, 
dust,  etc.,  may  cause  coryza.  (d)  Local  disease,  as  chronic  catarrh,  poh'ps 
and  ulceration  are  predisposing  factors. 

Symptoms. — The  initial  symptoms  are  depression,  chilliness,  fever  of 
101°  to  102°,  pains  in  the  limbs  and  sometimes,  in  the  young,  delirium. 
The  mucosa  is  dry,  reddened,  painful  and  swollen.  There  is  repeated 
sneezing  and  anosmia.  Herpes  is  common.  There  follows  a  clear,  watery, 
nasal  discharge  (coryza)  for  one  or  two  days,  which  subsides  at  night  and 
recurs  in  the  morning;  within  two  days  it  becomes  thickened  and  purulent. 
Extension  may  occur  to  the  eyes,  frontal  sinus,  antrum  of  Highmore, 
ear,  by  the  Eustachian  tube,  or  to  the  pharynx  or  larynx.  In  infants 
nasal  occlusion  prevents  nursing  and  may  cause  dyspnea,  because  the 
tongue  lies  so  near  the  palate.  Acute  rhinitis  lasts  one-half  to  one  week 
and  is  seldom  confused  except  with  incipient  measles. 

Treatment. — At  the  very  onset  lavage  with  simple  hot  water  is  often 
sufficient;  Dobell's  solution  (sod.  borat.  and  sod.  bicarb,  aa  oij.  phenol 
5  ss  to  water  5 x),  diluted  freely  to  avoid  irritation,  is  beneficial;  adrenalin 
solution  1  to  1000  is  excellent,  but  excessive  application  may  induce 
edema  of  the  throat  and  epiglottis.  A  cocaine  solution  (the  plain  alkaloid 
gr.  j  to  albolene  5  j)  relieves  turgescence  and  frontal  pain,  but  is  a  danger- 
ous remedy  to  give  into  the  patient's  hands.  Dover's  powder  gr.  x, 
a  saline  aperient  and  a  hot  bath  at  the  onset,  usually  give  relief,  especially 
when  followed  hy. 


412  DISEASES  OF   THE  NOSE 

^ — Extr.  belladonnEe gr.  iiss 

Fluidextr.  aconiti Tllx 

Acetphenetidini gr.  xv 

Camphorse  mouobromatse gr.  xv 

M.  et  ft.  capsuliB  x. 

S. — One  capsule  every  hour  for  five  or  six  doses. 

Ff — Phenolis gr.  iij 

Mentholis gr.  iv 

Olei  theobromatis q.  s. 

M.  et.  fac  suppositoria  no.  x. 
S. — One  locally  in  nose  every  two  hours. 
Menthol  in  infants  may  cause  cyanosis  and  asphj'xia. 

Drugs  are  futile  unless  the  patient  remains  in  bed.    Salicylates  mitigate 
the  frontal  pain.     Cool  baths  may  avert  recurrence. 

HAY  FEVER. 

Catarrhus  sestivus  or  summer  catarrh,  was  first  described  by  Bostock 
(1819).     :\Iorill  Wyman  described  the  "June"  or  "rose  cold." 

Etiology. — The  disease  has  long  been  attributed  to  the  pollen  of  timothy, 
rag  weed  and  golden  rod.  Dunbar  demonstrated  that  pollen  contains 
toxalbumins.  It  prevails  especially  in  the  United  States  and  England, 
develops  in  persons  between  fifteen  and  thirty  years  of  age,  and  twice 
as  frequently  in  males  as  in  females.  It  is  more  common  in  the  educated 
classes,  and  is  most  prevalent  in  the  warm  months  and  in  cities.  Three 
special  factors  are  noted:  (a)  .4  predisposition  in  the  form  of  nervous 
instability,  (b)  A  nasal  irritability  or  turgescence,  to  dust,  odors,  etc., 
h^-peresthesia  of  the  inferior  turbinates,  polyps  or  septal  irregularities; 
Austin  Flint  became  asthmatic  from  sleeping  on  feather  pillows,  (c) 
The  exciting  irritant,  as  pollen,  dust,  sudden  change  of  temperature  and 
apparently  in  some  cases,  mental  excitement.  Local  anaphylaxis  is  the 
most  recent  theory. 

Symptoms. — The  onset  is  that  of  the  vulgar  coryza,  but  with  greater 
constitutional  depression.  Injection  of  the  eyes  with  lachrymation  and 
photophobia  accompanies  or  precedes  the  coryza.  The  throat,  larynx 
and  bronchi  are  dry  and  burning.  Fever,  100°  to  101°,  is  fairly  common. 
There  is  pain  over  the  frontal  sinuses,  sometimes  over  the  temporal  and 
occipital  regions.  The  nasal  vessels  are  congested  and  the  nose  itself 
becomes  swollen  and  injected,  resembling  closely  the  alcoholic  facies. 
In  many  cases  cough  develops,  frequently  with  asthmatic  seizures  like 
bronchial  asthma  {q.  v.).  Recurrences  are  usual  and  attacks  of  coryza 
may  alternate  with  asthmatic  paroxysms.  With  the  first  frost  the 
affection  stops,  as  if  by  magic.  The  outlook  is  good  as  to  life,  for  death 
from  asthma  is  rare;  as  to  recovery,  the  outlook  is  much  less  favorable. 

Treatment. — (a)  Prophylactic  cauterization  of  irritable,  congested  or 
hypertrophic  areas,  and  correction  of  polypoid  or  other  abnormalities 
cure  some  cases  and  alleviate  others,  (h)  Nasal  treatment;  much 
relief  may  be  given  by  irrigating  the  nose  with  1  to  1000  adrenalin  or 
other  astringent  solutions;  suprarenal  extract  in  doses  of  gr.  ij  to  v  has 
been  used  internally,  (c)  The  general  physiological  resistance  is  increased 
by  fresh  air,  cool  rubs,  tonics  and  nervines,     {d)  Change  of  climate  is 


RHINITIS  FI  BRINGS  A  413 

advisable  before  the  date  on  which,  with  certain  regularity,  hay  fever 
appears;  a  sojourn  at  the  seaside,  in  northern  Michigan,  Canada  and  in 
a  high  altitude,  as  the  Adirondacks  or  White  Mountains,  greatly  relieves 
or  checks  the  symptoms,  (e)  Asthma  (v.  Bronchial  Asthma),  (/) 
Dimbar's  serum,  patented  as  pollantin,  is  used  in  the  nose  every  morning, 
as  a  powder.  In  1240  cases  Dunbar  claims  that  56  per  cent,  were  greatly 
helped,  and  31  per  cent,  benefited.    Vaccines  are  being  tested. 

CHRONIC  RHINITIS. 

Minor  cases  of  chronic  nasal  catarrh  are  often  treated  by  the  prac- 
titioner; some  are  due  to  syphilis,  anemia  or  to  other  constitutional 
causes.  Chronic  catarrh  may  develop  from  repeated  acute  attacks, 
or  may  be  chronic  from  the  onset. 

The  Hypertrophic  Form. — The  nasal  mucosa  is  red,  swollen  and 
covered  with  secretion  which  may  desiccate  and  sometimes  form  rhino- 
liths;  the  vessels  are  wide  and  surrounded  by  round  cells,  and  the  sub- 
mucosa  is  thickened.  The  nasal  obstruction  necessitates  oral  breathing, 
partially  nasal  speech,  obtunded  taste  and  smell,  and  produces  an 
elevation  of  the  hard  palate  and  a  peculiar  facial  expression — often 
associated  with  adenoids  and  follicular  hyperplasia  in  the  pharynx. 
The  secretion  is  usually  thick,  yellow  and  purulent,  rarely  thin  and 
abundant.  The  lachrymal  duct  may  be  obstructed,  and  Eustachian 
occlusion  may  induce  deafness;  laryngitis,  bronchitis,  bronchial  asthma, 
polyps  and  sinus  disease  are  not  infrequent  complications.  Nasal  disease 
may  be  the  cause  of  facial  spasm,  limitation  of  the  field  of  vision,  vertigo, 
mental  depression  and  dysmenorrhea.  In  its  treatment  possible  con- 
stitutional factors,  as  anemia,  syphilis  or  scrofula  are  to  be  considered. 
Douches  of  carbolic  acid,  insufflations  of  equal  parts  of  alum  and  calomel, 
and  the  cautery  or  chromic  acid  are  indicated.  Douches  should  be  given 
under  low  pressure,  lest  fluid  reach  the  middle  ear. 

The  atrophic  form  may  begin  as  an  atrophic  process  or  result  from 
hypertrophic  disease.  It  usually  begins  early  in  life.  The  mucosa  is 
pale,  dry  and  metaplastic,  the  erectfle  tissue  wastes,  the  nasal  passages 
are  unduly  roomy  and  the  secretion  emits  a  most  offensive  odor  (ozena). 
Its  actual  cause  is  not  determined;  it  may  originate  in  sinus  troubles. 
Various  microorganisms  have  been  found,  as  the  Bacillus  fcetidus,  mucosus 
and  fluorescens  liquefaciens.  It  is  associated  with  a  widening  of  the 
face  in  33  per  cent,  of  cases.  Its  sequences  are  those  of  the  hypertrophic 
variety.  The  treatment  is  not  satisfactory.  Douches  of  a  1  per  cent, 
permanganate  of  potash  solution,  iodoform  insufflations,  massage  with 
iodine  1  part,  potas.  iodide  10  and  glycerin  100  parts,  and  packing  with 
gauze  soaked  in  balsam  of  Peru  are  employed.  Paraffin  injections  beneath 
the  mucous  membrane  are  recommended  to  restore  the  normal  lumen  of 
the  nasal  passages. 

RHINITIS  FIBRINOSA. 

Rhinitis  fibrinosa  has  been  considered  under  nasal  diphtheria,  to  which 
it  is  most  often  due.     It  may  result  from  streptococcus  and  staphylo- 


414  DISEASES  OF   THE  LARYNX     ' 

COCCUS  infection;  it  occurs  in  measles,  scarlatina,  pneumonia,  typhoid 
and  also  as  an  independent  lesion.  Irrigation  with  1  per  cent,  carbolic 
acid  or  1  to  1000  sublimate  solution  is  efficacious. 

EPIS  TAXIS. 

Epistaxis  is  a  symptom  only.  Its  causes  are:  (a)  Local  nasal  lesions, 
trauma,  catarrh,  picking  of  the  nose,  foreign  bodies,  ulceration  (simple, 
tuberculous,  syphilitic,  carcinomatous)  and  telangiectases  of  the  skin 
and  nasal  mucosa,  (b)  Hyperemia,  either  venous,  as  in  cardiac  and 
respiratory  lesions,  or  arterial,  as  in  cardiac  hypertrophy,  interstitial 
nephritis,  atheroma,  etc.  Some  cases  are  seemingly  vicarious  to  sup- 
pressed menstruation,  (c)  Acute  infections,  principally  typhoid,  (d) 
Hemorrhagic  diseases,  as  pernicious  anemia,  chlorosis,  leukemia,  pseudo- 
leukemia, scurvy,  hemophilia  and  cachexia?,  (e)  Liver  cirrhosis,  icterus, 
and  high  altitudes  are  also  causative. 

The  most  frequent  point  of  hemorrhage  is  the  lower  anterior  part 
of  the  cartilaginous  septum.  The  symptoms  are  local  hemorrhage  from 
the  anterior  nares,  but  occasionally  trickling  into  the  pharynx  may 
simulate  hemorrhage  from  the  stomach  when  vomited,  from  the  intestme 
when  passed  with  the  stool,  or  from  the  lung  when  coughed  up.  Occasion- 
ally acute  anemia  or  death  may  occur,  especially  in  blood  diseases. 

Treatment. — The  patient  should  be  kept  quiet,  in  the  semi-erect 
posture.  After  douching  the  nose  with  hot  or  ice-cold  water  to  which 
adrenalin  1  to  1000  has  been  added,  the  nose  should  be  tamponed  by 
Bellocq's  catheter,  or  in  less  serious  cases  the  patient  enjoined  not  to 
blow  the  nose,  for  this  only  dislodges  the  forming  clot.  Gelatin  may  be 
injected  into  the  nose.  Horse  serum  excels  internal  remedies,  as  ergotin. 
Erosions  or  ulcers  may  be  cauterized  later. 


DISEASES  OF  THE  LARYNX. 

ACUTE  CATARRHAL  LARYNGITIS. 

Etiology. — Acute  catarrhal  laryngitis  is  observed  largely  in  males 
between  twenty  and  forty,  and  in  cold,  windy,  changeable  weather,  (a) 
Cold  operates  only  by  lessening  the  resistance,  particularly  in  delicate 
subjects;  the  bacteriology  of  these  "rheumatic  cases"  is  unknown,  (h) 
Acute  laryngitis  may  complicate  acute  or  chronic  affections  such  as 
measles,  pertussis,  typhoid,  hay  fever  and  tuberculosis,  (c)  Extension 
may  be  caused  per  contiguitatem  from  the  nose,  pharynx  or  bronchi. 
(d)  Chemical,  thermal  or  mechanical  agents,  as  dust,  trauma,  overuse 
of  the  voice,  alcoholism,  inhalation  of  tobacco  smoke  and  internal  use 
of  iodides  are  etiological  factors,  (e)  Stasis  from  thoracic  lesions  or 
enlarged  thyroid,  local  ulcerations  in  the  larynx,  nephritis,  liver  disease 
and  rhachitis  are  also  causes. 


ACUTE  CATARRHAL  LARYXGITIS  415 

Symptoms.— Sudden  fever  or  chill  is  seldom  observed.  The  local 
symptoms  are  rawness  or  tickling,  dry,  even  spasmodic  cough,  and  moder- 
ate pain  on  breathing;  external  tenderness  or  dysphagia  usually  indicates 
coincident  pharyngitis.  After  a  day  a  thin,  transparent  sputum  appears, 
which  later  becomes  purulent,  yellow  or  in  very  rare  cases,  hemorrhagic. 
Some  cases  void  no  sputum  (laryngitis  sicca).  The  voice  becomes  hoarse 
or  is  wholly  lost.  The  laryngoscope  reveals  redness,  viscid  mucus,  swelling 
and  occasionally  epithelial  erosions.  The  false  cords  are  often  swollen. 
The  true  cords  lose  their  smooth,  glistening  appearance  and  become 
uneven,  so  that  their  even  coaptation  is  hindered.  The  swollen  mucosa 
may  get  between  the  cords,  and  their  infiltrated  muscles  are  often  paretic. 
The  acute  symptoms  last  for  a  day  or  two  and  the  catarrh  remains  about 
a  week  longer. 

Diagnosis. — Nervous  aphonia  and  cordal  paralysis  are  distinguished 
by  means  of  the  mirror.     (See  Vagus  Disease.) 

Treatment. — Alcohol  and  tobacco  are  forbidden.  The  general  resist- 
ance is  increased  by  cold  rubbings,  douches  or  baths;  mufflers  should 
be  avoided  and  cold  compresses  should  be  applied  over  the  larynx.  The 
voice  mus.t  be  used  carefully  and  the  nose,  uvula  and  pharynx  should 
be  examined  for  predisposing  lesions. 

At  the  onset  sweating  should  be  induced  by  hot  drinks  and  a  hot  bath; 
Dover's  powder  gr.  x  or  aconite,  is  indicated  as  in  coryza;  rest  in  bed 
is  necessary.  The  voice  must  not  be  used.  An  ice-bag  should  be  applied 
locally;  codeine  or  morphine  with  bromides,  and  inhalations  of  moist 
air  or  steam  should  be  given  (v.  Acute  Bronchitis).  Painting  the 
larynx  with  a  3  per  cent,  silver  nitrate  solution  may  induce  submucous 
extension  and  is  not  to  be  recommended. 

IJ — Heroin,  hydrochloridi gr.  j 

Terpini  hydratis gr.  xl 

Ammonii  chloridi 3ss 

Extr.  glj-cjT:rhizae ' 3j 

M.  et  ft.  capsulse  xxx. 

S. — Two  after  meals. 

In  children  acute  laryngitis  is  attended  by  great  swelling  above  and 
below  the  cords  and  by  stenosis  of  the  small,  infantile  larynx,  resembling 
genuine  croup  (laryngeal  diphtheria),  from  which  it  is-  distinguished 
as  false  croup,  faux  croup  or  laryngite  striduhuse.  After  an  attack  of 
mild  laryngitis,  coryza  or  sore  throat,  the  child  becomes  restless  and 
anxious,  usually  during  the  night  when  the  secretion  accumulates. 
Inspiratory  dyspnea  develops,  there  is  inspiratory  retraction  of  the  inter- 
spaces and  epigastrium,  the  accessory  muscles  of  respiration  come  into 
play,  cyanosis  appears  and  asph^Tfia  seems  imminent.  The  paroxysm 
subsides,  spontaneously  or  after  an  emetic  has  been  given,  to  recur  on 
the  next  two  or  three  nights.  Trousseau  remarked  that  there  is  rarely 
that  complete  aphonia  observed  in  laryngeal  diphtheria.  The  diagnosis 
is  made  from  the  history  of  coryza;  the  absence  of  diphtheritic  patches 
in  the  pharynx  and  of  diphtheria  bacilli,  found  in  diphtheria  even  when 
the  throat  seems  normal;  and  the  absence  of  severe  constitutional 
reaction.    Laryngismus  strididits  {v.  Vagus  Nerve)  is  not  attended  by 


416  DISEASES  OF    THE  LARYXX 

fever,  laryngitis  or  aphonia.  Laryngoscopic  examination  is  notoriously 
difficult  m  easily  frightened  children.  Treatment  is  the  same  as  in  adults; 
hot  drinks,  inhalation  of  steaming  water  and  ipecac  should  be  given  to 
induce  vomiting  and  evacuation  of  laryngeal  secretion;  the  patient  is 
awakened,  at  intervals  and  given  a  hot  drink  to  evacuate  the  mucus. 

Other  acute  forms  are  [a)  laryngitis  acuta  nodosa,  observed  in  rheu- 
matism and  yielding  to  salicylates.  (6)  Laryngitis  fihrinosa,  which  is 
usually  diphtheritic,  but  may  be  streptococcic,  in  measles,  scarlatina  or 
other  infections.  U')  Laryngitis  submucosa  acuta  invades  the  submucous 
tissues.  This  rare  affection  may  develop  as  an  independent  lesion,  may 
follow  a  similar  process  in  the  pharynx  or  may  represent  a  septic  local- 
ization. The  invasion  symptoms  are  severe,  with  fever,  rigor  and  other 
septic  .phenomena.  The  la^^^lgoscope  shows  injection  and  yellowish- 
white,  bulging  areas  of  submucous  suppuration  which,  without  operation, 
almost  invariably  cause  death  by  edema  of  the  larynx  or  by  sepsis, 
for  spontaneous  rupture  is  exceptional.  For  treatment  (a)  an  ice-bag 
should  be  23laced  over  the  larynx,  morphine  given  for  pain  and  whisky 
for  the  sepsis;  (b)  incision  of  the  foci  is  indicated;  and  [c)  if  necessary, 
intubation  or  tracheotomy  should  be  performed. 


CHRONIC  CATARRHAL  LARYNGITIS. 

Etiology. — The  etiology  is  identical  with  that  of  the  acute  form,  of 
which  it  frequently  fpUows  repeated  attacks;  it  is  often  associated  with, 
or  is  dependent  on,  pharyngitis  or  rhinitis. 

Sjrmptoms. — The  symptoms  are  those  of  the  acute  form.  Hoarseness 
alternates  with  fairly  normal  phonation.  By  the  mirror  there  may  be 
seen  injection,  darker  than  m  the  acute  form,  swelling,  secretion  and 
sometimes  hemorrhages.  There  are  forms  "^-ith  no  secretion  [laryngitis 
sicca  chronica).  In  some  forms  granules  appear,  from  proliferation  of 
connective  tissue  (laryngitis  granulosa).  Erosions  and  rhagades  may 
develop  on  the  edges  of  the  cords. 

Treatment. — Prophylaxis  is  the  same  as  in  the  acute  form.  Inhalations 
of  1  per  cent,  tannic  acid  or  of  1  per  cent,  turpentine  and  sod.  bicarbonate 
solution;  insufflations  of  tannic  acid,  lead  acetate  and  alum  aa  gr.  j; 
and  painting  the  larynx  every  third  day  with  a  2  to  10  per  cent,  solution 
of  silver  nitrate  with  the  aid  of  the  laryngoscope,  are  valuable.  Terpin 
hydrate  gr.  iij  t.  i.  d.  is  often  helpful.    Sea  air  may  be  beneficial. 

Other  Chrome  Forms. — Chorditis  tuherosa  occurs  as  small,  grayish 
nodes  on  the  cordal  edges  at  the  jiniction  of  their  anterior  and  middle 
thirds,  especially  in  singers  and  in  alcoholics;  they  are  composed  of 
fibrous  and  epithelial  hypertrophy.  Scarification  and  lactic  acid  are 
indicated  (v.  Tuberculosis). 

Pachydermia  laryngis  U  an  increase  of  the  submucous  tissue  and 
transformed  epitlielium  into  whicli  connective  tissue  grows.  Warty 
excrescences  are  common  between  the  arytenoids,  and  the  thick  mucosa 
may  resemble  cancer.  Topical  application  of  salicylic  or  lactic  acid, 
iodine  in  glvcerin,  electrolvsis  and  the  cauterv  are  indicated. 


FERlCIiONDRITlS  LARYNGIS  417 

Laryngitis  hi/iJertroiJhica  inferior  is  a  hyperplasia  of  the  tissues  below 
the  cords,  and  is  identical  with  rhinoscleroma,  due  to  the  downward 
extension  of  the  rhinoscleroma  bacillus  from  the  nose.  It  may  stenose 
the  larynx.  It  is  treated  by  scarification,  dilatation,  prolonged  intubation, 
iodides,  or,  when  extreme,  by  tracheotomy. 

EDEMA  OF  THE  LARYNX. 

Edema  laryngis  is  a  better  designation  than  edema  of  the  glottis,  as  the 
vocal  cords  are  seldom  involved.  It  is  most  marked  in  the  submucous 
tissue,  about  the  epiglottis  and  aryepiglottidean  folds;  70  per  cent,  of 
cases  occur  in  males  and  89  per  cent,  in  those  over  fifteen  years. 

Etiology. — There  are  three  etiological  forms:  (a)  Inflammatory  edema 
results  from  infiammatory  diseases  of  the  larynx,  submucous  suppuration 
or  perichondritis;  from  typhoid,  syphilitic,  tuberculous  or  cancerous 
ulceration;  from  iodides,  trauma,  surgical  measures,  thermic,  chemical 
and  allied  causes;  extension  from  pharyngitis,  parotitis  or  cervical 
cellulitis;  and  from  infections,  (b)  Congestine  and  hydremic  forms  result 
from  chronic  heart  and  lung  disease,  tumors  and  nephritis,  in  which  it 
may  antedate  edema  elsewhere,  or  from  cachectic  conditions,  (c)  Angio- 
neurotic edema,  as  in  R.  S.  Morris's  fatal  case,  is  the  last  type. 

Symptoms. — Symptoms  appear  with  varying  acuity,  sometimes 
suddenly,  as  in  Bright's  disease,  at  other  times  gradually  but  progres- 
sively. Hoarseness  or  aphonia,  and  a  metallic  congh  are  common.  The 
chief  sign  is  insjpiratory  dyspnea,  which  characterizes  nearly  all  forms  of 
laryngeal  stenosis.  It  is  usually  stridulous,  and  is  attended  by  retraction 
of  the  interspaces,  cyanosis,  up-and-down  excursion  of  the  larynx  and 
ultimate  suft'ocation.  The  mirror  shows  a  pallid  swelling  on  incision  of 
which  a  clear  serum  escapes.  Edema  of  the  epiglottis  and  aryepiglotti- 
dean folds  may  be  felt  with  the  finger  if  the  tongue  is  drawn  forward,  or  it 
may  be  seen  without  the  mirror  if  the  larynx  is  pushed  up  and  the  tongue 
depressed. 

Treatment. — Treatment  is  urgent,  irrespective  of  the  cause,  for  the 
75  per  cent,  mortality  is  due  to  delay  until  the  patient's  strength 
is  exhausted.  Ice  over  the  larynx,  purgatives  and  painting  the  larynx 
with  a  10  per  cent,  silver  solution  are  at  best  palliative.  The  edematous 
tissue  should  be  fully  incised,  and  in  case  this  should  fail,  intubation  or 
tracheotomy  should  be  performed. 

PERICHONDRITIS  LARYNGIS. 

Purulent  perichondritis  of  the  larynx  nearly  always  results  secondarily 
to  various  inflammations  or  ulcerations.  Pus  accumulates  most  fre- 
quently under  the  arytenoid  or  cricoid  perichondrium.  The  cartilage 
may  necrose  secondarily.  Perichondritis  laryngis  most  often  develops 
in  males  between  twenty  and  forty  years  of  age. 

Symptoms. — Its  symptoms  are  commonly  obscured  by  the  causal 
disease.  The  rare  primary  cases  are  the  most  acute.  Well-localized 
pain  and  tenderness  are  peculiarly  significant.  Dysphagia,  especially 
27 


418  DISEASES  OF   THE  TRACHEA  AND  BRONCHI 

from  arytenoid  involvement,  is  frequent,  and  even  aphagia  may  result. 
Phonation  is  impaired  by  the  fundamental  disease,  cordal  paresis  and 
muscular  infiltration.  The  cervical  glands  sometimes  tumefy.  Stenosis 
and  dyspnea  are  present.  The  mirror  discloses  focal  accumulation  of  pus, 
swelling,  redness,  edema  and  perhaps  fistulse  from  intralaryngeal  rupture. 
The  probe  may  scrape  on  eroded  cartilage.  Differentiation  from  laryngitis 
and  edema  is  impossible,  unless  definite  pus  pockets  are  seen.  The 
outcome  may  be  suddenly  fatal  from  rapid  edema;  pus  and  cartilage 
fragments  may  rupture,  thus  giving  relief  or  perhaps  occluding  the  larynx; 
fistulse  may  remain,  and  may  burrow  to  the  mediastinum;  sepsis  and 
aspiration  pneumonia  are  not  uncommon,  and  if  recovery  ensues,  a 
distorted  or  stenosed  larynx  may  remain. 

Treatment.- — Pain  should  be  relieved  by  opiates,  but  early  incision 
under  cocaine,  or  tracheotomy  or  intubation  is  necessary. 

ULCERATIONS  AND  NEOPLASMS  OF  THE  LARYNX. 

The  tuberculous,  leprous  and  syphilitic  ulcers  and  glanders  have  been 
considered.  Superficial  erosions  may  follow  catarrh;  deep  ulcers  result 
from  submucous  suppuration,  perichondritis,  pressure  by  foreign  bodies 
or  laryngeal  "bed-sores"  analogous  to  intestinal  ulceration  in  typhoid,  etc. 

Tumors  include  the  benign  singer's  nodes  (v.  s.),  fibromata,  cysts, 
enchondromata,  lipomata  and  the  malignant  tumors  of  which  carcinoma 
is  far  more  frequent  than  sarcoma.  Primary  cancer  develops  as  an  ex- 
crescence which  assumes  a  cauliflower  appearance;  the  basis  of  the  later 
ulceration  is  nodular  (v.  page  209);  hoarseness  is  an  early  symptom; 
incipient  tumors  are  easily  mistaken  for  laryngitis.  Pain  radiating  to 
the  ears  or  temples,  cough  and  dysphagia  are  constant  in  the  advanced 
stage.  Early  operation  alone  affords  relief;  inoperable  cases  must  be 
narcotized. 

Nervous  aphonia,  the  paralyses  and  spasms  of  the  larynx  are  considered 
under  Affections  of  the  Vagus  Nerve. 


DISEASES  OF  THE  TRACHEA  AND  BRONCHI. 

TftACHEiTis  is  frequent  with  laryngitis  and  bronchitis.  Hemorrhage 
may  result  from  ruptured  varices.  Tuberculosis,  syphilis  and  tumors 
are  very  infrequent. 

ACUTE  BRONCHITIS. 

Acute  bronchitis  in  some  localities  constitutes  10  to  15  per  cent,  of  all 
diseases.  Three-fourths  of  all  cases  occur  in  cold,  dusty  or  variable 
weather,  between  December  and  April.  Its  forms  are  (a)  inflammation 
of  the  larger  air  tubes,  bronchitis  or  tracheobronchitis,  and  (b)  inflamma- 
tion of  the  smaller  tuhides,  known  as  bronchiolitis  or  capillary  bronchitis, 
which  in  children  is  identical  with  bronchopneumonia  {q.  v.).    Badham 


ACUTE  BRONCHITIS  419 

(1819)  coined  the  term  bronchitis  but  it  was  first  described  by  Laennec, 
who  described  every  essential  up  to  its  bacteriology. 

Etiology. — (a)  It  is  a  symptom  of  various  infections,  as  measles,  pertussis, 
influenza  and  typhoid;  or  frequently  also  in  pneumonia,  tuberculosis, 
sepsis,  etc.  In  these  maladies  bronchitis  is  secondary  and  toxemic. 
(b)  Cold  and  bacteria.  It  is  disputed  whether  cold  alone  is  an  adequate 
factor  without  bacterial  cooperation,  but  it  at  least  plays  a  potent  pre- 
disposing part.  Even  in  cases  of  primary  bronchitis  the  pneumococcus, 
pyogenic  cocci,  Friedlander's  pneumobacillus  and  rarely  fungi,  yeasts, 
streptothrix  or  Vincent's  organisms  (v.  s.)  are  detected.  PfeifPer's  Micro- 
coccus catarrhalis  is  found  in  59  per  cent,  of  cases  (Ghon,  Pfeiffer);  it  is 
larger  than  the  staphylococcus  and  often  occurs  in  pairs,  (c)  It  may  re- 
sult from  the  toxic  effects  of  potassium  iodide  orbromide,  tobacco,  mercury 
and  alcohol  which  acts  locally  on  the  air  passages,  (d)  Mechanical  irritayits 
are  dust  and  particles  of  wool,  stone,  etc.,  which  exist  in  many  factories. 
(e)  Constitutional  conditions,  as  nephritis,  rhachitis,  obesity,  diabetes  and 
various  cachexias,  such  as  cancer  or  syphilis,  are  important  etiologically. 
(/)  Venous  stasis  in  the  pulmonary  veins  favors  bronchitis;  mitral  lesions 
are  far  more  important  than  other  valvular  diseases,  arteriosclerosis, 
scoliosis,  etc.  {g)  Respiratory  diseases,  as  pneumonia,  tuberculosis, 
abscess  of  the  lung,  asthma  and  bronchiectasis  are  associated  with 
bronchitis,  {h)  Age:  Acute  bronchitis  is  peculiarly  frequent  in  the  aged 
and  in  children  between  six  and  thirty  months  old. 

Symptoms. — 1.  Acute  bronchitis  of  the  larger  tubes  {macrohronchitis 
or  tracheobronchitis)  begins  (a)  with  some  depression,  sometimes  with 
fever  and  chilliness,  or  in  children  with  marked  toxemia.  It  often  follows 
acute  coryza  or  pharyngitis.  (6)  The  local  symptoms  are  substernal 
raioness  or  tickling;  actual  or  intense  pain  or  tenderness  over  the  sternum 
is  mostly  tracheal,  for  the  bronchi  possess  no  pain  nerves.  On  inspection 
of  the  trachea  there  is  visible  inflammation,  diffuse  or  circumscribed 
injection,  submucous  ecchymosis,  swelling  and  laxness  of  the  mucosa, 
and  dryness,  which  is  followed  by  a  transparent,  glairy  mucous  secretion; 
the  mucous  glands  are  often  distended  by  globules  of  mucin  which  slightly 
resemble  young  tubercles;  these  findings  are  also  noted  in  the  bronchi 
in  the  rare  cases  which  come  to  autopsy,  but  injection  and  redness 
largely  disappear  after  death.  Microscopically  we  observe  inflammatory 
paresis  of  the  vessels,  round-cell  emigration  and  desquamation  of  the 
ciliated  epithelium,  (c)  The  cough  is  at  first  dry  and  unproductive  and 
may  remain  so.  Later  a  viscid,  transparent  sputum  is  raised,  consisting 
of  mucin  and  very  few  white  cells  {sputum  crudum).  A  day  or  two  later 
the  coughing  becomes  less  severe  as  the  sputum  grows  more  abundant 
and  mucopurulent  {sputum  coctum);  it  contains  polymorphonuclear 
and  sometimes  abundant  eosinophilic  leukocytes  and  epithelial  cells 
showing  myeloid  degeneration.  Localized  inflammation  at  the  tracheal 
bifurcation  causes  special  irritation,  {d)  The  symptoms  resulting  from 
cough  are  disturbed  sleep;  hoarseness  from  forcible  closure  of  the  glottis  in 
coughing;  pain  in  the  side  or  at  the  diaphragmatic  insertion,  from  unusual 
strain  on  the  expiratory  muscles;  venous  stasis  which  induces  head- 
ache, vertigo,  swollen  cervical  veins,  cyanosis  and  epistaxis;  mechanical 


420  DISEASES  OF   THE   TRACHEA  AND  BRONCHI 

sequences,  as  vomiting,  involuntary  urination,  especially  in  females, 
weak  and  old  subjects;  and  in  women,  even  abortion  or  uterine  prolapse, 
(e)  Physical  findings  are  usually  hilateral;  unilateral  signs  suggest  other 
lesions,  especially  tuberculosis.  Auscultation  reveals  rhonchi,  wliich 
result  from  swelling  of  the  bronchial  mucosa,  slight  stenosis  by  bronchial 
secretion  and  air  passing  through  or  dislodging  the  secretion;  they  at 
first  are  dry  (r.  sicci),  and  later  moist  (/•.  humidi).  Over  the  large  tubes 
these  rales  are  sonorous,  in  the  smaller  tubules  they  are  sibilant.  They 
may  be  heard  simultaneously  over  the  large  and  small  passages,  or  over 
the  large  and  then  by  extension  over  the  small  tubules.  These  rales, 
large  and  small,  may  be  felt  ■udth  the  hand  (mucous  fremitus)  or  may  be 
heard  without  the  stethoscope.  The  breathing  may  be  "cog-wheel," 
lengthened  or  slowed,  but  in  quality  it  is  only  exaggerated  or  puerile, 
never  bronchial.  Thoracic  breathing  develops  in  men  when  the  tubes  in 
the  lower  lobes  are  invaded.  Percussion  is  wholly  negative.  ^Nlacrobron- 
chitis  lasts  a  few  days,  possibly  longer  than  a  week. 

2.  Microbronchitis  or  capillary  bronchitis  will  be  considered  under 
bronchopneumonia,  because  of  its  great  tendency  toward  pulmonary 
inflammation. 

Treatment. — In  the  early  stage  a  full  hot  bath  may  be  given,  followed 
by  a  hot  alcoholic  drink.  A  hot  Turkish  bath  is  dangerous  from  the 
exposure  afterward.  Hot  fomentations,  a  hot  water-bag  or  large  poultice 
may  be  applied  over  the  sternum,  but  cold  packs  over  the  neck  and  chest 
are  even  more  efficacious.  But  few  patients  recover  promptly  unless 
they  are  kept  in  bed.  With  the  initial  symptoms,  gr.  x  of  Dover's  powder 
should  be  given;  it  relieves  pain,  muscular  soreness  and  coughing  and 
modifies  the  inflammation;  in  children  it  should  be  given  with  caution 
because  of  the  frequently  unequal  mixture  of  its  constituents,  and  the 
peculiar  susceptibility  of  the  youthful  nervous  system  to  narcotics; 
in  the  aged  it  should  likewise  be  administered  with  care,  because  the 
kidneys  in  old  persons  excrete  slowly,  and  in  cerebral  atheroma  may 
induce  psychical  disturbance  and  Cheyne-Stokes's  breathing.  Opiates 
are  followed  by  some  saline  aperient.  Other  treatment  is  frequently 
superfluous,  but  if  the  cough  persists  or  the  initial  symptoms  are  severe, 
we  administer: 

I^ — Vini  antimonii 5iv 

Heroin  hydrochloridi gr.  is 

Vini  ipecacuanha 5v 

SjT.  tolutani q.  s.  ad.     gij 

M.  et  S. — One  teaspoonful  every  three  or  four  hours.  The  physician  should  watch  lest 
gastric  symptoms  appear. 

Brown  mixture  may  be  given  (see  Chkonic  Bronchitis). 

I^ — Potassii  citratis oiiss  3J 

Codeinse  sulphatis gr.  iv         gr.  j 

SjTupi  ipecacuanhse 3iv  3iss 

Succi  limonis §j  5ss 

AquEe q.  s.  ad.  gij  §ij 

M.  et  S. — One  teaspoonful  every  two  hours.  The  first  column  is  the  dosage  for  adults, 
the  second  for  children. 


CHRONIC  BRONCHITIS  421 

For  high  fever  aconite  and  belladonna  may  be  given,  as  in  coryza,  but 
tepid  sponging  is  more  beneficial.  A  kettle  of  water  (with  co.  tr.  benzoin 
oj-Oj)  kept  boiling  in  the  room  moistens  the  atmosphere,  or  a  steam 
tent  may  be  advisable,  as  in  croup  (see  page  89).  See  formulae  under 
Chronic  Bronchitis. 

CHRONIC  BRONCHITIS. 

Etiology. — The  etiology  is  that  of  the  acute  type.  Chronic  bronchitis, 
common  in  advanced  life,  may  develop  as  a  chronic  process,  or,  more 
often,  follows  repeated  acute  attacks.  It  most  often  develops  on  change 
of  weather  or  as  the  "winter  cough." 

Pathology. — The  larger  bronchi  are  most  involved.  Their  color  is  a 
grayish-red  or  brown;  the  bloodvessels  are  thickened,  and  the  bronchi 
become  thicker  from  extravasation  of  leukocytes  and  proliferation  of  the 
peribronchial  connective  tissue;  the  mucous  membrane  sometimes  hyper- 
trophies and  even  protrudes  in  papillary  excrescences,  or  is  atrophied, 
and  appears  thin  and  pale  like  a  serous  membrane.  Erosions  are 
sometimes  seen  at  the  tracheal  bifurcation.  Stagnation  of  secretion  is 
common.  The  inner  surface  of  the  bronchi  is  at  times  reticular,  due  to 
the  prominence  and  hyperplasia  of  some  elastic  fibers  and  the  wasting 
and  sinking  of  other  elastic  or  muscular  fibers.  Emphysema  is  frequently 
found  at  autopsy. 

Symptoms. — Fever  and  pain  are  absent,  except  in  the  frequent  acute 
exacerbations.  The  usual  physical  findings  in  chronic  macrohronchitis 
are  large  sonorous  rales,  and  sibilant  rales  when  acute  exacerbations 
cause  invasion  of  the  finer  tubules.  The  cough  varies  with  the  intensity 
of  the  inflammation,  the  amount  and  character  of  the  secretion,  or 
changes  in  the  weather.  The  sputum  varies  greatly,  and  upon  its  char- 
acter is  based  the  division  into  the  following  forms:  (a)  Dry  bronchitis, 
the  bronchitis  sicca  of  Laennec,  which  is  seen  in  the  aged,  associated  with 
emphysema;  the  sputum  is  absent  or  very  scant  and  viscid.  (6)  Bro7i- 
chorrhea,  in  which  the  excessive  bronchial  secretion  may  be  mucous,  serous 
or  purulent;  in  the  serous  form  the  secretion  is  thin  and  transparent, 
as  in  Laennec's  case,  in  which  tw^o  quarts  were  raised  daily  for  twelve 
years;  serous  bronchorrhea  may  result  from  enlarged  peribronchial 
glands;  the  purulent  form  may  be  confused  with  bronchiectasis,  lung 
abscess  or  rupture  of  an  empyema  into  the  bronchi,  (c)  Putrid  bronchitis, 
which  complicates  chronic  bronchitis  but  occurs  more  often  with  bron- 
chiectasis, foreign  intrabronchial  bodies  and  tuberculosis;  in  this  form 
the  sputum  stinks,  particularly  when  first  voided.  It  consists  of  three 
layers:  an  upper  foamy,  a  middle  serous  and  a  lower  one  of  granular, 
grayish-green  sediment,  in  which  are  the  mycotic  plugs  of  Dittrich  (1850) ; 
these  plugs  contain  various  bacteria,  leptothrix,  strepto-  and  staphylo- 
cocci, etc.,  and  "acid-fast"  bacilli  which  closely  resemble  tubercle  bacilli, 
though  narrower  and  more  pointed  at  their  ends.  Fat  and  myelin  drop- 
lets, fatty  needles,  leucin  and  tyrosin  are  also  present.  Fever  is  common ; 
"drumstick"  fingers  may  develop,  and  complications  may  follow,  as 
lung  induration,  gangrene,  pleurisy,  hemoptysis,  abscess,  cerebrospinal 
meningitis    or    pseudorheumatism.      (d)    Blood-stained   sputum    occurs 


422  DISEASES  OF   THE   TRACHEA   AND  BRONCHI 

particularly  in  the  brown  induration  of  the  lungs,  due  to  stasis  (see  page 
368). 

Chronic  emphysema  («.  i.)  is  an  almost  regular  complication. 

Diagnosis. — Determination  of  its  relation  to  tuberculosis,  chronic 
nephritis  and  other  causal  factors  is  most  important. 

Prognosis. — The  prognosis  depends  on  the  etiological  factors.  Ab- 
solute recovery  is  most  unlikely. 

Treatment. — 1.  Prophylaxis.  Causal  affections  require  treatment. 
Woolen  underwear  protects  against  sudden  changes  of  temperature. 
In  obstinate  cases  restriction  of  fluids  may  benefit. 

2.  Climate. — ^A  dry,  warm,  even  climate  is  beneficial,  as  Florida, 
California,  New  Mexico,  Egypt  and  the  Riviera. 

3.  Cough. — Codeine,  morphine,  creosote,  cod-liver  oil  and  other 
remedies  are  employed  as  in  tuberculosis  (g.  v.).  Ammon.  carb.  {v. 
PneujMONIa)  gr.  iij  can  be  given  with  syr.  senegse  5j;  syr.  scillse  5j  is 
incompatible  with  ammon.  carb.  but  may  be  combined  with  ammon. 
chlor.  gr.  v-x. 

I^ — -Ammonii  chloridi oiss 

Misturae  glycyrrhizse  composite §iv 

M.  et  S. — One  teaspoonful  after  meals. 

The  mistura  glycyrrhizse  composita  (Brown  mixture;  paregoric  12 
parts,  antimonial  mne  6  and  sweet  spirits  of  nitre  3)  may  be  given, 
5j-iv.  If  the  heart  is  weak,  it  is  contra-indicated  because  of  the  anti- 
mony. The  stomach  may  become  deranged  by  the  ammonium,  syrups, 
etc.  Chloroform  is  valuable  in  paroxysmal,  unproductive  coughs,  which 
opiates  may  not  alleviate. 

I^ — Amimonii  carbonatis     .       .       . 3  3 

Spiritus  chloroform! oiss 

Syrupi  senegse q.  s.  ad.  3  iij 

M.  et  S. — One  teaspoonful  in  hot  water  as  indicated. 

I^ — Apomorphinse  hj^drochloridi gr.  ss 

Heroin  hydrochloridi gr.  j 

Spiritus  chlorofornii 5j 

Aquse q.  s.  ad.  gij 

M.  et  S. — One  teaspoonful  two  or  three  times  a  day. 

Syr.  scillse  compositus  (Hive  Syrup)  gtt.  xx-xl,  also  contains  senega, 
tartar  emetic  and  antimony.  Terpini  hydras  is  excellent,  gr.  iij,  t.  i.  d., 
given  in  capsules  with  an  equal  amount  of  benzoic  acid.  The  balsams  are 
even  more  efiicacious,  as  emulsum  ol.  terebinthince  5j  in  milk,  though 
ol.  santali  TTlx-xx  in  emulsion  is  less  likely  to  disturb  the  kidneys; 
halsamum  Penmanwn  5  ss  ranks  with  the  best.  The  balsams  and  creosote 
are  directly  indicated  in  fetid  bronchitis.  Retention  of  secretion  may  be 
treated  by  rhythmical  compression  of  the  chest  during  expiration.  Potas. 
iodide  gr.  v-x,  t.  i.  d.,  is  excellent  in  bronchitis,  asthma  and  emphysema. 

4.  Cardiac  Weakness. — Cardiac  weakness  is  relieved  more  effica- 
ciously by  strychnine  than  by  digitalis. 


BRONCHIAL  DILATATION— BRONCHIECTASIS  423 


FIBRINOUS  BRONCHITIS. 

Etiology. — There  are  three  types  of  fibrinous  or  croupous  bronchitis; 
(a)  The  infrequent  'primary  form,  of  which  McPhedran  collected  204 
cases  (1907);  it  occurs  in  males  (66  per  cent.),  between  ten  and  thirty 
years  of  age,  and  in  weakly  subjects;  it  results  from  the  Bacillus  diph- 
therise,  pneumo-,  strepto-  and  staphylococcus,  aspergillus  fungus,  and 
protozoa,  or  from  their  toxms.  {h)  The  secondary  type  develops  by  ex- 
tension from  laryngeal  and  pulmonary  disease,  or  in  infections,  as  diph- 
theria, pneumonia,  etc.;  tuberculosis  causes  50  per  cent,  of  this  group. 
(c)  Mechanical,  thermal  and  chemical  agents,  valvular  heart  disease 
and  exophthalmic  goitre  are  causative  factors  in  a  few  cases.  Fibrinous 
bronchitis  was  first  clearly  described  by  Clark,  in  1697,  though  Hippo- 
crates and  Galen  mentioned  the  condition. 

Symptoms. — The  early  symptoms  of  bronchitis,  sometimes  with  fever, 
chills  and  hemoptysis  (in  33  per  cent.),  are  ambiguous  until  bronchial 
casts  of  fibrin  or  mucin  are  expectorated,  after  a  severe  coughing 
paroxysm.  The  casts  may  be  eight  inches  long,  and  as  thick  as  a  finger; 
their  upper,  larger  parts  are  circular  or  oval,  solid  or  hollow,  but  the 
lower,  small  portions  are  branched,  solid,  spiral  and  often  beaded  with 
air  an,d  clubbed  at  their  tips.  Though  usually  fibrinous  or  croupous, 
many  casts  are  mucous  (bronchitis  mucinosa).  Their  microscopic  appear- 
ance is  hyaline,  their  tex;ture  fibrillar,  and  their  surface  covered  with 
blood  disks,  hematoidin  or  Charcot-Leyden  crystals.  Smaller  casts  may 
not  be  seen  until  the  sputum  is  washed  of  the  adherent  blood,  pus  or 
mucus.  Pending  their  evacuation,  there  are  signs  of  unilateral  bronchial 
stenosis,  e.  g.,  dyspnea,  cyanosis  and  inspiratory  retraction,  and  absence 
of  breath  sounds  in  the  corresponding  lung.  Slipping  of  the  casts  in  the 
bronchus  may  cause  peculiar  flapping  rales.  Niemeyer  observed  the 
daily  shedding  of  a  complete  cast  of  a  bronchus  and  its  divisions. 

Diagnosis. — In  some  cases  casts  are  not  voided  during  life,  and  are 
found  first  at  autopsv.  Asthma  and  bronchitis  fibrinosa  have  certain 
common  symptoms,  as  paroxysmal  occurrence,  eosinophilia,  crystals  and 
spirals,  but  are  usually  differentiated  with  ease. 

Course  and  Prognosis. — In  the  acute  form,  which  lasts  two  weeks  or 
less,  there  is  a  death-rate  of  75  per  cent,  in  the  young  and  50  per  cent, 
in  adults  from  asphyxia  during  evacuation  of  the  casts.  In  chronic 
forms  the  process  lasts  for  months,  years  or  decades. 

Treatment. — Treatment  is  unsatisfactory  if  not  futile.  Inhalation  of 
steam  and  alkaline  vapors  and  pilocarpin  are  given  to  loosen  the  casts, 
emetics  to  facilitate  evacuation  and  iodides  and  mercurial  inunctions 
to  inhibit  reformation. 


BRONCHIAL  DILATATION,  BRONCHIECTASIS. 

Etiology  and  Pathology. — Laennec  first  described  bronchiectasis  in 
1819.  It  is  found  in  2  per  cent,  of  autopsies  and  is  always  secondary 
(a)  to  bronchial  disease,  stenosis  preeminently,  and  influenza,  pertussis. 


424       DISEASES  OF   THE   TRACHEA   AXD  BROXCHI 

foreign  bodies  or  pressure  by  aneurysm;  (h)  to  lung  disease,  tuberculosis, 
interstitial  or  bronchopneumonia  or  atelectasis;  coughing  increases  the 
expiratory  pressure,  even  fortyfold;  (c)  to  pleural  disease,  such  as  ad- 
hesions pulling  on  the  bronchi.  Xearlv  all  cases  are  acquired  and  77 
per  cent,  occur  in  middle-aged  males.  The  rare  congenital  cases  may  be 
divided  into  (i)  the  unilateral,  universal  or  diffuse  form,  (ii)  those  due  to 
congenital  atelectasis  and  (iii)  those  resulting  from  bronchial  (syphilitic) 
stenosis. 

There  are  tico  forms  of  bronchiectasis:  (a)  The  cylindrical  or  fusi- 
form, multiple  or  pafer  noster  form,  which  develops  from  the  atrophv 
of  the  muscular  and  elastic  fibers  induced  by  protracted  coughing  and 
stagnation  of  secretion,  e.  g.,  in  catarrhal  pneumonia,  whooping-cough  or 
emphysema,  (b)  The  rarer  sacculated  form,  in  which  the  bronchus,  reach- 
ing a  diameter  of  even  3  inches,  might  be  called  a  bronchial  aneurysm. 
The  connective  tissue  wastes,  the  ciliated  are  replaced  by  flat  epithelia, 
and  the  mucosa  is  thin,  red,  sometimes  villous.  The  sacs  close  at  their 
necks,  particularly  when  caused  by  aneurysm,  syphilis  or  tuberculosis, 
and  are  filled  with  gelatinous  or  cheesy  contents.  Lung  stones  of  calcium 
carbonate  and  phosphate  may  develop;  they  sometimes  cause  "bronchial 
colic,"  or  symptoms  like  phthisis. 

In  multiple  bronchiectasis  the  lung  sometimes  resembles  a  sponge  or 
porous  cheese.  It  occurs  principally  in  the  lower  lobes,  in  bronchi  of 
the  third  and  fourth  order,  and  is  bilateral  in  60  per  cent.  Adhesions 
are  very  common  when  the  cavity  reaches  the  pleura. 

Symptoms. — Weil  stated  that  most  cavities  escape  detection  and  most 
diagnoses  of  cavities  are  incorrect.  Sacculated  give  more  symptoms  and 
signs  than  cvlindrical  forms,  which  are  almost  always  impossible  to 
recognize. 

1.  The  sputoi  axd  cough  are  paroxysmal.  On  change  of  posture 
or  when  secretion  fills  the  sac  and  flows  over  onto  the  normal  sensitive 
mucous  membrane  beyond  it,  cough  develops  and  quantities  of  mucopus 
are  voided  in  the  ''  rnouihfuV  fashion  described  by  "Wintrich.  The 
largest  amount  is  raised  in  the  morning  and  frequently  evokes  vomiting. 
The  daily  quantitv  may  amount  to  a  quart.  Its  odor  is  acid,  sweat-like, 
but  less  offensive  than  the  fetor  of  putrid  bronchitis  or  the  foulness 
of  gangrene.  When  collected  it  forms  in  three  layers;  the  upper  one  is 
foamy,  the  middle  serous  and  the  lower  purulent.  A  nummular  sputum 
may  be  noted,  as  in  tuberculosis,  but  if  put  in  water  it  is  more  flocculent, 
more  granular  and  airless;  and  microscopically  it  contains  altered 
leukocytes  and  fatty  needles,  occasionally  red  cells,  hematoidin  crystals 
and  very  rarely,  when  the  bronchial  wall  is  ulcerated,  elastic  fibers. 

2.  Physical  Ex-\mixatiox. — {a)  Inspection  may  reveal  diminished 
respiratory  movement,  inspiratory  retraction  over  the  cavity  or  flattening 
of  the  chest  wall.  The  patient  generally  leans  toward  the  diseased  side 
to  lessen  the  trickling  out  of  the  secretion.  In  the  rare  bronchiectasis 
of  an  upper  lobe  the  constant  escape  of  the  secretion  results  in  exhausting 
coughing.  The  .T-rays  may  locate  the  ca^■ity.  In  rare  cases  the  cavity 
may  bulge  through  the  interspaces.  (6)  Palpation  and  (c)  percussion: 
Dulness  prevails  when  the  cavity  is  full;   when  it  is  empty  there  is 


BRONCHIAL  DILATATION—BRONCHIECTASTS  425 

tympany.  A  higher  note  on  opening  the  mouth,  on  inspiration  or  change 
of  posture  has  the  same  value  as  in  tuberculous  cavities  (g.  v.).  (d) 
On  auscultation,  bronchial  or  metallic  breathing  may  be  heard  when  the 
cavities  are  superficial  but  it  is  absent  in  dilatations  which  are  small, 
deep  or  full  of  secretion.  Metamorphosing  breathing  is  a  certain  sign  of  a 
cavity,  Skoda's  superficial,  "veiled-puff"  sound  is  frequent.  Large  and 
small  rales,  heard  persistentl}'^  in  the  same  locality,  are  suggestive  of  a 
deep  bronchiectasis.  The  sound  tissue  over  the  cavity  imparts  a  metallic 
consonance. 

3.  Complications. — Emaciation,  putrid  bronchitis,  slight  cyanosis 
and  anemia  are  frequent.  Hectic  fever  is  often  absent,  but  death  may 
result  with  symptoms  resembling  phthisis.  Hemoptysis  from  ulceration 
of  varices  occurs  in  40  per  cent,  of  cases;  pneumothorax,  pleurisy, 
empyema,  lung  induration  or  gangrene,  emphysema,  lobular  pneumonia, 
amyloidosis  and  hypertrophy  and  dilatation  of  the  right  ventricle  are 
fairly  common.  Marie's  osteo-arthropathie  hypertrophiante  pneumonique, 
rheumatoid  affections,  suppurative  meningitis  and  brain  abscess  are 
occasional. 

Diagnosis. — Diagnosis  depends  upon  the  character  of  the  sputum, 
its  paroxysmal  voidance  and  the  signs  of  cavity.  Differentiation  is 
required  (a)  from  tuberculous  cavities;  this  is  made  by  elastic  fibers  and 
tubercle  bacilli  (definitelv  determined  by  inoculation);  tuberculous 
cavities  are  most  often  apical,  but  frequently  bilateral;  they  void  less 
sputum  and  suffer  less  rapid  variation  in  their  physical  signs.  Bronchiec- 
tatic  cavities  occur  mostly  in  the  lower  lobes,  void  more  sputum,  less  often 
induce  hemorrhage  and  more  frequently  cause  right-heart  changes; 
(6)  from  perforating  empyema,  in  which  cholesterin  and  hematoidin 
crystals  are  far  more  frequent  than  in  bronchiectasis;  (c)  from  abscess; 
(d)  from  gangrene  of  the  lung  (v.  i.) ;  (e)  from  putrid  bronchitis,  in  which 
there  is  no  sudden  volume  of  evacuated  sputum  or  signs  of  cavity;  (/) 
from  encapsulated  pyopneumothorax,  which  may  be  very  difficult  of 
dift'erentiation ;  and  {g)  aneurysm  or  tumor  causing  bronchiectasis. 

Prognosis. — Ultimate  recovery  is  exceptional,  except  in  acute  cases, 
e.  g.,  postinfluenzal;  patients  have  lived  half  a  century.  The  complica- 
tions require  consideration  {v.  s.). 

Treatment. — The  therapeutic  indications  are  (a)  evacuation  of  the 
secretion,  for  which  expectorants,  raising  the  foot  of  the  bed,  and  ex- 
piratory compression  of  the  chest,  as  in  bronchitis,  are  somewhat  useful; 
sedatives  should  never  be  given  lest  gangrene  develop;  (6)  modification 
of  putrescence  by  balsamic  remedies,  as  in  fetid  bronchitis;  a  dram  of 
creosote  is  slowly  vaporized  over  a  flame,  and  the  patient,  in  a  closed 
room,  inhales  the  fumes  with  the  eyes  closed  and  the  anterior  nares 
plugged;  the  procedure  may  be  gradually  lengthened  from  a  few  minutes 
to  half  an  hour;  the  irritation  evacuates  the  residual  secretion;  (c)  surgical 
drainage;  an  accessible  cavity  may  be  incised  and  drained,  though 
accurate  diagnosis  of  its  location  is  difficult,  the  mortality  high  and  the 
aft'ection  multiple.  In  Garre's  57  cases,  63  per  cent,  recovered  and  37 
per  cent,  died;  (rZ)  change  of  climate  {v.  Tuberculosis). 


426  DISEASES  OF  THE  TRACHEA  AND  BRONCHI 

TRACHEAL  AND  BRONCHIAL  STENOSIS. 

I.  Tracheal  Stenosis. — Etiology. —  Tracheal  causes  are  rhinoscleroma, 
syphilis  (g.  v.),  tumors  (cancer,  polyp,  fibroma,  enchondroma,  sarcoma 
or  aberrant  thyroid),  foreign  bodies  and  in  rare  cases  perichondritis. 
Causes  outside  the  trachea  are  more  frequent,  as  retrosternal,  cystic 
and  circular  goitre,  or  struma  in  which  hemorrhage  or  inflammation 
has  occurred.  Aneurysm,  adenopathies,  mediastinal  tumors,  vertebral 
tumors  or  caries  and  thymus  hyperplasia  are  other  factors.  Thiesen 
collated  135  cases  of  tracheal  tumor,  of  which  89  were  benignant  and  46 
malignant;  24  were  fibromata  and  10  intratracheal  struma  (penetrating 
the  rings  of  the  trachea,  when  sudden  death  may  result,  Paltauf). 

Symptoms. — The  symptoms  develop  three  stages:  (a)  no  symptoms 
or  symptoms  only  on  exertion;  (b)  constant  dyspnea,  and  (c)  suffocative 
attacks  and  final  asphyxia.  Dyspnea  is  mixed,  i.  e.,  inspiratory  and 
expiratory;  respiration  is  slowed,  there  is  inspiratory  stridor  and  inter- 
costal retraction,  all  tihe  accessory  muscles  come  into  play  and  the  head 
is  held  well  forwardr  The  pulse  is  tense.  Tracheoscopy  may  reveal  the 
location  of  the  lesion;  the  patient  should  stand  with  his  back  to  the 
strong  sunlight,  with  the  head  bent  forward,  and  the  observer  seated  on 
a  low  seat  before  him.  In  25  per  cent,  of  tracheal  stenoses,  due  to  tumor 
or  aneurysm,  there  is  coincident  paralysis  of  the  vocal  cords. 

II.  Bronchial  Stenosis.  —  Etiology. — Intrabronchial  causes  are  most 
common  and  consist  of  pus,  mucus,  blood,  fibrin  and  foreign  bodies; 
obstruction  due  to  the  latter  is  laryngeal  in  33,  tracheal  in  26  and  bronchial 
in  41  per  cent,  of  the  cases.  Extrabronchidl  factors  are  next  in  frequency; 
aneurysm,  mediastinal  lymphosarcoma  and  perilymphadenitis  leading 
to  fibrosis  occur  most  often;  less  common  are  pericarditis  with  effusion, 
dilatation  of  the  left  auricle,  cancer  of  the  esophagus,  tumor  of  the  lung 
and  thyroid  or  thymic  strumas.  Twenty  cases  have  been  reported  in 
which  lymph  glands  ruptured  into  the  trachea  or  bronchi,  causing  suffoca- 
tion; only  three  were  saved  by  tracheotomy.  Interbronchial  causes 
{i.  e.,  in  the  bronchial  wall)  are  the  least  common,  as  syphilis,  rhino- 
scleroma  and  tumors.  Thirty-six  cases  of  primary  cancer  are  recorded. 
The  right  is  stenosed  nearly  twice  as  often  as  the  left  bronchus. 

Symptoms. — Occlusion  of  a  bronchus  lessens  the  amount  of  air  entering 
the  lung  which  it  supplies,  whence  the  vocal  fremitus  and  breath  sounds 
are  weakened  or  suspended  and  the  respiratory  excursion  and  Litten's 
diaphragmatic  sign  are  decreased.  There  is  inspiratory  retraction  of  the 
intercostal  spaces  on  the  affected  side.  Inspiratory  dyspnea  occurs, 
particularly  in  acute  cases.  The  head  is  thrown  forward.  Absence  of 
dulness  excludes  many  causes  of  dyspnea,  as  pneumonia,  etc.;  after  a 
time  a  somewhat  tympanitic  note  may  result  from  relaxation  of  the  lung 
or  acute  emphysema.  A  local  stenotic  murmur  over  the  bronchus  is  present 
in  a  few  cases.  Paroxysmal  dyspnea  may  result  from  stagnating  secretion. 
Coughing  is  usual  and  may  resemble  that  of  pertussis.  The  pulse  is  more 
tense.  The  rr-rays  and  bronchoscopy  may  locate  the  obstruction.  Death 
results  from  (a)  the  original  disease,  as  aneurysm  or  tumor;  (&)  failure 
of  the  right  heart;   (c)  asphyxia,  with  delirium,  cyanosis  or  Cheyne- 


BRONCHIAL  ASTHMA  427 

Stokes's  breathing,  or  (d)  pulmonary  edema,  gangrene,  tuberculosis, 
lobular  pneumonia  or  hemorrhage. 

Diagnosis. — (a)  Of  the  location:  In  laryngeal  obstruction  there  are 
local  findings  and  free  up-and-down  laryngeal  excursion;  the  subject 
holds  the  head  well  back,  and  the  ingress  of  air  to  both  lungs  is  equally 
impaired;  tracheoscopy,  bilateral  lung  involvement,  absence  of  laryngeal 
excursion  and  the  holding  of  the  head  forward  are  proof  of  tracheal 
obstruction;  in  bronchial  stenosis  but  one  lung  suffers  for  air,  the  larynx 
is  nearly  immobile  and  the  head  is  thrown  forward,  (h)  Of  the  nature 
of  stenosis,  certainty  is  impossible  without  physical  signs,  as  aneurysm, 
history  of  foreign  bodies,  etc. 

Treatment. — Treatment  is  that  of  the  cause,  as  syphilis,  tuberculosis; 
thyroid  extract  in  struma;  or  rest,  mercury  iodides  and  venesection 
in  aneurysm.  To  dislodge  foreign  bodies  the  patient  should  be  inverted, 
sharply  struck  on  the  back  and  shaken;  the  physician  should  have  long 
forceps  and  tracheotomy  instruments  in  readiness;  the  mortality  is 
52  per  cent,  without,  and  23  per  cent,  with,  operation. 

Bronchial  and  lung  stones  {v.  s.)  result  from  tuberculosis  of  the  bronchial 
glands,  bronchiectasis,  petrification  of  the  bronchi,  calcification  and 
ossification  of  the  lungs,  and  foreign  bodies.  Boerhaave  described  the 
case  of  the  botanist,  Vaillant,  who  expectorated  400  calculi.  Symptoms 
are  frequently  absent  or  are  those  of  the  primary  disease;  purulent 
bronchitis,  asthma  ("bronchial  colic"),  hectic  fever  and  hemoptysis  mark 
some  cases. 

Stenosis  may  result  from  bronchiolitis  fibrinosa  obliterans. 

BRONCHIAL  ASTHMA. 

Definition. — A  paroxysmal  dyspnea,  due  to  nervous  or  reflex  stenosis 
or  spasm  of  the  smaller  bronchioles,  and  characterized  by  expiratory 
dyspnea,  slowing  of  respiration,  congestion  of  the  bronchioles,  a  peculiar 
mucous  exudation  and  acute  emphysema.  It  is  also  known  as  asthma 
spasmodicum  or  nervosum,  to  distinguish  it  £rom  other  so-called  asthmas, 
as  the  cardiac  and  renal  types. 

Etiology. — When  due  to  no  obvious  cause,  asthma  is  termed  essential 
or  primary,  and  when  due  to  a  clear  cause  it  is  called  symptomatic  asthma, 
reflex  through  the  vagus:  (a)  Nasopharyngeal  disease  often  initiates 
reflex  asthma,  e.  g.,  rhinitis,  tonsillar  hypertrophy,  adenoids  or  pharyn- 
gitis granulosa;  the  nose  may  be  so  hypersensitive  that  the  odor  of  flowers, 
dust,  feathers  or  smoke  precipitates  an  attack.  (6)  Asthma  may  be 
induced  by  pressure  on  the  vagus  trunk,  by  thyroid  tumors  or  enlarged 
bronchial  glands,  following  tuberculosis,  measles,  pertussis  or  rickets, 
(c)  Abdominal  diseases  are  not  frequent  causes,  e.  g.,  asthma  dyspepticum, 
uterinum,  etc.  {d)  Asthma  toxicum  occurs  in  lead  and  mercurial  poisoning, 
uremia  and  gout,  {e)  It  occurs  especially  in  weakly,  anemic,  nervous, 
scrofulous  and  rhachitic  subjects,  in  the  upper  classes,  and  in  males 
(66  per  cent.)  between  the  ages  of  twenty  and  forty  (it  has  recently 
been  claimed  that  33  per  cent,  of  the  asthma  cases  develop  under  ten 
years) . 


428 


DISEASES  OF   THE   TRACHEA   AND  BRONCHI 


The  mechanism  of  the  asthmatic  paroxysm  is  explained  as:  (a)  A 
spasm  of  the  bronchial  muscles;  Trousseau  spoke  of  asthma  as  "  an  epi- 
lepsy of  the  lungs."  (b)  Like  the  exudative  diatheses,  e.  g.,  urticaria, 
angioneurotic  edema,  intermittent  hydrops  of  the  joints,  eczema,  colica 
mucosa,  etc.  (c)  An  acute  exudative  bronchitis,  causing  bronchial  spasm. 
(d)  Meltzer  suggests  that  it  is  an  anaphylaxis.  Its  pathology  is  uncertain, 
as  but  half  a  dozen  autopsies  are  recorded;  the  ciliated  epithelium  is 
desquamated,  the  bronchioles  are  congested  and  there  is  eosinophilic 
exudation. 

Symptoms. — The  attack  begins  very  suddenly,  often  at  night  and 
with  or  without  such  causes  as  fright,  cold,  heat,  change  of  residence, 
etc.  Sometimes  there  are  prodromes,  as  conjunctivitis,  coryza  or  flat- 
ulence and  sometimes  the  attack  coincides  with  the  menses,  (a)  Dysp- 
nea is  the  first  and  the  essential  symptom;  at  first  slight,  it  soon  becomes 
urgent;  the  patient  opens  the  windows,  sits  upright,  grasps  the  arms  of 


Fig.  32. 


-Spirals  and  crystals  in  bronchial  asthma,    b,  Charcot-Leyden  crystals;   a,  Leyden 
and  Curschmann  spirals  magnified,  and  c,  their  natural  size. 


the  chair  to  brace  the  accessory  respiratory  muscles  and  exhibits  extreme 
distress,  anxiousness  and  pallor,  followed  by  cyanosis;  the  dyspnea  is 
expiratory  and  the  abdominal  muscles  are  board-like  during  expiration; 
inspiration  is  somewhat,  and  expiration  is  greatly,  prolonged,  wheezing 
and  whistling;  respiration  is  generally  slow.  (6)  There  is  extreme  cyanosis, 
the  cervical  veins  bulge  out  like  cords,  the  skin  is  clammy,  and  the  pulse 
indicates  poor  oxygenation  by  its  tenseness,  smallness  and  frequency, 
as  also  do  the  far  rarer  headache,  delirium,  twitchings,  convulsions 
and  coma,  (c)  The  cough  is  dry  and  unproductive,  (d)  Other  physical 
signs  are  as  follows:  On  palpation,  the  vocal  fremitus  is  found  decreased 
by  the  bronchial  spasm  or  secretion;  rales  are  often  felt.  The  normal 
percussion  note  is  replaced  by  a  tympanitic  note,  due  to  acute  pulmonary 
emphysema;  the  voluminous  lungs  distend  the  thorax,  cover  the  heart 
and  depress  the  diaphragm,  whose  excursion  is  thus  minimal.  On 
auscultation,  the  vesicular  murmur  is  usually  faint  or  absent  (Laennec) 
because  of  secretion  in  the  bronchioles,  and  loud  whistling,  piping  or 
sibilant  rales  are  heard  often  without  the  stethoscope,  largely  during 


1i 


PLATE    XII 


.:ym^ 


mmm 


'  ^jM^ijUjUf  ^  ^^^ 


'■'■■■"  ^*J^i:W 


''■''"'^■^^ 


1%C 


'% 


1-v. 


sputum  from  a  Case  of  Bronchial  Asthma,  showing  large 
numbers  of  Eosinophilic  Leukocytes  and  Free  Granules. 
(Simon.) 


It  will  be  noted  that  the  leukocytes  are  all  mononuclear. 
(Eye-piece  I,  objective  1-8,  Bausch  &  Lomb.) 


BRONCHIAL  ASTHMA  429 

expiration  and  due  to  bronchiole  stenosis,  (e)  Sputum  is  first  voided 
toward  the  end  of  the  attack,  as  a  species  of  crisis  to  the  threatening, 
but  very  seldom  fatal,  asphyxia.  A  few  drams  of  tenacious  mucus, 
resembling  egg  albumen,  and  minute  gray  balls  are  seen.  The  latter  are 
the  "perles"  of  Laennec;  when  unrolled  the  "pearls"  are  seen  to  contain 
the  spirals,  best  detected  with  the  naked  eye,  and  on  a  black  background; 
they  measure  2  or  3  to  10  x  ^  to  1  mm.  and  are  mucin  casts  of  the  bron- 
chioles, to  which  may  cling  leukocytes,  epithelia,  fat  or  myelin  droplets; 
some  show  a  central  band  of  mucin;  it  is  thought  that  they  occur  from 
the  passage  of  mucin  through  the  contracted  bronchioles;  they  disappear 
within  a  day  or  two;  spirals  are  also  present  in  catarrhal  or  fibrinous 
bronchitis  and  pneumonia.  The  Charcot-Leyden  crystals  may  be  seen 
as  yellow  dots  in  the  sputum;  they  are  pointed  and  hexagonal  (not 
octahedral),  consist  of  an  organic  basis  w4th  phosphoric  acid,  and  originate 
from  the  eosinophile  leukocytes  which  are  increased  in  the  sputum  and 
blood,  constituting  a  quarter  to  more  than  half  of  the  white  cells;  W.  W. 
Herrick's  case  had  11  per  cent,  polynuclears,  15  per  cent,  lymphocytes 
and  72  per  cent,  eosinophiles.  The  crystals,  spirals  and  the  occasional 
fibrinous  casts  are  a  result,  not  a  cause  of  the  asthma.    (Plate  XII.) 

The  attacks  last  an  hour  or  two,  to  be  repeated  at  long  or  short  intervals. 
In  the  hebdomadal  form,  attacks  recur  every  Sunday  or  Monday,  due  to 
change  in  routine  or  to  digestive  excesses. 

Diagnosis. — The  diagnosis  is  made  by  its  paroxysmal  occurrence,  the 
expiratory  dyspnea  and  the  transient  emphysema. 

Differentiation. — (a)  All  diseases  causing  inspiratory  dyspnea  can 
be  at  once  excluded,  such  as  edema  or  spasm  of  the  glottis,  paralysis 
of  the  post,  crico-arytenoid  muscles,  tracheal  or  bronchial  stenosis. 
In  glottis  spasm  the  spasm  is  inspiratory  and  short,  the  larynx  moves 
up  and  down,  and  the  epigastrium  retracts  during  inspiration;  there 
is  no  emphysema  and  no  spirals  are  found.  Spasm  of  the  diaphragm 
is  very  rare  (v.  Phrenic  Nerve);  it  lasts  a  much  shorter  time,  the 
epigastrium  bulges  during  inspiration,  there  is  spasm  of  all  the  inspiratory 
muscles,  hysterical  stigmata  are  often  observed  and  the  lungs  are  normal. 
(6)  Expiratory  dyspnea  may  also  occur  in  (i)  chro7iic  hrojichitis  with 
emphysema,  in  which  the  emphysema  and  rales  are  constant  and  eosino- 
philia  is  absent,  (ii)  It  also  occurs  in  movable  tumors  below  the  vocal 
cords  which  may  turn  upward  during  expiration,  as  shown  by  the  laryngo- 
scope, (c)  Asthma  cardiale  is  inspiratory  and  expiratory,  and  therefore 
readily  differentiated;  the  " lungenstarr"  or  lung  distention,  due  to 
engorged  vessels,  may  simulate  the  emphysema  of  bronchial  asthma 
(see  page  368).  Cardiac  asthma  may  occur  either  with  high  or  low 
arterial  tension.     Eosinophilia  is  absent. 

Prognosis. — The  prognosis  is  uncertain  and  depends  on  the  etiological 
accessibility  of  the  asthma.  It  is  more  favorable  in  young  individuals 
than  in  those  of  advanced  years.  Cases  which  recurred  for  sixty-four 
years  are  recorded.  Chronic  bronchitis  and  emphysema  are  likely  to 
develop.    Death  in  an  attack  is  very  rare. 

Treatment. — 1.  Of  the  Attack. — A  hypodermic  injection  of  mor- 
phine  gr.  \,  with  atropine  gr.  -g^  and  spt.  glycerylis  nitratis  Tllij,  gives 


430  DISEASES  OF   THE  LUSG 

the  most  prompt  and  reliable  results.  Chloral  is  useless,  for  the  condi- 
tion requires  single  doses  of  gr.  xxx-xl,  which  are  too  large  for  safety. 
Adrenalin  solution  (1  to  lOOOj  lUx  hypodermically,  usually  gives  instant 
relief ;  it  is  not  w'ithout  danger,  and  the  author  saw  edema  of  the  lungs  and 
doubling  of  the  blood-pressure  follow  its  use.  It  also  may  be  sprayed  into 
the  larynx.  Strong  coffee,  whisky,  a  cigar  or  cigarette,  the  application  of 
cocaine  to  the  nose,  nitrite  of  amyl  pearls,  or  a  few  whiffs  of  chloroform, 
sometimes  give  relief.  The  vexing  question  arises  as  to  lea^^ng  morphine 
in  the  hands  of  the  patient  whose  attacks  often  come  and  go  without 
medical  aid;  as  a  rule  it  is  dangerous.  Inhalation  powders,  burned  like 
incense,  are  very  generally  used.  CLobelia,  powdered  black  tea  and 
powdered  stramonium  leaves,  each  one  ounce;  soak  well  in  two  ounces 
of  a  satiu'ated  solution  of  potassium  nitrate;  dry.;  The  Cigarettes  cVEspic 
contain  the  following: 

Belladonna  leaves 5  5  parts 

Hyoscyamus  leaves 21  parts 

Stramonium  leaves 2f  parts 

Phellandrium  aquaticum 1    part 

Extract  of  opium. i  part 

CherTA'-laurel  water a  sufficiency 

All  these  drugs  depress  the  peripheral  filament.-^  of  the  vagus. 

2.  Of  the  Tendency. — Etiological  therapy  helps  over  half  the  cases; 
cauterization  of  sensitive  areas  in  the  nose,  even  "^^-ithout  gross  lesions,  is 
imperative.  Striimpell  effected  11  cures  by  sweating  ■v\'ith  strong  lamps. 
The  evening  meal  should  be  light,  and  carbohydrates  and  tea  should 
be  restricted;  an  emetic  may  abort  an  attack  of  the  gastric  type.  Xer- 
^dnes  (valerian,  arsenic,  bromides)  may  be  used.  The  best  remedy 
between  attacks  is  potassium  iodide,  continued  for  months;  it  is  com- 
bined to  advantage  with  Fowler's  solution  and  belladonna,  not  only 
to  correct  its  action  on  the  skin  and  secretory  glands,  but  also  for  their 
antispasmodic  effects : 

I^ — Liq.  pota^sii  arsenitis 3j 

Tr.  belladonnse 3J 

Potassii  iodidi 5ij 

Fluidextr.  grindeliae  (U.  .S.  P.j 3vj 

AquEB q.  s.  ad.  giv 

AI.  et  S. — One  teaspoonful  in  water  after  meals. 

A  low  level  near  the  sea,  in  a  semitropical  climate,  helps  tiic  brojicJiitis, 
emphysema  and  dilated  right  heart.  General  hygiene  and  the  hardening 
by  fresh  air  and  cold  rubs  are  important. 


DISEASES  OF  THE  LUNG. 


EMPHYSEMA. 


Definition. — A  pulmonary  disease,  characterized  pathologically  by 
ah'eolar  atrophy  and  distention,  and  clinically  by  a  large  chest  of  the 
inspiratory  type,  distended  lungs,  and  hypertrophy  and  dilatation  of 


EMPHYSEMA  431 

the  right  ventricle.  Emphysema  means  a  "blowing  up"  of  the  lungs. 
It  was  first  described  by  Laennec  (1826). 

Etiology. — Substantive  or  alveolar  emphysema  occurs  mostly  in  indi- 
viduals over  30  or  40  years  of  age,  in  men  more  than  in  women,  and 
in  cold  climates.  The  immediate  cause  is  chronic  bronchitis  and  bron- 
chiolitis (Laennec),  catarrhe  sec;  it  may  follow  bronchial  asthma,  etc.;  its 
infrequency  (0.7  per  cent,  of  autopsies)  is  not  und,erstood,  whence  a 
congenital  hypoplasia  of  the  elastic  tissue  of  the  lung  is  sometimes 
assumed.  Coughing,  blowing,  as  on  wind  instruments,  straining  during 
parturition  or  physical  toil,  artificial  respiration  in  the  newborn,  and 
alcoholism  are  possibly  causative. 

Pathology. — On  opening  the  chest  at  autopsy,  the  lungs  are  found 
distended  {volwnen  pulmonum  auctum,  Traube);  they  overlap  the 
heart,  depress  the  diaphragm  and  narrow  the  mediastinum.  Their 
surface  is  pale  rose-colored  and  presents  numerous  small  vesicles,  |  to 
4  mm.  in  diameter,  or  some  large  bullous  areas  representing  the  fusion 
of  several  alveoli.  The  lungs  crepitate  slightly  to  the  fingers,  under 
which  they  feel,  as  Laennec  put  it,  "like  a  pillow  of  down."  The  lungs 
collapse  but  little  on  section.  In  some  places  the  pigment  deposit  is 
lessened — albinism.  Emphysema  is  most  marked  on  the  surface  of  the 
lung,  particularly  over  the  upper  lobes,  anteriorly  and  near  the  spine. 
The  normally  thin  edges  of  the  lung  are  greatly  rounded.  Histologically , 
two  findings  are  characteristic:  ia)  There  is  atrophy  of  the  inter  alveolar 
elastic  tissue,  so  that  the  alveoli  fuse,  corresponding  to  the  vesicles  seen 
on  the  surface;  these  changes  account  for  nearly  all  the  clinical  findings 
in  the  lung,  (b)  The  capillaries  are  obliterated  by  thrombosis,  which 
explains  the  clinical  hypertrophy,  dilatation  and  ultimate  failure  of 
the  right  heart.  The  bronchi  are  frequently  inflamed,  thickened  and 
shortened. 

Pathogenesis. — The  changes  may  be  brought  about  (a)  mechanically 
by  forced  inspiration  or  forced  expiration,  a  theory  favored  by  clinicians; 
or  according  to  the  pathologist,  (6)  by  nutritive  alterations,  as  vascular 
changes  or  atrophy  of  elastic  or  muscular  tissue;  calcification  of  the 
costal  cartilages  is  probably  more  sequential  than  causal. 

Symptoms. — Symptoms  fall  under  two  headings:  (1)  Expiratory  in- 
sufficiency of  the  lungs,  due  to  their  distention  (from  the  loss  of  elastic 
tissue);  and  (2)  cardiac  insufficiency,  resulting  from  obliteration  of  the 
vessels  in  the  lesser  circuit. 

1.  Expiratory  Pulmonary  Insufficiency. — Normally  expiration  is 
wholly  passive,  resulting  from  tlie  elasticity  of  the  lungs  and  collapse 
of  the  chest.  Expiration  in  emphysema  is  incomplete,  as  shown  by 
the  cyrtometer  (showing  the  chest  more  circular) ;  the  spirometer,  showing 
a  decrease  of  20  to  60  per  cent,  in  the  normal  vital  capacity  (2000  to  4000 
c.c.) ;  and  mensuration  giving  a  reduction  of  the  normal  expansion  of  2 
to  3  inches.  Upon  inspection,  dyspnea  is  the  most  conspicuous  finding; 
it  is  expiratory  and  is  due  to  the  loss  of  lung  elasticity  and  consequent 
impairment  of  lung  circulation  and  oxygenation;  it  is  enhanced  by  exer- 
tion, bronchial  catarrh,  accessions  of  true  asthma  and  by  cardiac  insuf- 
ficiency.   The  respiration-rate  is  increased  to  twenty-five  or  thirty  and 


432  DISEASES  OF   THE  LUNG 

the  type  is  costal.  The  faoies  and  hahitns  are  most  characteristic;  the 
eyes  are  somewhat  prominent,  the  nose  is  bluish  and  thickened,  the  head 
is  thrown  back  and  the  chest  forward  to  give  play  to  the  accessory 
muscles  of  respiration,  and  the  skin  is  cyanotic.  A  network  of  dilated 
veins  is  often  seen  over  the  lower  chest,  resulting  from  venous  obstruction. 
The  jugular  veins  fill  enormously  on  expiration  and  often  pulsate  during 
the  diastole.  The  neck  is  short,  and  the  hypertrophied  sternomastoids, 
scaleni  and  trapezii  protrude  rigidly.  The  back  and  abdominal  muscles 
are  rigid,  and  thus  supplement  the  inadequate  action  of  the  diaphragm. 
The  shoulders  are  elevated,  though  stooped ;  the  chest  is  of  the  permanent 
inspiratory  type  and  is  usually  harrel-shajjed  (from  the  elastic  atrophy), 
rarely  of  the  paralytic  type;  the  anteroposterior,  oblique  and  sometimes 
the  transverse  dimensions  of  the  chest  are  increased.  The  raised  clavicles 
accentuate  the  supraclavicular  spaces  in  which  the  apices  sometimes 
protrude,  on  coughing,  as  hernial  tumors.  The  angle  of  Louis  is  prominent 
and  the  interspaces  are  wider  in  the  upper,  and  narrower  in  the  lower, 
parts  of  the  chest,  and  retract  with  each  inspiration.  The  lower  thorax 
shows  a  groove  indicating  the  attachment  of  the  expiratory  muscles. 
The  play  of  the  diaphragm  is  limited,  as  shown  by  the  .r-rays  and  by  the 
absence  of  Litten's  sign.  Palyation  detects'  the  rigidity  and  dilatation 
of  the  thorax,  its  poor  excursion,  the  hard  muscles,  the  calcified  costal 
cartilages  and  decreased  vocal  fremitus.  The  edge  of  the  liver  may  be 
found  depressed  and  tender  but  the  spleen  is  seldom  palpable.  Per- 
cussion, absolutely  essential  to  a  diagnosis,  gives  a  note  which  is  loud  and 
deep — hyperresonant — or  on  the  sides  and  back  is  actually  "box-like" 
or  tympanitic,  also  described  as  wooden  and  in  extreme  cases  as  dull 
(Skoda).  The  voluminous  lungs  narrow  or  wholly  cover  the  cardiac 
dulness,  depress  the  upper  level  of  the  splenic  and  hepatic  dulness, 
invade  Traube's  space,  and  show  little  respiratory  excursion.  At  the 
back  the  lungs  may  reach  the  twelfth  dorsal  or  second  lumbar  vertebra. 
Upon  auscultation,  expiration  is  found  greatly  lengthened  so  that  it  is  to 
inspiration  as  2  or  4  to  1,  the  converse  of  normal.  Vesicular  breathing 
is  absent,  or  the  breathing  is  indeterminate,  even  when  the  stethoscope 
rises  and  falls.  Rales  result  from  bronchitis  or  stasis;  a  pearly  mucin 
with  few  cells  may  be  evacuated  after  coughing. 

2,  Cardiac  Insufficiency. — The  work  of  the  right  ventricle  is 
increased  because  the  pulmonary  arterioles  are  in  part  occluded,  and 
the  imperfect  expiration  allows  neither  free  aspiration  of  venous  blood 
into  the  auricles  nor  adequate  filling  of  the  aorta.  The  right  ventricle 
therefore  hypertrojjhies,  mostly  about  the  conus,  causing  the  accentuated 
second  pulmonic  tone.  The  diaphragm  is  low,  whence  the  hypertrophied 
and  more  horizontal  heart  beats  in  the  epigastrium.  Dilatation  soon 
follows  and  is  accompanied,  in  advanced  cases,  by  tricuspid  leakage, 
nutmeg  liver,  congested  kidneys,  and  other  signs  of  cardiac  insufficiency. 
The  cardiac  alteration,  so  marked  at  autopsy,  is  obscured  during  life,  as 
the  lungs  cover  the  heart  and  muffle  its  tones.  Functional  heart  murmurs, 
mostly  systolic,  result  from  myocardial  degeneration  or  relaxation. 

The  clinical  course  often  covers  decades.  Patients  may  acquire  emphy- 
sema in  childhood  and  live  to  60  or  70  years  of  age. 


EMPHYSEMA  433 

Diagnosis. — Developed  types  are  easily  recognized  by  the  barrel-chest, 
its  hyperresonance,  the  low  borders  of  the  lungs,  their  lack  of  excursion, 
the  obscuration  of  cardiac  dulness,  the  expiratory  dyspnea  and  cardiac 
stasis. 

Differentiation. — (a)  Acute  distention  of  the  lung  or  acute  emphysema, 
as  after  asthma  or  pertussis,  cannot  be  distinguished  by  one  examination. 
It  is  seen  repeatedly  in  bronchial  stenosis  due  to  aneurysm.  It  regresses 
rapidly  even  after  months,  when  its  cause  is  removed,  (b)  Vicarious  or 
compensatory  emphysema  often  develops  in  one  lung  when  contralateral 
pleurisy  or  cirrhosis  of  the  lung  exists;  it  may  occur  on  the  same  side 
with  the  lesion;  marked  apical  emphysema  almost  certainly  indicates 
some  deeper  induration,  (c)  Emphysema  senile,  Jenner's  "small-lunged" 
emphysema,  is  merely  atrophy  of  the  connective  tissue;  the  lungs  are 
not  enlarged,  but  smaller,  the  diaphragm  stands  higher,  the  cardiac 
dulness  is  increased,  the  chest  flattened,  the  ribs  oblique,  the  respiratory 
muscles  wasted,  the  right  heart  is  not  hypertrophied  and  respiratory 
excursion  is  retained,  (d)  From  interalveolar  interstitial  emphysema  the 
first  differential  point  is  the  etiology;  (i)  trauma,  external  or  internal 
(in  tracheotomies),  and  frequently  with  pneumothorax,  (ii)  Foreign 
bodies,  (iii)  Ulceration  of  the  air  passages,  gangrene,  abscess  or  tuber- 
culosis and  less  often  gastric  ulcer  or  cancer.  Other  etiological  factors 
are  (iv)  forced  entrance  of  air,  as  in  resuscitation  of  the  newborn;  (v) 
severe  coughing  efforts,  as  in  whooping-cough;  (vi)  severe  pressure 
efforts,  as  in  parturition;  and  (vii)  spasm  of  the  glottis.  The  second 
point  is  a  series  of  symptoms  often  present,  as  creaking  in  the  medi- 
astinum, sometimes  systolic;  emphysema  and  crepitation  of  the  cervical 
cellular  tissue,  bulging  of  the  interspaces,  creaking  and  tympany  at  the 
edge  of  the  ribs;  absence  of  the  vesicular  murmur;  and  obliteration  of  the 
heart  dulness.  It  is  usually  fatal,  (e)  In  congenital  hypertrophy  of  the 
lung  (pulmo  excessivus)  the  lungs  are  very  voluminous,  but  their  ex- 
cursion, auscultation  and  percussion-note  are  normal.  (/)  Pneumothorax 
(g.  V.)  is  unilateral,  has  a  more  tympanitic  note  and  is  associated  with 
succussion,  tinkling  rales  and  other  pathognomonic  signs. 

Prognosis. — Recovery  is  unknown  in  the  genuine  substantive  form. 
Transient  forms  often  or  usually  regress  completely.  Life,  even  relative 
comfort,  may  be  sustained  for  years  or  decades.  Much  depends  on 
associated  conditions,  as  frequent  severe  bronchitis,  chronic  nephritis, 
arteriosclerosis  or  myocarditis.  Extreme  forms  impede  the  flow  of  chyle 
which,  with  dyspnea  and  fatigue,  impair  nutrition.  The  most  grave 
complication  is  failure  of  the  right  heart  upon  which  compensation 
devolves. 

Subjects  of  emphysema  show  no  predisposition  to  pulmonary  inflam- 
mation. The  doctrine  that  tuberculosis  (Rokitansky)  or  valvular  disease 
(Bouillaud)  excludes  emphysema  is  incorrect. 

Treatment. — (a)  Prophylaxis  concerns  chiefly  the  concomitant  or  causal 
bronchitis.  Severe  exercise  is  to  be  avoided,  (b)  Coincident  gastric, 
renal  or  gouty  disease  must  be  treated,  (c)  Climate  is  as  important  a 
factor  as  in  chronic  bronchitis,  the  inseparable  associate  of  emphysema; 
high  altitudes  are  avoided,  as  they  directly  promote  emphysema,  (d) 
28 


434  DISEASES  OF   THE  LUNG 

Pneumothcrapy  is  sometimes  beneficial.  It  includes  inhalation  of  thinned 
air,  or,  where  there  is  marked  catarrh,  of  compressed  air.  Two  or  three 
treatments  of  ten  minutes  should  be  given  daily,  and  the  time  should 
soon  be  extended  to  half  an  hour,  (e)  Chronic  hroncJiitis  {q.  v.),  and  (/) 
asthma  (q.  v.)  are  important  considerations  in  treatment.  (</)  Rhythmic 
cominession  of  the  chest,  three  or  four  times  daily,  should  be  practised 
during  20  to  30  expirations;  it  increases  the  circulation  in  the  lung. 
Qi)  Cardiac  insufficiency  is  treated  as  in  valvular  or  myocardial  disease 
(g.  V.)  and  strychnine,  venesection  and  other  measures  may  be  used. 
(i)  Freund's  operation  for  calcification  of  the  first  chondrocostal  joints, 
has  been  done  in  over  50.  instances;  in  some  cases,  striking  benefit  is 
at  once  apparent  but  chondrotomy  has  narrow  indications.  The  therapy 
is  discussed  briefly,  as  no  measure  can  restore  lost  elastic  tissue  or 
patency  to  obliterated  vessels. 

BRONCHOPNEUMONIA. 

This  affection  was  first  well  described  in  1840,  by  Rilliet  and  Barthez, 
who  separated  it  from  lobar  pneumonia  and  recognized  it  as  a  secondary 
disease.  It  might  be  well  classed  among  the  infections,  except  that  unlike 
fibrinous  pneumonia,  it  is  not  due  to  a  specific  microorganism. 

Definition. — Bronchopneumonia  is  defined  with  difficulty;  (a)  etio- 
logicaUy  due  to  various  microbes,  it  is  generally  secondary  to  the  bron- 
chiolitis of  some  specific  infection,  chiefly  in  children;  (b)  pathologically 
it  develops  about  the  bronchioles  (bronchopneumonia)  and  in  a  few 
lobules  (p.  lobularis),  rather  than  throughout  a  lobe;  its  exudate  is 
rather  catarrhal  (p.  catarrhalis)  than  fibrinous,  and  its  distribution  is 
multiple  or  disseminated  (p.  disseminata);  (c)  clinically  it  is  identical 
with  capillary  bronchitis,  which,  in  the  first  years  of  life,  almost  never 
spares  the  lung  tissue;  it  is  marked  by  fever,  cough,  dyspnea  and  cyanosis, 
often  without  signs  of  hepatization. 

Etiology. — (a)  Some  cases,  especially  in  children  under  two  years,  are 
primary;  these  are  estimated  by  Holt  and  Connor  at  35  per  cent.,  by 
others  at  a  much  lower  figure;  (6)  most  cases  are  secondary  to  infections 
aftecting  the  upper  air  passages;  32  per  cent,  follow  measles;  24  per  cent, 
pertussis;  16,  diphtheria;  15,  macrobronchitis;  7,  ileocolitis;  3,  scarlatina; 
2,  influenza;  0.5  per  cent,  each  varicella  and  erysipelas,  (c)  Predisposing 
causes  in  the  young  are  poor  sanitation,  malnutrition,  syphilis,  tuberculosis 
and  rickets.  Bronchopneumonia  causes  9  per  cent,  of  deaths  in  foundling 
asylums,  (rf)  Age.  Most  cases  are  observed  in  children  two  or  three 
years  old.  Seventy-five  per  cent,  of  cases  of  pneumonia  in  children  under 
five  years  of  age  are  lobular  (Holt).  Less  frequently  in  weak,  cachectic, 
nephritic  and  aged  persons  it  may  cause  death,  (e)  In  some  cases  microbes 
may  act  directly  on  the  lungs,  as  in  the  primary  cases  in  children,  in  the 
influenza  of  adults,  and  in  aspiration  or  inhalation  pneumonia.  "Schluck 
pneumonic"  is  prone  to  develop  in  diseases  in  which  the  laryngeal 
sensibility  is  decreased,  as  in  diphtheritic  or  bulbar  palsies;  in  ether 
anesthesia  in  which  the  germ-laden  saliva  is  drawn  into  the  lungs;  in 
comatose  states,  as  apoplexy  or  uremia;  in  mental  diseases;  in  the  new- 


BRONCHOPNEUMONIA  435 

born;  in  partial  drowning;  in  operations  on  the  throat;  or  when  there  is 
persistent  vomiting.  (/)  It  is  probable  that  injection  may  occur  by  the 
hjvvph  or  Wood  stream. 

Bacteriology. — Bronchopneumonia  has  no  specific  bacteriology.  In 
adults  one-third  of  the  cases  show  more  than  one  organism,  the  pneu- 
mococcus  ranking  first  and  the  streptococcus  second;  and  two-thirds 
show  one  germ,  of  which  the  pneumococcus  constitutes  39,  the  strepto- 
coccus 31,  Friedlander's  bacillus  23,  and  the  staphylococcus  7  per  cent.; 
in  children  mixed  infection  is  present  in  half  the  cases,  the  streptococcus 
predominating;  while  in  the  other  half  there  is  but  one  organism,  the 
pneumococcus  being  the  most  common.  Other  germs  found  are  the 
influenza,  typhoid,  tubercle  and  colon  bacilli,  Pfeiff'er's  Micrococcus 
catarrhalis,  tetragenus  and  the  meningococcus.  The  tubercle  bacillus  is 
often  associated  with  the  pneumococcus. 

Pathology. — The  foci  of  consolidation  are  usually  diffused  in  the 
lower  and  sometimes  in  the  upper  lobes,  posteriorly  and  usually  bi- 
laterally. They  vary  in  size  from  a  pin-head  to  a  walnut  or  larger; 
most  foci  lie  near  the  pleura,  through  which  they  may  be  seen  and  felt; 
the  pleura  is  often  granular  or  fibrinous.  On  section  the  consolidated 
nodes  appear  reddish-brow^i  and  later  yellowish  from  fatty  degeneration 
of  the  cells;  they  are  firm,  airless,  whence  they  sink  in  water,  and  on 
section  are  generally  smooth  and  glistening,  though  some  pneumococcus 
infections  show  the  granulation  and  viscid  secretion  of  genuine  fibrinous 
pneumonia.  The  bronchioles  supplying  the  consolidated  nodes  are 
plugged  with  mucopus,  so  that  air  cannot  be  forced  through  them;  the 
bronchioles  are  reddened,  swollen  or  ecchymotic.  Though  atelectasis  is 
frequent  its  importance  has  been  overestimated.  In  fortunately  made 
sections  a  dendritic  or  grape-like  arrangement  may  be  seen  in  which 
the  bronchioles  correspond  to  the  stems  and  the  alveoli  to  the  leaves 
or  grapes.  MicroscojncaUy  the  bronchioles  show  dilated  vessels  and 
leukocyte  emigration,  the  alveoli  show  epithelial  desquamation,  serous 
exudation,  leukocyte  outpouring  and  a  scattering  of  red  cells;  the 
alveolar  walls  show  interstitial  inflammation.  Though  influenza  pneu- 
monia is  strictly  cellular  {catarrhal),  aspiration,  pneumococcic  and  other 
forms  not  infrequently  show  a  fibrin  network,  though  decidedly  less  tlian 
in  lobar  types.  Near  the  foci  and  in  the  upper  lobes  compensatory 
emphysema  appears.  Extension  occurs  from  alveolus  to  alveolus  or 
along  the  peribronchial  tissues.  In  some  forms  numerous  lobular  foci 
fuse  so  that  the  greater  part  of  a  lobe  consolidates;  this  pseudolobar 
form  is  often  due  to  the  pneumococcus,  is  seen  in  measles  and  diph- 
theria and  clinically  may  closely  simulate  lobar  pneumonia,  though 
pathologically  areas  of  collapsed,  vascular  or  sound  tissue  lie  between 
the  bronchopneumonic  patches. 

Symptoms. — The  clinical  picture  varies  considerably.  In  the  primary 
form,  most  often  pneumococcic,  the  onset  is  brusque,  with  chill,  vomiting 
or  pain  in  the  side.  The  fever  rises  suddenly,  and  often  falls  by  crisis. 
Capillary  bronchitis  is  absent,  consolidation  is  often  marked,  the  course 
short  and  the  death-rate  low.  In  adults  this  form  is  frequently  unilat- 
eral.    The  more  common  secondary  form  begins  insidiously,  if  it  follows 


436  DISEASES  OF   THE  LUXG 

a  microbronchitis ;  it  is  often  obscured  by  tlie  disease  it  complicates. 
The  fe\'er  gradually  rises  to  103°  or  104°,  and  is  irregular  or  remittent, 
rising  with  each  new  focus;  fever  in  bronchitis  seldom  exceeds  102° 
and  higher  registrations  suggest  pneumonia;  it  may  be  low  or  absent 
in  marantic  subjects.  There  may  be  no  physical  findings,  or  they  are 
frequently  indeterminate.    If  recovery  ensues,  lysis  is  the  usual  solution. 

Subjective  and  Gexeral  INIaxifestatioxs. — These  are  often  more 
obvious  than  the  objective  pulmonary  symptoms.  The  pulse  rises  to 
120  or  even  180  and  in  convalescence  is  more  tardy  in  reaching  normal 
than  the  fever.  The  respiration  is  often  60  to  80,  the  expiration  is  fre- 
quently catchy  or  grunting,  and  the  respiration-pulse  ratio,  normally  1  to  4, 
becomes  1  to  3  or  2;  dyspnea,  restlessness  and  irritability  develop  early. 
Cyanosis  arises  from  impaired  flow  of  blood  due  to  continued  coughing 
and  stagnant  secretion.  •  Pain  is  not  as  common  as  in  lobar  pneumonia. 
The  cough  becomes  drier  and  more  distressing;  the  sputum  is  usually 
swallowed  in  patients  under  seven  years  of  age,  but  if  obtained  shows 
nothing  characteristic.  ^Nleteorism  is  not  uncommon  in  severe  or  mori- 
bund cases. 

Lrx'G  FiXDiXGS. — On  inspection,  irregular  excursion  is  sometimes 
seen.  The  accessory  muscles  of  the  nose,  neck,  chest  and  abdomen 
are  in  full  play.  The  interspaces,  ribs,  sternum  and  epigastrium  in 
young  plastic  chests  retract  greatly  with  each  inspiration.  Palpation 
may  show  increased  fremitus  in  a  focus  near  the  surface  and  measuring 
2x5  cm.  Stagnant  secretion  in  the  air  tubes  may  temporarily  suspend 
fremitus.  Percussion  is  often  negative  for  a  few  days  or  even  through- 
out the  course,  as  deep,  isolated  foci  cannot  produce  dulness.  In  the 
thin,  infantile  thorax,  special  importance  should  be  attached  to  light 
palpatory  percussion.  Dtilness  obtains  over  a  focus  having  an  area  of 
2x5  cm.  It  is  most  often  found  along  the  spine  over  the  lower  lobes. 
Dulness  is  most  marked  in  the  pseudolobar  (confluent)  forms.  Atelec- 
tasis may  cause  dulness  but  not  bronchial  breathing.  A  hyperresonant 
note  in  front  indicates  emphysema;  behind  it  shows  relaxation.  Auscul- 
tation reveals  subcrepitant  or  crepitant  rales,  often  heard  over  an  area 
not  exceeding  the  bell  of  the  stethoscope.  Bronchial  breathing  and 
bronchophony  are  fairly  frequent,  and  occur  especially  when  the  child 
cries.    In  other  cases  the  breathing  may  be  rude  or  puerile. 

Special  Types. — Special  types  have  been  considered  under  measles, 
pertussis,  etc.  The  following  classification  gives  the  clearest  under- 
standing of  the  physical  findings:  (a)  hi  capillary  bronchitis  there  is 
no  sign  of  consolidation.  Sibilant  rales,  coarse  and  fine  crepitant  rales 
are  spread  over  one  or  both  lungs.  Sibilant  rales  are  due  to  swelling 
of  the  mucosa  of  the  larger  and  smaller  tubes.  A  feeble  respiratory 
murmur  indicates  areas  of  congestion,  (b)  In  disseminated  broncho- 
pneumonia, characterized  by  small  areas  of  consolidation,  percussion 
usually  gives  negative  results,  or  very  slight  dulness,  and  the  fremitus 
is  not  altered,  since  the  consolidated  areas  are  deep  in  the  lung,  or  too 
small  to  alter  the  percussion-note.  Auscultation  reveals  crepitant  rales 
and  bronchovesicular  breathing  over  the  consolidated  areas.  Vocal 
and  crying  resonance  is  exaggerated,     (c)  In  acute  generalized  broncho- 


BRONCHOPNEUMONIA  43? 

imeumonia,  the  percussion-note  is  dull  over  a  large  area,  even  an  entire 
lobe,  with  increased  vocal  fremitus,  bronchial  breathing  and  fine  moist 
rales,  while  the  rest  of  the  lung  shows  bronchitis. 

Issues. —  Death  may  occur  from  carbonic  acid  narcosis,  irritability 
passing  into  apathy,  the  harassing  cough  becoming  less  marked  and 
allowing  stagnation  of  bronchial  secretion  ("suffocative  catarrh"), 
eventuating  in  heart  failure.  Complete  resolution  is  the  rule  in  cases 
which  recover.  Delayed  resolution  with  remissions  and  exacerbations 
may  occur.  Complications  may  develop;  (a)  pleurisy  is  the  most  fre- 
quent; (b)  gangrene;  (c)  abscess,  especially  in  aspiration  and  influenzal 
forms;  (d)  pulmonary  induration;  (e)  bronchiectasis;  and  (/)  tuber- 
culosis, less  often  a  sequel  than  awakened  by  the  new  infection. 

Diagnosis. — Reliance  on  physical  signs  alone  leads  to  many  errors  and 
a  diagnosis  is  often  determined  only  by  the  symptoms,  sudden  high 
fever,  mild  fever  suddenly  rising  during  bronchitis,  dyspnea,  rapid  res- 
piration, cyanosis,  etc.  In  the  very  young  or  marantic  and  aged  the 
symptoms  may  be  very  atypical.  Lobar  pneumonia  {q.  v.,  variations  in 
children)  occurs  mostly  in  sound  children  over  three  years  of  age,  runs 
a  cyclical  course,  ends  by  crisis,  is  unilateral  and  involves  one  or  more 
lobes;  while  bronchopneumonia  occurs  more  often  in  younger  weakly 
children,  often  after  bronchiolitis,  runs  a  longer,  more  atypical,  unfavor- 
able and  relapsing  course,  resolves  by  lysis,  is  bilateral  and  is  less  marked 
by  definite  pulmonary  findings.  Tuberculosis  is  often  distinguished  only 
by  the  course;  it  invades  the  upper  lobes  more  and  bacilli-laden  sputum 
may  be  recovered  by  washing  the  stomach  or  swabbing  the  throat  after 
the  child  coughs.  Pleurisy  {q.  v.)  is  diagnosticated  by  the  aspirating 
needle. 

Course  and  Prognosis. — The  acute  course  lasts  a  week,  of  which  the 
measles  pneumonia  is  the  prototype;  the  subacute,  lasts  two  to  eight 
weeks,  exemplified  by  pertussis  pneumonia,  and  the  chronic,  covering 
months,  as  tuberculous  bronchopneumonia. 

The  prognosis  depends  on  the  patient's  social  situation,  age,  the  disease 
which  the  pneumonia  complicates  and  its  extent.  The  outlook  is  serious, 
especially  in  the  secondary  forms  (measles  and  pertussis);  in  the  very 
young  it  is  almost  as  fatal  as  infantile  diarrhea;  aspiration  forms  are 
very  grave,  as  are  those  in  marantic  and  aged  subjects.  In  private 
practice  the  death-rate  ranges  from  10  to  33  per  cent.,  in  hospitals  33 
to  50  per  cent.,  and  in  asylums  even  50  to  100  per  cent. 

Treatment. — 1.  Prophylaxis — (a)  In  nasal  or  pharyngeal  infections 
the  nose  and  throat  should  be  frequently  cleaned  with  alkaline  anti- 
septics. (6)  In  laryngeal  or  bronchial  inflammation,  congestion  and 
atelectasis  are  avoided  by  frequent  and  regular  change  of  posture.  It  is  a 
great  advantage  to  avert  influenza,  pertussis  and  measles,  in  the  first 
three  years  of  life,  (c)  Deep  breathing  is  enforced  by  affusions  of  cold 
water  on  the  neck  and  thorax,  {d)  Exposure  should  be  avoided  by 
firmly  fastening  the  nightgown  to  the  foot  of  the  bed. 

2.  Therapy. — Actual  treatment  is  symptomatic,  (a)  The  tempera- 
ture of  the  room  is  maintained  at  67°  to  70°  with  constant  moderated, 
ventilation,     (b)  The  diet  should  be  fluid,  diluted  or  predigested;  egg 


438  DISEASES  OF   THE  LUNG 

albumen,  milk  and  plenty  of  water  are  indicated.  At  the  onset  calomel 
gT.  Y-Q  every  hour  for  five  doses,  is  followed  by  castor  oil.  (c)  Expec- 
toranis,  as  ammonium  carbonate,  tartar  emetic  or  ipecac,  derange  the 
digestion,  which  is  of  greatest  importance.  Aromatic  spirits  of  ammo- 
nia, TUv-xx  every  three  or  four  hours,  is  the  least  deranging,  and 
stimulates,  {d)  Pain  rarely  indicates  opiates,  which  induce  stagnation 
of  secretion,  notably  in  young,  old  or  weak  subjects;  dyspnea,  pain, 
restlessness,  cough,  cyanosis  and  rapid  pulse  may  be  relieved  by  pare- 
goric, which  is  preferable  to  Dover's  powder  or  morphine.  Fresh  air 
is  better  than  drugs,  ie)  Local  applications,  as  poultices  or  pneumonia 
jackets  and  blisters,  are  useless.  (/)  In  the  treatment  of  jever,  anti- 
pyretics, aconite,  antimony  and  other  cardiac  depressants  must  be 
avoided;  cool  applications  are  equally  efficacious;  they  also  lessen 
tympany  and  carbon  dioxide  narcosis,  stimulate  the  heart  and  brain 
centres  and  deepen  respiration,  but  they  must  be  used  with  care  in  very 
young  and  marantic  subjects;  in  such  cases  a  warm  sponge  or  bath 
may  be  given,  with  cold  affusions  to  the  neck  {i\  s.).  (g)  For  cardiac 
stimidants,  brandy  in  daily  doses  of  5ss-iij,  very  well  diluted  in 
water  or  peptonized  milk,  aromatic  spirits,  digitalis,  saline  infusions 
or  enemata,  camphor  or  strychnine  may  be  used.  (See  page  269  for 
dosage.)  {h)  Respiratory  stimulants  include  tr.  belladonna,  ox^'gen, 
thoracic  faradization  and  mechanical  compression  of  the  chest,  ii) 
Emetics  are  unreliable;  ipecac  has  no  effect  in  carbon  dioxide  intoxica- 
tion, whence  it  is  given  with  coffee,  camphor  or  cognac.  Phlebotomy 
is  inadvisable,  {j)  Inhalations  of  steam  (;v.  Diphtheria  and  Croup). 
(/t)  During  convalescence  a  sojourn  in  the  country  or  in  a  warm  climate 
is  advisable. 


INDURATIVE   PNEUMONIA,   LUNG   CIRRHOSIS,   FIBROID   PHTHISIS. 

Definition. — An  overgrowth  of  the  pulmonary  connective  tissue. 

Etiology. — 1.  Diseases  of  the  Lung. — These  may  induce  local, 
lobular  or  lobar,  unilateral  or  bilateral  fibrous  induration.  Local  indura- 
tion frequently  occurs  about  tumors,  tubercles,  gummata,  abscess,  gan- 
grene, etc.,  and  is  of  no  importance,  except  as  it  demarks  dangerous  foci 
of  disease.  Diffuse  induration  is  important,  (a)  Fibrinous  pneumonia 
sometimes  results  in  lobar  induration  (0.7  per  cent.),  notably  in  marantic 
subjects  from  delayed  resolution;  the  lung  becomes  airless  and  dense 
from  fibrous  tissue  within  the  alveoli  whence  it  involves  contiguous 
structures;  on  section  its  surface  is  smooth,  and  the  connective  tissue 
is  strikingly  translucent.  (6)  Bronchopneumonia  in  measles,  pertussis  or 
influenza,  sometimes  leads  to  induration,  beginning  from  an  alveolitis  or 
peribronchitis,  (c)  Foreign  bodies  and  aspiration  pneumonia;  (d)  chronic 
tuberculosis;  and  (e)  syphilis,  gangrene,  etc.,  are  etiological  factors. 

2.  Bronchial  Affections. — (a)  Bronchiectasis,  noted  by  Corrigan, 
who  first  used  the  term  lung  cirrhosis;  (6)  bronchial  stenosis,  as  by 
aneurysm  or  gumma;  and  (c)  pneumohoniosis  and  putrid  and  chronic 
l)ronchitis  may  cause  indurative  pneumonia. 


INDVRATIYE  PNEUMONIA  439 

o.  Pleural  Affections. — In  Charcot's  "pleurogenoiis"  interstitial 
pnenmonia,  strands  of  connective  tissue  invade  and  cirrhose  the  hnig, 
coIl^■e^^•ing  toward  the  hihun. 

Pathology. — The  pathology  of  an  affection  Avith  such  numerous  causes 
can  scarcely  be  described.  The  early  induration  is  reddish,  and  the  older 
connective  tissue  is  darker,  slate-colored  or  gray.  The  new  connective 
tissue  may  be  formed  in  the  bronchi,  septa,  alveoli,  bloodvessels  or 
pleurae.  The  lung  is  airless  and  dense;  is  cut  with  difficulty  and  on  sec- 
tion presents  either  a  granulated  or  a  smooth  surface,  the  latter  in  cases 
following  lobar  or  aspiration  pneumonia  and  sometimes  gangrene.  The 
lung  shrinkage  produces  changes  in  the  mediastinum,  heart,  diaphragm 
and  sound  lung  (d.  i.). 

Symptoms. — Symptoms  in  incipient  or  localized  lesions  may  be  insepar- 
able from  the  caudal  affection  (tuberculosis,  bronchiectasis)  or  may  follow 
closely  upon  it  (pneumonia,  pleurisy).  There  may  be  a  low  fever,  cough, 
dyspnea  on  exertion,  pain  in  the  side,  rapid  pulse,  cyanosis,  anemia, 
malnutrition  and  night  sweats. 

Physical  findings  in  the  typical  chronic  case  are  as  follows:  (a)  On 
inspection  the  interspaces  are  narrowed  on  the  affected  side,  the  nipple 
and  scapula  are  nearer  to  the  median  line,  the  shoulder  is  lower,  the  spine 
is  convex  toward  the  sound  side  and  the  measurement  is  unilaterally 
decreased.  In  left-sided  induration  the  lung  retracts  from  the  heart, 
increasing  its  pulsation  and  disclosing  the  pulmonary  artery,  over  which 
may  be  seen  and  felt  its  systolic  filling  and  the  strong  diastolic  closure 
of  the  pulmonary  valves;  in  right-sided  induration  the  heart  beat  may 
appear  to  the  right  of  the  sternum  or  may  be  covered  up  hy  the  compen- 
satory emphysema  of  the  left  lung,  (b)  Palpation  corroborates  these 
findings,  and,  as  a  rule,  shows  increased  vocal  fremitus.  The  second 
pulmonic  tone  is  much  accentuated,  corresponding  to  the  routine  hyper- 
trophy of  the  right  ventricle  and  the  occasional  atheroma  of  the  pul- 
monary artery,  (c)  Percussion  elicits  dulness  below,  and  sometimes  a 
slightly  h^-perresonant  note  above,  the  indurated  area;  the  apex  of  the 
upper  lobe  is  on  a  lower  level  and  the  diaphragm  stands  higher  (the 
liver  rising  or  Traube's  space  increasing);  there  is  no  respiratory  excur- 
sion, {d)  Auscultation  brings  out  the  absence  of  breath  sounds  below, 
and  bronchial  breathing  and  subcrepitant,  crepitant  and  bubbling  rales 
above.  Additional  signs  result  from  the  right  heart  hypertrophy  and 
dilatation,  from  coincident  bronchiectasis  or  cavitv  formation  on  the 
same  side,  and  compensatory  emphysema  on  the  opposite  side.  There 
is  nearly  always  some  sputum. 

Diagnosis. — Diagnosis  is  more  easily  made  in  chronic  than  in  the 
subacute  postinfluenzal  or  postpneumonic  induration  which  may  sug- 
gest tuberculosis  or  interlobular  suppuration.  Slow-growing  tumors  of 
the  limg  may  cause  confusion.     The  .r-rays  are  helpful. 

Prognosis. — The  prognosis  varies  with  the  etiology.  Ulcers  from  arte- 
rial occlusion  or  infected  bronchial  secretion,  explain  the  frequent  lung 
hemorrhage  (in  .50  per  cent.)  and  its  occasional  role  as  a  cause  of  death. 
Amyloidosis  sometimes  results  but  death  is  usually  caused  by  right 
heart  failure. 


440  DISEASES  OF  THE  LUNG 

Treatment. — Life  may  be  prolonged  for  decades  under  proper  hygiene. 
Exercises  with  the  arms  may  check  the  early  shrinking,  but  nothing  can 
remove  an  established  induration.  Warm  climates  at  the  sea  level  or 
at  slight  elevation  are  beneficial.  Some  writers  hold  that  turpentine 
checks  induration. 

PNEUMOKONIOSIS. 

Zenker  employed  the  term  to  include  various  indurative  diseases  of 
the  lungs  due  to  "dust"  inhalation. 

Etiology  and  Pathology. — 1.  Anthracosis  is  due  to  inhalation  of  carbon, 
coal  dust,  soot,  charcoal  or  graphite,  and  is  known  as  "coal  miner's 
disease"  or  phthisis  melanotica.  (a)  Moderate  amounts  of  carbon 
inhaled  into  the  bronchi  are  absorbed  by  the  leukocytes,  worked  upward 
by  the  ciliated  epithelial  cells  and  expectorated.  (6)  Larger  amounts 
penetrate  the  bronchial  mucosa  to  the  connective  tissue,  or  enter  the 
lymph  stream  whence  they  reach  the  small  lymph  nodes  around  the 
vessels  and  bronchi  or  mediastinal  lymph  glands.  A  moderate  pigmen- 
tation occurs  in  all  city  inhabitants,  while  the  lungs  of  countrymen 
ai'e  pink,  (c)  Very  large  amounts  reach  the  alveoli,  when  the  lungs  are 
ink-black;  connective  tissue  'proliferation  develops  in  insular  foci  (endo- 
perialveolitis  nodosa  and  endoperilymphangitis  fibrosa);  the  foci  occa- 
sionally measure  5  x  15  cm.,  on  section  are  hard  and  exude  an  inky 
fluid.  Induration  involves  the  mediastinal  lymjjJi  glands,  and  often 
extends  beyond  them  (perilymphadenitis) ;  by  this  latfer  process  the 
glands  may  become  adherent  to,  and  rupture  into,  the  pulmonary  veins, 
whence  pigment-metastases  into  the  liver,  spleen,  kidneys  and  mesenteric 
glands  are  not  infrequent.  Bronchial  perilymphadenitis  may  also  lead 
to  diffuse  induration,  mediastinopericarditis,  stenosis  of  the  trachea, 
bronchi,  esophagus,  cava,  vena  azygos  and  pulmonary  artery,  to  esopha- 
geal diverticulum,  fatal  hemorrhage  into  the  pericardium  or  bronchi 
when  the  aorta  is  also  eroded,  to  aspiration  pneumonia  by  intrabronchial 
rupture  or  to  recurrent  laryngeal  paralysis  by  pressure.  Lehmann  holds 
that  the  great  bulk  of  dust  and  similar  bodies  find  their  way  into  the 
system  by  absorption  from  the  digestive  tract. 

2.  Siderosis  pulmonum  (Zenker)  is  a  similar  change,  due  to  inhalation 
of  metallic  dusts,  as  iron,  brass  or  bronze;  there  are  the  same  interstitial 
deposit,  lung  induration,  bronchial  gland  cirrhosis  and  metastases.  The 
irritation  is  greater,  nodes  are  more  frequent  and  induration  is  more 
intense  than  in  anthracosis. 

3.  Chalicosis  pulmonum  (Peacock)  is  due  to  inhalation  of  alumina, 
quartz  or  sandstone,  known  as  "stone-cutter's  or  millstone-maker's 
phthisis,"  "grinder's  rot"  or  "potter's  asthma."  Calcium  is  less  irritating 
than  silica  or  quartz.  Of  all  forms,  the  most  nodules  and  induration 
occur  in  chalicosis. 

4.  Similar  changes  are  observed  from  inhalation  of  wool,  flax,  cotton, 
grain,  tobacco,  glass,  porcelain,  pepper,  cinnamon,  bone,  lead,  mercury, 
phosphorus,  zinc,  arsenic  and  horn. 

Symptoms. — After  many  years,  the  symptoms  of  chronic  bronchitis, 
asthma,  emphysema  and  finally  of  lung  cirrhosis  appear.     The  sputum 


ATELECTASIS  441 

contains  coal  dust,  soot,  charcoal  particles,  as  in  Traube's  celebrated 
case,  and  yellow  oxide  or  dark  phosphate  of  iron,  quartz  and  silica. 
Cavities  may  form  from  bronchiectasis,  softening  of  the  nodose  indura- 
tions or  tuberculous  complications;  in  some  cases  lung  stones,  set  free 
by  ulceration,  may  be  raised.  Tuberculosis  occurs  in  13  per  cent,  of 
anthracosis  and  in  44  per  cent,  of  chalicosis.  Scissor-grinders  rarely 
live  beyond  forty  years  of  age  and  blasters  in  mines  usually  succumb  in 
four  years. 

Treatment. — Treatment  is  largely  prophylactic  and  that  of  the  con- 
comitant bronchitis  and  emphysema. 

ATELECTASIS. 

Apneumatosis  is  a  congenital  or  acquired  "absence  of  air." 

I.  Congenital  atelectasis  was  first  described  by  Jorg  (1834). 
Etiology  and  Pathology. — This  variety  is  due  to  deficient  inspiratory 

efforts  from  weak  muscles,  insufficient  stimulation  of  the  bulbar  centres 
and  aspiration  of  mucus  or  meconium.  The  base,  anterior  margin  and 
lingual  lobe  are  most  involved  and  the  distribution  is  lobular.  If  the 
subject  lives,  the  atelectatic  portions  do  not  become  pigmented.  These 
airless  areas  are  sunken,  bluish,  lax,  do  not  crepitate  and  sink  when  put 
in  water.  Bronchiectasis  may  result;  the  ductus  Botalli  and  foramen 
ovale  are  usually  patent,  the  right  heart  is  dilated  and  thrombosis  is 
frequent  in  the  brain  sinuses,  kidney  and  right  heart. 

Symptoms. — The  newborn  with  atelectasis  breathe  superficially  and 
cry  but  little.  Inspiration  is  marked  by  retraction  of  the  epigastrium, 
subclavicular  and  intercostal  spaces,  for  the  lungs  cannot  follow  the 
inspiratory  distention  of  the  thorax.  If  the  undistended  area  measures 
2  by  5  cm.  it  may  be  dull  and  increased  fremitus  with  bronchial  breathing 
may  be  detected,  but  more  often  the  breathing  is  weak  or  entirely  absent. 
Carbon  dioxide  narcosis  develops,  the  pulse  becomes  small,  the  sensorium 
becomes  dulled  and,  without  active  intervention,  asphyxia  causes  death. 
If  the  patient  lives,  the  chest  is  peculiarly  deformed,  its  lower  parts 
being  sunken,  so  as  to  show  the  ribs. 

Treatment. — Removal  of  meconium  and  mucus  by  swabbing  or  aspira- 
tion, artificial  respiration,  swinging,  and  warm  baths  with  cold  affusions 
to  the  neck  and  chest  are  indicated. 

II.  Acquired  Atelectasis. — Acquired  atelectasis  was  first  described  by 
Legendre,  Bailly  and  Traube. 

Etiology. — The  lungs,  already  distended  and  ventilated,  collapse  and 
the  air  is  absorbed,  (a)  The  marantic  form  occurs  in  bed-ridden  indi- 
viduals reduced  by  typhoid,  infantile  diarrhea  or  cachectic  conditions. 
(b)  Obstructive  collapse  develops  most  frequently  in  bronchopneumonia, 
as  the  bronchioles  in  the  young  are  narrow,  or  in  any  stenosis,  bronchial, 
etc.  (c)  Compressive  apneumatosis  follows  compression  by  aneurysm, 
dilated  heart,  tumors,  exudates,  pneumothorax,  abdominal  tumors, 
kyphoscoliosis,  etc. 

Pathology. — Pathologically  the  same  general  findings  obtain  as  in 
the  congenital  type.     The  lung  is  reddish-brown  or  bluish.    Hyperemia 


442  DISEASES  OF  THE  LXJNO 

may  cause  a  flesh-like  appearance  (carnification),  or  serous  transudation 
may  cause  a  spleen-like  aspect  (splenization).  There  may  be  coincident 
inflammation  or  vicarious  emphysema.  Long-standing  atelectasis 
results  in  bronchiectasis,  fatty  degeneration  of  the  alveolar  epithelium 
and  hyperplasia  of  the  interalveolar  connective. tissue,  known  as  collapse 
induration. 

Symptoms. — Symptoms  are  easily  obscured  by  the  causal  pleural 
eft'usion  or  bronchopneumonia,  with  whose  foci  it  may  be  confused. 
Inspiratory  retraction,  lessened  vesicular  breathing,  a  slightly  tympanitic 
note  from  relaxation  of  the  collapsed  lung  and  crepitant  rales  are  com- 
mon. Increased  vocal  fremitus  and  bronchial  breathing  are  uncommon. 
Dilatation  of  the  right  heart  is  usual.  In  recent  cases  the  physical  signs 
disappear  after  a  few  hours  of  change  of  posture,  or  after  deep  breathing, 
which,  with  absence  of  fever,  pain  and  cough,  effectually'  differentiates 
from  infarct,  pneumonia  or  effusive  pleurisy.  After  sleep  for  some  hours 
on  the  back,  a  few  crepitant  rales  may  be  heard  physiologically  over  the 
lower  posterior  parts  for  three  or  four  inspirations. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  vary  accord- 
ing to  the  cause.  In  all  fevers  and  all  respiratory  inflammations  the 
posture  must  be  changed  frequently;  orders  to  this  effect  should  be 
written,  and  the  change  should  be  recorded  on  the  history  sheet.  Cold 
affusions,  hydrotherapy  and  cardiants  are  indicated. 


ABSCESS    OF    THE   LUNG. 

Suppuration  may  occur  in  a  sound  or  diseased  lung. 

Etiology. — (a)  Lobar  pneumonia  causes  62  percent.;  upper  lobe  localiza- 
tion, alcoholism,  pneumonia  complicating  emphysema  and  lung  indura- 
tion and  hemorrhagic  types  are  the  predisposing  factors.  (6)  Lobidar 
pneumonia,  especially  the  influenzal  type,  may  suppurate,  (c)  Aspira- 
tion pneumonia  is  causal  in  18  per  cent.,  particularly  in  insane  or  delirious 
subjects;  foreign  bodies,  food,  saliv^a  or  pus  from  lesions  in  the  upper 
respiratory  tract,  vomiting,  esophageal  cancer  rupturing  into  a  bronchus, 
are  its  usual  causes,  {d)  Embolic  suppuration  produces  17  per  cent. 
ie)  Trauma  is  another  factor.  (/)  Abscess  may  complicate  tuberculosis, 
bronchiectasis,  echinococcus,  etc.  {g)  Rupture  into  the  lung  of  contiguous 
suppuration,  such  as  empyema,  suppurating  peribronchial  glands,  sub- 
phrenic abscess,  spinal  caries  and  gastric  ulcer,  causes  3  per  cent,  of  lung 
abscesses.    Most  cases  occur  in  middle-aged  males. 

Bacteriology. — The  staphylococcus  is  most  frequently  the  causative 
-microorganism;  the  streptococcus,  pneumococcus,  pneumobacillus, 
influenza  bacillus,  colon  bacillus  and  leptothrix  are  also  found. 

Pathology. — The  cavity  varies  from  the  size  of  a  hazel-nut  to  an  orange ; 
it  may  occupy  even  an  entire  lobe  or  lung.  The  abscess  is  usually  single, 
except  in  the  embolic  form.  Its  shape  is  irregular  and  it  is  sometimes 
multilocular.  Its  inner  surface  is  irregular  with  floccular  mural  shreds, 
and  is  walled  with  pus-secreting  granulations,  which  in  some  cases  fill 
and  obliterate  the  cavity.     Fibrous  tissue  develops  about  the  cavity,  and 


ABSCESS  OF   THE  LUNG  443 

ill  chronic  abscess  becomes  dense  and  scar-like.  The  cavity  is  usually 
neiir  the  lung's  surface,  whence  the  frequency  of  complicating  pleurisy; 
80  per  cent,  of  lung  abscesses  are  in  a  lower  lobe  (Tuffier). 

Symptoms. — The  symptoms  vary  with  the  causal  lesion;  in  lobar  pneu- 
monia the  crisis  is  delayed  and  resolution  is  incomplete;  in  influenza 
the  respiratory  symptoms  and  fever  persist;  in  sepsis,  multiple  lung 
involvement  perpetuates  the  septic  process,  (a)  The  simtum  is  purulent, 
offensive  or  rancid  without  putridity,  alkaline  and  may  measure  a  pint 
to  a  quart  daily.  It  separates,  on  standing,  into  two  layers,  a  granular 
sediment  and  a  serous  upper  layer,  sometimes  with  frothy  surface.  In 
metapneumonic  cases  the  sputum  is  sometimes  grass-green.  The  sedi- 
ment reveals  shreds  of  lung  tissue  (Traube  and  Leyden)  and  yellowish- 
green  or  gray  flocculi;  these  are  absolutely  essential  to  diagnosis  and 
consist  of  elastic  fibers  to  which  alveolar  epithelium  adheres.  Hematoidin 
crystals  or  platelets,  short  sheaths  of  fatty  crystals,  bacteria  {v.  s.)  and  in 
chronic  cases  cholesterin  and  scar-like  connective  tissue  are  also  found. 
The  "mouthful  expectoration"  is  voided  periodically,  as  from  cavities 
of  other  causation.  (6)  The  decubitus  varies  with  the  location  of  the 
cavity;  the  patient  assumes  the  erect  posture  if  the  cavity  is  in  a  lower 
lobe,  to  prevent  leaking  of  the  secretion  into  the  bronchi,  (c)  Signs 
of  cavity  are  found  if  the  exulceration  is  large  and  superficial,  and  in  80 
per  cent,  occur  in  the  lower  lobes.  They  are  essentially  those  of  tuberculous 
or  bronchiectatic  cavities  (g.  v.)  and  vary  with  the  stagnation  or  evacua- 
tion of  the  pus;  thus  a  tympanitic  note,  bronchial  or  amphoric  breathing 
and  increased  vocal  fremitus  are  found  when  the  vomica  is  empty,  and 
dulness,  weakened  breath  sounds  and  decreased  fremitus  obtain  when  it 
is  full.  The  ic-rays  also  serve  to  localize,  but  when  the  findings  differ 
the  physical  signs  are  more  trustworthy,  {d)  Hectic  fever,  sweats,  rigors 
and  leukocytosis  occur  from  resorption. 

Diagnosis. — The  etiology  and  cavity  formation  are  often,  and  the 
sputum  always,  characteristic,  (a)  Abscess  breaking  into  the  king  from 
the  spine  or  the  subphrenic  or  pleural  spaces  is  sudden,  sometimes 
suffocative  in  onset,  and  the  hematoidin  crystals  and  shreds  of  pul- 
monary tissue  are  absent,  (b)  Gangrene  (v.  i.).  (c)  Tuberculosis  usually 
occurs  in  an  upper  lobe;  abscess  in  a  lower  one;  elastic  fibers  and  hema- 
toidin crystals  are  more  abundant  in  abscess,  and  tubercle  bacilli  are 
found  in  tuberculosis,  {d)  In  bronchiectasis  elastic  fibers  are  seldom 
voided. 

Prognosis. — Spontaneous  recovery  may  follow  granulation  and  cica- 
trization, especially  in  lobar  pneumonia,  where  recovery  is  the  rule. 
In  influenzal  or  aspiration  pneumonia  or  in  sepsis  the  outlook  is  far 
less  favorable;  marasmus,  hectic  fever,  amyloidosis,  lung  induration, 
empyema,  pneumothorax  and  pericarditis  are  frequent  issues. 

Treatment. — (a)  The  general  strength  should  be  maintained  by  a  full 
diet,  tonics  and  alcohol.  (6)  Decomposition,  if  present,  should  be  modi- 
fied as  in  bronchiectasis  or  gangrene,  by  administration  of  creosote  or 
turpentine  internally,  (c)  Surgical  hitervention  is  indicated  (i)  when  the 
abscess  is  large,  shows  no  tendency  toward  spontaneous  cure  and  the 
contents    decompose;  (ii)  when    rupture    into    the    pleura    occurs;  and 


444  DISEASES  OF  THE  LUNG 

(iii)  when  the  abscess  results  from  the  breaking  into  the  lung  of  a 
contiguous  focus  of  suppuration.  The  mortality  is  25  per  cent,  under 
surgical,  and  54  per  cent,  under  expectant,  treatments 

GANGRENE    OF    THE   LUNG. 

Definition. — A  necrosis  and  mortification  of  lung  tissue.  Gangrene, 
though  more  common  than  abscess,  is  found  in  0.1  per  cent,  of  clinical 
cases  only  and  in  1.6  per  cent,  of  autopsies. 

Etiology. — Reduced  physiological  resistance,  e.  g.,  from  diabetes,  is 
a  necessary  factor.  Lobar  •pneumonia  may  terminate  in  gangrene  when, 
as  in  abscess,  the  patient  is  weakly,  diabetic,  addicted  to  alcohol  or 
suffering  from  putrid  bronchitis;  though  its  frequency  is  but  0.4  per 
cent.,  pneumonia  causes  23  per  cent,  of  lung  gangrene.  Lobular  pneumonia 
is  less  frequently  causal,  though  grippe  pneumonia  may  terminate  in  gan- 
grene. In  Coupland  and  Hensel's  combined  cases,  14  per  cent,  were  due  to 
pulmonary  tuberculosis  and  10  per  cent,  to  tumor  of  the  lung.  Aspiration 
pneumonia  resulting  in  gangrene  occurs  particularly  in  insane,  delirious, 
paralyzed  or  emaciated  subjects;  foreign  bodies,  necrotic  diseases  of  the 
throat,  larynx  or  bronchi,  bronchiectasis,  putrid  bronchitis  and  bronchial 
stenosis  promote  gangrene.  Embolic  gangrene,  a  cause  of  19  per  cent, 
of  lung  gangrene,  may  result  from  suppurative  gangrenous  lesions  in 
the  appendix,  uterus  or  extremities.  Rupture  into  the  lung,  as  of  esopha- 
geal cancer  or  diverticulum,  putrid  pleurisy,  subphrenic  abscess  or 
gastric  ulcer  may  cause  gangrene.  Gangrene  usually  occurs  within 
the  second  to  fourth  decades  of  life  and  in  males. 

Bacteriology. — Some  maintain  that  certain  germs  produce  the  necrosis 
and  other  germs  the  gangrene,  but  probably  one  microorganism  pro- 
duces both  changes.  The  staphylococcus  is  found,  also  the  strepto- 
coccus, colon  bacillus  and  "acid-fast"  pseudotubercle  bacillus;  the  B. 
pyocyaneus.  Micrococcus  tetragenus,  a  micrococcus  which  produces 
skatol  and  indol,  and  causes  a  putrid  odor  in  the  cultures,  and  a  bacillus 
resembling  that  of  malignant  edema,  are  enumerated. 

Pathology. — Genuine  gangrene  must  not  be  confused  with  softening 
of  the  lung,  due  to  regurgitation  of  the  gastric  juice  into  the  lung  during 
the  death  agony  or  after  death.  There  is  a  rare  non-putrid  pneumo- 
malacia,  analogous  to  myomalacia  cordis.  Lung  gangrene  occurs  in 
the  right  lung  in  45  per  cent.,  in  the  left  in  37  and  in  both  lungs  in  18 
per  cent,  of  the  cases.  Laennec,  who  first  described  pulmonary  gangrene, 
distinguished  two  types,  the  circumscribed  and  the  diffuse,  (a)  Cir- 
cumscribed gangrene  occurs  chiefly  in  the  lower  lobes  near  the  surface, 
and  oftener  on  the  right  than  on  the  left  side.  The  focus  may  attain  the 
size  of  an  orange.  Laennec  distinguished  three  stages:  (i)  The  forma- 
tion of  a  yellow,  green  or  brown  slough,  which  may  be  expectorated 
entire;  (ii)  liquefaction,  or  moist  gangrene;  and  (iii)  formation  of  a 
cavity  which  is  irregular  in  shape,  has  ragged  walls  and  contains  a  stink- 
ing liquid  resembling  the  sputum  of  gangrene  {v.  i.).  The  cavity  is 
limited  by  granulations  and  later  by  connective  tissue,  or  gradually 
spreads,  corroding  more  and  more  lung  tissue,  or  extension  may  follow 


GANGRENE  OF   THE  LUNG  445 

aspiration  of  the  septic  matter  into  other  lung  areas.  Recovery  may 
follow  localization,  organization  of  granulations  and  contraction  of  con- 
nective tissue.  ^Microscopically  there  is  (i)  an  inner  zone  of  offensive 
fluid  or  necrotic  tissue,  bacteria  and  emigrated  leukocytes;  (ii)  outside 
of  this  is  a  zone  of  granulations,  beyond  which  is  (iii)  congested  or  edema- 
tous lung,  (b)  The  rarer  diffuse  gangrene  has  no  demarkation,  and  a 
large  area,  an  entire  lobe,  or  even  the  whole  lung  may  be  discolored, 
stinking  and  macerated.  The  diffuse  form  occurs  more  often  in  the 
upper  lobes,  and  on  the  right  side.  In  both  forms  the  sputum  irritates 
and  injects  the  bronchial  mucosa,  the  bronchial  glands  are  tumefied 
and  degeneration  or  metastasis  may  occur  in  various  viscera. 

Symptoms. — 1.  Sputuivi. — The  sputum  is  characteristic,  essential  to 
diagnosis,  and  absent  only  w^hen  the  putrid  focus  has  no  bronchial  con- 
nection. It  is  extremely  offensive,  fecal,  stinking  or  garlicky.  It  is 
most  offensive  at  the  moment  of  evacuation,  and  on  standing  may 
gradually  lessen.  The  sputum,  voided  periodically  and  sometimes  in 
mouthfuls,  is  usually  abundant  (a  pint  to  a  quart),  and  on  standing 
separates  into  three  layers,  an  upper  layer  of  foam,  a  middle  of  green 
or  gray  serum,  and  a  lower  of  green  or  brownish  granular  sediment.  In 
'the  sediment  there  are  floccidi  of  lung  tissue,  best  seen  against  a  dark 
background,  varying  in  size  from  small  particles  to  pieces  as  large  as 
the  thumb  and  showing  alveolar  arrangement;  elastic  fibers  are  much 
less  common  than  in  abscess  of  the  lung,  for  a  trypsin-like  ferment  rapidly 
digests  the  fibers;  Dittrich's  plugs  are  found,  consisting  of  detritus  and 
bacteria,  and  emitting  a  most  fetid  odor  {v.  pages  421  and  422);  long 
fatty  needles,  lung  pigment,  pus  cells,  red  corpuscles,  hematoidin  crystals, 
bacteria,  infusoria,  leucin,  tyrosin,  phenol,  indol,  skatol,  ammonia  and 
sulphuretted  hydrogen  are  also  found. 

2.  Chest  Findings. — Besides  bronchitis  caused  by  the  offensive 
sputum,  signs  of  infiltration  or  cavity  formation  are  obtained  if  the  focus 
is  superficial  and  measures  two  and  one-half  inches.  In  the  common  cir- 
cumscribed form  the  signs  of  cavity  are  identical  with  those  in  tuber- 
culosis, bronchiectasis  or  abscess,  i.  e.,  a  tympanitic  note,  increased 
vocal  fremitus,  bronchial  or  amphoric  breathing  and  metallic  rales  are 
obtained  w4ien  the  cavity  is  empty,  or  dulness,  decreased  fremitus  and 
weak  breathing  when  it  is  full.  In  the  rare  diffuse  form  there  are  signs 
of  infiltration,  as  in  pneumonia,  which  signs  are  also  found  in  the  initial 
stage  of  the  circumscribed  gangrene.  The  ,T-rays  are  valuable  in  localiza- 
tion of  the  gangrene.  The  patient  lies  so  that  the  cavity  is  dependent, 
to  avoid  constant  trickling  of  the  secretion  into  the  bronchi,  i.  e.,  on  his 
back  when  it  is  posterior  or  on  his  face  when  it  is  anterior  or  in  an  upper 
lobe. 

3.  General  symptoms  result  from  the  causal  disease  or  sepsis.  Remit- 
tent fever,  chills,  sweats,  emaciation,  pallor,  rapid  pulse,  vomiting, 
diarrhea,  leukocytosis,  albuminuria  and  in  severe  cases  a  profound 
typhoid  state  mark  the  degree  of  intoxication. 

4.  Complications  may  dominate  the  clinical  picture,  (a)  Pleurisy, 
usually  purulent  or  putrid,  may  be  the  chief  symptom,  and  operation 
may  evacuate  offensive  fluid  with  fragments  of  necrotic  lung,    (b)  Hemop- 


44(3  DISEASES  OF   THE  LUNG 

tysis  is  seldom  fatal,  though  frequently  profuse,  (c)  Pyopneumothorax, 
or  (d)  rupture  into  the  esophagus,  aorta,  mediastinum,  etc.,  may  occur. 
(e)  There  may  be  metastatic  deposits  in  the  brain,  liver,  joints  or  muscles. 
(/)  Clubbed  fingers  or  am^'loid  degeneration  occasionally  result  from 
septic  absorption. 

Course  and  Prognosis. — The  course  is  usually  fatal  within  a  week  in 
diffuse,  and  is  more  chronic  in  circumscribed,  forms.  The  prognosis 
depends  on  the  etiology,  resistance  of  the  patient,  degree  of  toxemia, 
localization  and  surgical  accessibility. 

Diagnosis. — Exploratory  puncture  is  dangerous,  for  it  favors  diffusion. 
(a)  In  fcBior  ex  ore  the  breath  is  fetid  but  the  sputum,  if  any,  shows  no 
findings  characteristic  of  gangrene,  (b)  In  yutrid  bronchitis  the  sputum 
shows  Dittrich's  plugs  and  fetor,  but  no  fatty  crystals  or  pulmonary 
tissue,  (c)  In  abscess  elastic  fibers  and  pus  are  more  abundant,  the 
fatty  crystals  are  oftener  in  sheaths  than  in  long  needles  and  hematoidin 
crystals  are  more  common;  bronchial  plugs  and  fetor  are  absent,  (d) 
In  bronchiectasis  elastic  fibers  are  very  rare  and  lung  tissue  has  never 
been  found,  (e)  In  tuberculosis  coincidence  of  the  two  aftections  and  the 
pseudotubercle  bacillus  may  alone  cause  confusion  (r.  TuBERcrLOSis). 

Treatment. — 1.  Suegical. — Expectant  treatment  results  in  a  mor- 
tality of  90  per  cent.  With  operative  treatment  the  death-rate  is  45 
per  cent.  (In  20  personal  cases,  66  per  cent,  recovered  under  medical 
treatment.)  The  sm-gical  indications  are  (a)  the  vital  indication  when 
acute  gangrene  assumes  the  foudroyant  type,  or  (6)  when,  in  chronic 
forms,  there  is  no  tendency  toward  spontaneous  healing.  Accurate 
localization  by  physical  findings  or  by  the  .r-rays  was  possible  in  65 
per  cent,  of  Tuffier's  series. 

2..ExPECTA]srr  treatment  is  indicated  in  deep-seated  gangrene, 
hopeless  metastases  or  apparent  demarkation.  The  patient  is  kept  on 
his  back  to  avoid  leakage  into  sound  bronchi.  The  diet  should  support 
the  strength  and  include  full  alcoholic  stimulation.  Carbolic  acid, 
balsam  of  Peru,  creosote,  or  turpentine  (when  there  is  a  complicating 
hemorrhage)  may  be  given  internally. 


TUMORS    OF    THE   LUNG. 

I.  Carcinoma. — Cancer  of  the  lung  may  be  primary  (17  per  cent.), 
metastatic  (73  per  cent.)  and  extension  by  contiguity  (10  per  cent.). 
It  occurs  in  0.17  per  cent,  of  autopsies  or  in  1.8  per  cent,  of  cancer  autop- 
sies (Passler).  ^lost  primary  cases  develop  between  forty  and  sixty 
years  of  age.  In  primary  forms  Passler  found  73  per  cent,  in  males; 
the  secondary  forms  are  more  frequent  in  women,  following  cancer  of 
the  mamma  or  the  digestive  or  genital  organs. 

Etiology  and  Pathology. — Cancer  usually  develops  in  the  bronchi, 
in  which  previous  ulceration,  syphilis  or  adherent  rupturing  lymph 
glands  are  predisposing  factors.  It  probably  may  develop  from  the 
bronchial  mucous  glands  or  even  from  the  alveolar  epithehum.  His- 
|;ologically  the  cylindrical  type  is  by  far  the  most  frequent,  though 


TUMORS  OF   THE  LUNG  447 

medullary,  scirrhous  and  other  forms  are  encountered.  Cancer  usually 
begins  at  the  hilum,  and  may  extend  toward  the  pleura,  either  by 
contiguity  along  the  bronchi  or  by  the  lymph  spaces.  The  upper  lobes 
are  more  often  involved  than  the  lower  and  the  right  twice  as  frequently 
as  the  left.  Primary  disease  is  generally  unilateral.  Secondary  cancer  is 
generally  bilateral;  the  lungs  are  strewn  with  miliary  nodules  resembling 
miliary  tubercles,  or  present  many  larger  nodules.  Calcification  and 
ossification  may  occur.  Krieg  collected  201  primary  tracheal  tumors 
(40  carcinomas  and  21  sarcomas,  most  of  the  balance  being  benign). 

Symptoms. — With  a  primary  tumor  in  another  part  of  the  body, 
cyanosis,  dyspnea,  blood-stained  sputum  and  signs  of  lung  infiltration 
or  of  cavity,  facilitate  a  diagnosis  of  lung  metastasis.  When  there  is  a 
hidden  primary  focus  or  a  primary  lung  tumor,  diagnosis  is  for  a  long 
time  difficult  or  impossible. 

1.  Early  General  Symptoms. — These  are  usually  ambiguous  or 
suggestive  of  tuberculosis,  pleurisy  or  bronchitis.  Thoracic  oppression, 
coughing,  stridor  and  dyspnea  result  from  pressure  on  the  trachea  and 
vagus  or  wide  substitution  of  tiunor  for  lung  tissue.  Cyanosis,  dyspnea, 
rapid  breathing,  emaciation  and  sweats  may  suggest  miliary  tubercu- 
losis; this  resemblance  may  also  be  noted  at  autopsy  in  miliary  carcinosis; 
fever  develops  in  over  half  the  cases.  Rokitansky's  contention  that 
pulmonary  cancer  and  tuberculosis  do  not  coexist  is  disproved  by  Wolff's 
31  cases  of  cancer  of  the  lung  of  which  23  had  tuberculosis. 

2.  Sputl'^vi. — The  sputum  in  over  half  the  cases  is  rather  characteristic. 
Altered  blood  gives  it  a  reddish-brown  color  or  it  resembles  raspberry 
jelly  in  hue  and  in  consistency;  it  is  sometimes  grass-green  or  prune- 
juice  in  color.  Occasionally  macro-  and  microscopic  bits  of  cancer  tissue 
in  characteristic  nest-like  arrangement  are  seen. 

3.  Physical  Signs. — (a)  Inspection:  .  The  patient  usually  lies  on  the 
affected  side  to  give  freer  play  to  the  sound  lung.  jNIarked  ectasia  is 
common;  sometimes  the  diseased  side  is  shrunken  from  lung  cirrhosis 
or  bronchial  stenosis.  (&)  Palpation  elicits  increased  fremiius  if  the  tumor 
partially  occludes  the  bronchi,  (c)  Permission  gives  increased  resistance 
and  irregular  dulness,  increasing  to  absolute  flatness,  most  often  over  an 
upper  lobe  or  substernally.  Flatness  persisting  after  tapping,  and 
blood-stained  sputiun  without  tubercle  bacilli  in  a  patient  over  fifty 
years,  at  once  suggest  pulmonary  neoplasm,  {d)  Auscultation  varies 
with  the  patency  of  the  bronchus,  giving  bronchial  breathing  when  it  is 
open  and  weak  or  absent  breathing  when  occluded. 

4.  Compression  Symptoms. — Besides  the  early  dyspnea  and  cough, 
(a)  the  heart  is  often  luxated  or  its  yielding  auricles  are  crowded,  {b) 
The  venous  trunks  suffer  compression,  with  cyanosis  and  edema  of  the 
face,  neck  and  arms  and  with  collateral  dilatation  of  other  veins  of  the 
thorax,  (c)  Other  symptoms  of  compression  are  rapid  or  slow  heart 
(vagus compression),  recurrent  laryngeal  compression  with  phonic  changes, 
dysphagia,  intercostal  neuralgia,  brachial  neuralgia  or  paralysis,  and 
bronchial  stenosis. 

5.  ^Metastasis.— This  occurs  in  85  per  cent,  of  cases;  there  may  also 
be  extension,  by  contiguity,  to  the  axillary  or  cervical  glands. 


448  DISEASES  OF   THE  LUNG 

G.  Complications  include  hemoptysis  from  necrosis  and  cavity  forma- 
tion; gangrene  and  bronchiectasis;  and  pleurisy,  which  is  usually  serous 
(hemorrhagic  in  12  per  cent.,  even  like  venous  blood,  or  rarely  adipose 
or  chyliform  effusions);  hydropic,  fatty  and  granular  cells  or  flocculi 
of  tumor  tissue,  may  be  obtained  by  puncture.  Carcinomatous  nodes 
may  develop  at  the  site  of  puncture.  The  course  is  indicated  by 
]Marfan's  types;  the  acute  or  galloping  pleuropulmonary  cancer,  and  the 
chronic  type  (the  typical,  bronchopulmonary,  the  mediastinal,  and  the 
pleuritic  with  or  without  effusion). 

II.  Sarcoma  and  Lymphosarcoma. — Sarcoma  and  lymphosarcoma 
are  more  frequent  than  cancer.  They  probably  begin  chiefly  in  the 
lymph  nodes  of  the  bronchi,  and  oftener  on  the  left  than  on  the  right 
side.  Extension  in  all  directions  occurs  along  the  peribronchial  tissues 
from  the  hilum.  A  primary,  very  malignant  lymphosarcoma  develops 
in  cobalt  miners  of  Saxony;  150  cases  among  less  than  700  miners  were 
described  by  Anke  in  1884.  Ulceration  is  less  common  than  in  cancer, 
but  the  symptoms  are,  in  the  main,  identical.  Sarcomatous  tissue  is 
occasionally  voided  in  the  sputum  or  aspirated  by  the  exploring  needle. 
The  differentiation  of  malignant  lung  tumors  must  be  made  chiefly 
from  aneurysm  (q.  v.)  and  pleurisy  (q.  v.).  The  .r-rays  may  be  of  value. 
There  are  three  main  clinical  groups,  (a)  in  which  a  neoplasm,  perhaps 
its  exact  type,  can  be  diagnosticated;  (6)  in  which  some  growth  is 
present  but  differentiation  from  aneurysm  is  uncertain ;  and  (c)  in  which 
the  disease  escapes  detection  or  is  only  suspected. 

Prognosis. — Death  generally  occurs  in  less  than  a  year  with  cachexia 
or  suffocation,  but  sometimes  within  a  few  weeks. 

III.  Other  Tumors  of  the  Lung. — Fibroma,  lipoma,  osteoma,  hyper- 
nephroma and  enchondroma  are  of  solely  anatomical  interest. 

Treatment. — It  is  only  palliative — morphine  for  extreme  dyspnea  and 
cough.    The  .T-rays  and  arsenic  oifer  little  encouragement. 

CIRCULATORY   AFFECTIONS    OF   THE   LUNG. 

I.  Active  Congestion. — As  a  secondary  lesion  acute  hyperemia  occurs 
commonly  with  tuberculosis,  pneumonia,  influenza,  pleurisy  or  cardiac 
strain.  French  writers  describe  an  acute  primary  congestion  {Maladie 
de  Woillez);  some  cases  are  apparently  abortive  pneumonia;  perhaps 
it  is  due  to  attenuated  pneumococci,  which  Carriere  has  demonstrated 
by  puncture  of  the  lung  It  develops  like  pneumonia,  with  chill,  fever 
of  101°  to  103°,  pain  in  the  side,  dyspnea,  cough  and  an  abundant,  viscid 
but  not  blood-stained  sputum.  Physical  examination  is  said  to  elicit 
somewhat  impaired  resonance  and  weak  or  occasionally  bronchial 
breathing. 

II.  Passive  Congestion;  Hypostasis. — In  broken  compensation,  par- 
ticularly in  mitral  stenosis,  the  lungs  are  distended,  heavy,  indurated, 
and  pigmented  a  brownish-red;  this  is  brown  induration  {induratio 
imlmonum  fusca).  The  capillaries  are  turgid,  the  connective  tissue  is 
increased,  the  lungs  are  tinged  with  blood  pigment  and  the  sputum  con- 
tains the  so-called  heart  disease  cells  (see  page  368). 


CIRCULATORY  AFFECTIOXS  OF   THE  LUNG  449 

Ilypustasis  is  a  passive  congestion  from  weak  heart,  in  typhoid  and 
other  fevers,  old  age,  cachexife,  in  opinm  and  other  narcoses  and  in 
apoplectic  or  other  comas;  it  rarely  occurs  if  the  patient's  position  is 
changed  every  feic  hours.  The  lung  is  dark  red,  engorged  with  blood  and 
serum,  and  may  also  show  aspiration  pneumonia  and  atelectasis;  the 
latter  conditions  are  incorrectly  called  hypostatic  pneumonia.  There 
is  moderate  dulness  over  the  lower  lobes  posteriorly,  in  apoplexy  perhaps 
only  on  the  paralyzed  side;  the  breathing  is  more  often  weak  than 
bronchial,  and  moist  or  crepitant  rales  are  heard.  Fever  is  no  part  of 
hypostasis. 

Treatment. — Treatment  of  the  fundamental  lesion,  phlebotomy,  stimu- 
lation and  frequent  change  of  posture  are  indicated. 

in.  Infarct;  Embolism. — Etiology.  —  Embolism,  first  observed  by 
Laennec,  is  most  frequently  caused  by  (a)  fibrinous  coagula  from  the 
right  heart,  the  frequency  and  mechanism  of  which  have  been  discussed 
under  Acute  axd  Chroxic  Exdocarditis  and  Septic  Ixfectioxs. 
Clots  may  also  reach  the  lung  from  peripheral  tliromboses  or  rarer  causes 
are  (b)  tumor  or  hepatic  tissue,  fat  embolism  after  fractures  and  liver 
injury,  air  embolism  or  echinococcus  cysts. 

Pathology. — The  embolus  may  obstruct  a  main  branch  of  the  pul- 
monary artery,  straddle  one  of  its  bifurcations  or  lodge  in  a  smaller 
vessel.  Not  every  embolism  produces  an  infarct,  for  the  occlusion  may 
be  incomplete  or  collateral  circulation  possible.  Occlusion  of  an  end- 
vessel  results  in  the  hemorrhagic  infarct,  which  is  often  wedge-shaped 
with  its  base  toward  the  pleura,  is  airless,  on  section  projects  above  the 
cut  siu-face,  and  is  attended  by  extravasation  of  blood  into  the  lung, 
though  the  lung  is  not  torn.  This  is  known  as  a  fibrinous  or  simple 
infarct.  If  the  embolus  contains  pus  or  putrefactive  microorganisms, 
it  initiates  abscess  or  gangrene.  Infarcts  occur  in  the  right  lower  lobe 
in  46  per  cent.,  right  upper  in  21,  left  lower  in  15,  left  upper  in  12  and 
right  middle  lobe  in  6  per  cent.  They  are  often  multiple.  Small  infarcts 
may  be  absorbed,  but  larger  ones  leave  pigmented  cicatrices. 

Symptoms. — (a)  Infarction  of  the  main  pulmonary  trunk  may  result 
in  immediate  death,  as  from  sitting  up  after  childbirth  (two-thirds  of 
these  cases  die) .  In  other  cases  death  occurs  in  a  short  time  from  cerebral 
anemia  and  cardiac  failure.  The  infarct  may  cover  the  greater  part  of 
the  lobe  involved,  and  a  systolic  murmur  may  develop  over  the  pul- 
monary artery,  (b)  Infarction  of  a  smaller  vessel  is  often  ushered  in 
with  chill,  vomiting,  dyspnea,  cyanosis  and  fever,  even  with  bland 
embolism.  The  sputum  contains  dark  blood  and  a  "stitch  in  the  side" 
denotes  pleuritic  participation.  Physical  examination  frequently  elicits 
a  pleural  rub  and  later,  in  some  cases,  slight  dulness,  especially  behind, 
between  the  spine  and  scapular  line;  crepitant  rales  and  bronchial 
breathing  are  frequently  present.  Pyogenic  or  putrid  clots  cause  abscess, 
gangrene,  empyema  or  pneumothorax. 

Diagnosis. — Sudden  cardiac  failure  is  very  difficult  to  differentiate 
from  embolic  occlusion  of  the  pulmonary  trunk,  especially  when  death 
occurs  \^ithout  hemoptysis.  The  etiology,  sudden  onset  and  circum- 
scribed chest  signs  are  of  diagnostic  importance.  Treatment  lies  in 
29 


450  DISEASES  OF   THE  LUNG 

cardiac  stimulation  and  prophylaxis — rest  during  endocarditis,  cardiac 
insufficiency  or  phlebitis. 

IV.  Edema  of  the  Lungs. — ^Etiology. — Pulmonary  edema  was  described 
by  Laennec  (1819).  In  the  etiology  of  this  secondary,  common,  fre- 
quently terminal  or  agonal  affection,  three  important  causes  stand  in  the 
foreground,  viz.,  heart,  kidney  and  lung  disease.  Edema  is  a  serous  trans- 
udation into  the  air  cells  and  interstitial  tissue.  Classification  of  its 
mechanism  is  difficult:  {a)  Stasis  due  to  heart  weakness  is  its  most 
frequent  mechanism.  Cohnheim  and  Welch  demonstrated  experimen- 
tally that  it  may  result  from  failure  of  the  left  ventricle,  with  continued 
activity  of  the  right  ventricle  (this  explanation  is  not  entirely  satisfac- 
tory, for  cases  in  which  the  pulse  is  strong;  however,  general  cardiac 
anasarca  may  occur  when  the  radial  pulse  is  strong,  though  it  is  known 
that  the  heart  must  be  weak).  Weak  heart  may  result  from  any  disease 
of  the  endo-,  myo-  or  pericardium.  Sahli  explains  certain  cases  by  (6) 
paralysis  of  the  pulmonary  vessels.  Under  (a)  or  (6)  nephritic  or  toxic 
edema,  edema  from  pleural  paracentesis,  the  iodides,  ether,  adrenalin  or 
pilocarpine  may  be  included,  (c)  Inflammatory  edema,  e.  g.,  around 
fibrinous  pneumonia  and  other  pulmonary  disease,  is  an  exudation,  not 
a  transudation;  the  pulse  is  usually  strong  and  there  is  often  fever. 
It  is  possible  that  (d)  angioneurotic  edema  or  (e)  occult  changes  in  the 
blood  and  bloodvessels  are  causal  factors.  These  varied  mechanisms, 
most  common  in  cardiac,  renal  and  pulmonary  lesions,  may  also  operate 
in  cachexia,  anemia,  cerebral  disease,  old  age  or  innumerable  other 
conditions. 

Pathology. — Edema  may  be  circumscribed  or  oftener  diffuse.  The 
lungs  are  large,  heavy  and  spongy;  they  pit  and  on  section,  especially 
of  the  bases,  a  frothy  serosanguineous  fluid  exudes. 

Symptoms. — Symptoms  usually  come  on  precipitately,  with  dyspnea 
and  cyanosis.  The  sputum  is  copious,  foamy,  somewhat  resembling 
soapsuds  or  at  times  tinged  with  blood;  it  is  rich  in  albumin  and  poor 
in  mucus  and  cells.  The  bubbling  breathing  indicates  serum  in  the 
alveoli.  The  second  pulmonic  sound  is  accentuated,  the  pulse  is  weak, 
the  lung  note  is  slightly  tympanitic  from  relaxation  and  coarse  and 
fine  rales  are  heard  everywhere.  If  the  lower  lobes  are  filled,  the  physical 
signs  may  closely  resemble  those  of  consolidation.  Recurrent  attacks  are 
described.    The  diagnosis  is  determined  from  the  sputum  and  lung  findings. 

Treatment. — Too  often  edema  is  the  death  agony  itself,  (a)  Prophyl- 
axis concerns,  e.  g.,  the  causal,  cardiac  weakness  or  anasarca  in  nephritis. 
(6)  DiffiLsive  stimulants  are  indicated  hypodermically,  as  camphor, 
strophanthus  and  strychnine,  and  by  mouth,  coffee  or  champagne,  (c) 
Morphine  is  almost  specific,  {d)  Venesection  relieves  the  right  heart 
and  is  particularly  indicated  in  hypertension,  (e)  Stimulating  expec- 
torants and  rapid  purgation  by  croton  oil,  TTliij,  on  the  tongue  and 
artificial  respiration  are  rarely  of  value.  The  author  has  obtained  no 
results  from  the  acetate  of  lead.  Atropine  and  adrenalin  are  dangerous, 
adrenalin  not  infrequently  inducing  edema. 

V.  Hemoptysis. — Hemoptysis  or  hemoptoe  refers  to  "spitting  of 
blood,"  while  profuse  hemorrhage  is  known  as  pneumorrhagia. 


CIRCULATORY  AFFECTIONS  OF   THE  LUXG  451 

Etiology. —  a  i  LanTigeal  ulceration  or  inflanunation;  (b)  tracheal 
ulceration  or  aneurysm  bursting  into  the  trachea;  (c)  severe  inflamma- 
tion or  ulceration  of  the  bronchi,  cardiac  stasis,  bronchiectasis,  putrid 
and  fibrinous  bronchitis,  rupture  into  the  air  passages  of  aneurysm  or 
antliracotic  l^Tnph  glands;  hemoptysis  may  also  occm-  in  the  acute 
exanthemata,  in  blood  affections  as  hemophilia,  scurfy,  purpura  and 
leukemia,  and  in  renal  disease  and  cholemia;  hemoptysis  occurring  as 
vicarious  menstruation,  mentioned  by  Hippocrates,  is  an  estabhshed, 
though  rare,  variety';  hemoptysis  \*icarious  to  suppression  of  hemorrhoidal 
bleeding  must  be  regarded  with  scepticism,  (d)  Lung  disease  is  its 
most  important  etiology,  notably  uj  tuberculosis  (q.  r.),  which  explains 
SO  to  90  per  cent,  of  blood-spitting.  It  very  rarely  occurs  under  six 
years  of  age.  as  children  seldom  develop  ca^-ities.  It  occurs  as  capillary 
or  profuse  hemorrhage.  Hemoptysis  sometimes  occurs  epidemically 
among  tuberculous  subjects,  referable  to  the  pnemnococcus.  ^ii)  Infarcts 
are  characterized  by  hemoptysis.  (_iiij  Pneumonia,  abscess  and  gangrene; 
(iv)  tumors;  (v)  parasites  of  the  lung,  trauma;  and  (vi)  s^'pb^]^s  and 
leprosy  are  more  uncommon  causes,  (e)  Hemopt^'sis  nervosa  is  most 
rare,  though  authentic  cases  have  occurred  in  cerebral  traumatism. 
hysteria  (where  it  has  caused  death  and  epilepsy,  (f;  Toxic  hemoptoe 
from  mercur^'  or  iodides  is  very  rare. 

Symptoms. — S^inptoms  follow  those  of  the  causal  tuberculosis,  mitral 
stenosis  oj  aneurysm,  or  develop  in  apparent  health.  Blood  poured  out 
into  a  ca^'ity  or  into  the  lung  substance  may  not  be  voided,  in  weak  or  mori- 
bund persons.  Prodromes  are  imusual;  without  learning,  a  salty  taste  in 
the  mouth,  substernal  warmth,  a  sense  of  something  rising  from  the  chest 
and  coughing  are  followed  at  once  by  a  few  spoonfuls  or  more  of  blood, 
which  also  may  be  accidentally  noted  in  a  pre^'iously  muc-ous  sputum. 
The  blood  varies  from  the  merest  stain  to  5  quarts;  it  may  appear  but 
once  or  repeatedly.  It  is  generally  bright  red  and  weU  mixed  with  air. 
If  the  blood  has  clotted,  the  clot  is  mixed  with  air  and  perhaps  with 
mucus.  Casts  of  the  bronchioles  may  be  voided.  In  gangrene  or  abscess, 
the  blood  may  be  brown  or  buff'-colored  and  the  red  cells  disintegrated. 
Brown  hemosiderm  granules  or,  if  the  blood  has  remained  as  a  clot  two 
weeks,  hematin  crystals  may  occur. 

Physical  findings,  other  than  those  of  the  causal  condition,  are  fre- 
quently lacking;  if  blood  stagnates  in  a  large  bronchus,  there  may  be 
broncliial  breathing,  bronchophony  or  duhiess  if  the  affected  area  measure 
2  by  5  cm.  In  the  bronchioles,  blood  gives  rise  to  small  rales,  in  the 
bronchi  to  coarser  rales. 

Complications. — Fever,  aside  from  the  causal  disease,  may  result  from 
resorption  ferment  fever;.  Urobilin  icterus,  functional  heart  murmur. 
relaxation  of  the  right  heart,  albuminuria  and  puffiness  of  the  ankles 
are  possible  complications. 

Diagnosis. — Examination  of  the  nose,  gums,  throat  and  larynx  exckides 
hemorrhage  simulating  hemoptoe.  Differentiation  lietween  bronchial 
and  pulmonary  bleeding  is  decided  by  the  history,  later  physical  exami- 
nation and  clinical  evolution. 


452  DISEASES  OF   THE  LUNG 

Hematemesis — vs. Hemoptysis. 

(a)  The  blood  is  acid  (unless  a  very  large       Is  alkaline. 

amount  is  voided). 

(b)  The  patient  always  recognizes  whether  it  is  vomited  or  coughed  up. 

(Blood    from    the    lung    is    very   rarely       (Hemoptysis,  very  rarely,  causes  consensual 
swallowed    and    then    vomited.)  vomiting.) 

(c)  Is   often    dark    (though   large   amounts       Nearly  always  bright   (though  when  stag- 

of  bright  red  blood  may  be  vomited,  nating  in  a  cavity  it  may  become  dark 

as  in  ulcer).  or  buff). 

(d)  Is  mixed  with  food,  HCl,  ferments,  etc.        Mixed  with  air,  which  is  also  found  in  the 

clots.     (Not  infrequently  tubercle  bacilli 
or  heart  disease  cells  are  found.) 

(e)  In  16  per  cent,  of  cases  blood  is  in  the       Is  very  rare  in  stools. 

stools. 

Prognosis  and  Course. — Spontaneous  cessation  is  the  rule.  The  imme- 
diate prognosi'^  is  good,  as  early  death  occurrs  in  3  per  cent,  only,  except 
in  profuse  pneumorrhagia,  resulting  from  aneurysmal  rupture  (even 
then  the  patient  may  live  years).  Drowning  of  the  patient  in  his  own 
blood  is  rare.  The  final  outcome  depends  on  the  etiology.  In  Ware's 
386  cases  62  per  cent,  recovered. 

Treatment. — Prevention. — In  tuberculosis  (q.  v.)  the  patient  should 
be  kept  quiet,  the  cough  suppressed  and  exertion  and  vocal  efforts 
avoided;  in  heart  disease  and  marantic  thrombosis,  rest  is  indicated 
to  obviate  detachment  of  the  thrombi. 

Therapy. — Absolute  physical  and  mental  quiet  should  be  enforced. 
Movement  and  talking  are  prohibited;  coughing  is  suppressed  by  hypo- 
dermics of  morphine,  which  allay  the  mental  excitement  (opiates  are 
employed  guardedly  in  very  large  hemorrhages,  for  bronchial  occlusion 
may  result).  The  patient  is  assured  of  a  favorable  outcome;  no  physical 
examination  should  be  made  except  auscultation  of  the  chest  in  front, 
for  treatment  takes  precedence  of  diagnosis;  if  rales  indicate  the  side 
of  the  hemorrhage,  the  patient  should  lie  on  that  side  to  prevent  aspira- 
tion into  the  contralateral  bronchus. 

Arterial  press2ire  should  be  reduced  by  inhalation  of  10  to  15  drops 
of  amyl  nitrite,  which  lessens  tension  in  the  pulmonary  and  arterial 
circulation.  A  liquid  diet  is  ordered.  Alcohol,  coffee  and  tea  should  be 
interdicted.  Even  if  the  patient  collapses  cardiants  should  be  avoided, 
for  syncope  is  nature's  hemostatic;  the  old  practice  of  venesection  in 
this  way  promoted  thrombosis.  Cardiac  excitement  is  lessened  by  plac- 
ing a  large  ice-bag  over  the  precordium.  Active  purgation  by  croton 
oil  is  very  beneficial. 

Hemostatics  do  not  control  the  lesser  circuit,  which  is  independent  of 
drugs  which  operate  on  the  arterial  circuit.  Ergot  raises  the  blood-press- 
ure in  the  lungs.  Calcium  lactate,  gr.  xxx,  and  common  salt  on  the 
tongue  are  of  some  value  (salt  acts  reflexly,  by  way  of  the  vagus,  on  the 
pulmonary  vessels) .  Horse  serum  may  be  used  in  urgent  cases  and  the 
beneficial  efi^ects  of  turpentine  have  long  been  known.  Nature,  as  a  rule, 
effects  the  cure.  Hippocrates  employed  ligature  of  the  extremities,  i.  e., 
binding  tightly  for  a  few  minutes  the  vessels  of  the  groin  and  axilla,  to 
lessen  the  return  flow  of  blood.  Artificial  pneumothorax,  to  compress 
the  bleeding  lung,  is  advocated  in  desperate  and  persistent  hemoptysis. 


PLEURISY  453 


DISEASES  OF  THE  PLEURA. 

PLEURISY. 

Definition. — An  inflammation  of  the  pleura,  secondary  to  tuberculosis 
or  other  lung  disease,  general  and  septicemic  infections  and  disease  in 
contiguous  tissues.  Hippocrates  recognized  the  dry  and  humid  types  and 
tapped  for  empyema  and  pneumothorax.  The  first  full  description  dates 
from  Laennec. 

Pleurisy  constitutes  3  per  cent,  of  internal  maladies  and  is  the  most 
common  of  all  postmortem  findings  (in  over  50  per  cent.).  It  is  suscep- 
tible of  division  into  infinite  varieties,  acute,  subacute  or  chronic  accord- 
ing to  its  course,  dry  or  effusive  according  to  its  consistence,  primary  or 
secondary  as  to  its  cause,  diffuse  or  circumscribed  as  to  its  distribution, 
and  serofibrinous,  hemorrhagic  or  suppurative  as  to  its  nature.  It  seems 
preferable  to  describe  all  its  symptoms  first  and  group  special  types  later. 

Etiology.  —  1.  Tuberculosis.  —  So-called  primary,  spontaneous  or 
cryptogenetic  pleurisy  is  usually  tuberculous.  Landouzy  considers  that 
98  per  cent,  of  all  pleurisies  are  tuberculous  and  Le  Damany  proved  by 
inoculation  that  92  per  cent,  of  "primary"  pleurisies  were  tuberculous. 
Lord  states  that  two-thirds  of  pleuritics  have  no  obvious  disease  in  other 
organs  and  three-quarters  respond  to  tuberculin.  The  causal  lesion  may 
be  recognized  at  autopsy  in  calcified  bronchial  glands  or  as  small  lung 
foci  {v.  page  459). 

2.  Diseases  of  the  Lung  Substance. — Pneumonia,  abscess,  gan- 
grene, infarcts,  tuberculosis,  tumors,  pneumothorax,  etc.,  are  etiological 
factors;  according  to  Jvoplik,  95  per  cent,  of  pleurisies  in  children  follow 
pneumonia.  It  is  less  frequent  in  diseases  involving  the  bronchi,  as  in 
grippe  or  measles. 

3.  Acute  Infections. — Rheumatism,  sepsis,  endo-  and  pericarditis, 
scarlatina,  and  other  acute  infections  may  result  in  pleurisy.  It  develops 
in  about  2  per  cent,  of  typhoid  cases. 

4.  Diseases  of  Adjacent  Organs. — (a)  Intrathoracic  affections, 
involving  the  ribs,  spine,  esophagus,  mediastinum,  lymph  glands,  dia- 
phragm and  pericardium;  and  (6)  abdominal  affections,  as  of  the  stomach, 
spleen  or  liver  (abscess,  tumor  or  cirrhosis),  subphrenic  abscess,  sup- 
purative, carcinomatous  or  tuberculous  peritonitis  (in  25  per  cent.), 
perinephritic  abscess,  etc.,  may  excite  pleural  infection  by  direct  local 
invasion  or  by  the  lymph  and  blood  streams;  in  neglected  appendicitis, 
hepatic  and  diaphragmatic  invasion  are  the  steps  to  pleural  infection. 

5.  Tumors. — Echinococcus  and  endothelioma  are  the  most  important 
types;  carcinoma,  sarcoma,  ecchondroma  and  rarely  lipoma  are  also  fac- 
tors; pleural  neoplasms  are  far  more  frequently  secondary  than  primary. 

6.  Altered  Conditions  of  the  Blood. — Gout,  nephritis  and  scurvy 
are  often  causative  of  pleurisy,  as  reduced  physiological  resistance  pre- 
disposes to  infection. 

7.  Terminal  Pleurisy. — Various  forms  of  sepsis  are  often  fatal  to 
subjects  of  chronic  disease  of  the  heart,  liver  and  kidneys. 


454  DISEASES  OF   THE  PLEURA 

8.  Age,  Sex,  Localization. — Age:  most  cases  occur  between  the 
twentieth  and  fiftieth  years,  but  no  age  is  exempt.  Sex:  Eichhorst 
observed  pleurisy  in  3  per  cent,  of  all  his  male  and  2  per  cent,  of  all  his 
female  cases,  and  found  the  following  localizations:  right-sided  in  54 
per  cent.,  left-sided  in  42  per  cent,  and  bilateral  in  4  per  cent.  Cases 
following  nervous  disease,  cold  or  exposure,  venous  thrombosis  or 
trauma  can  usually  be  brought  within  the  above  given  classification. 

Bacteriology. — The  above  etiological  classification  does  not  correspond 
to  the  bacteriological  division.  Suppurative  pleurisy  may  result  from 
the  streptococcus,  pneumococcus,  tubercle  bacillus  or  less  often  from 
the  staphylococcus  or  typhoid  or  colon  bacillus;  serous  pleurisy  may 
be  due  to  the  tubercle  or  pyogenic  organisms.  The  frequently  negative 
cultural  results  favor  the  hypotheses  that  chemical  products  may  induce 
pleurisy  or  that  bacteria  produce  pleurisy  and  then  die.  It  must  be 
remembered  that  cultures  are  made,  not  from  the  pleura  directly,  but 
from  the  fluid  eft'used  from  it.  The  organisms  found  are  most  frequently 
the  pneumococcus,  tubercle  bacillus  and  streptococcus;  less  often  the 
staphylococcus,  pneumobacillus  of  Friedlander,  typhoid,  paratyphoid, 
colon,  influenza  and  diphtheria  bacilli,  gonococcus,  meningococcus,  ray 
fungus,  etc.  (a)  Purulent  pleurisy  (empyema)  is  due  most  often  to  the 
streptococcus  in  adults  and  the  pneumococcus  in  children.  About  10 
per  cent,  of  empyema  is  tuberculous;  empyema  giving  no  results  cul- 
turally or  by  inoculation  is  usually  tuberculous — a  cold  abscess  of  the 
pleura.  Other  bacteria  (v.  s.)  are  infrequent  factors.  (6)  Serous  yleurisy 
is  usually  tuberculous,  as  shown  by  the  increasing  percentage  of  successful 
inoculations.  Tubercle  bacilli  when  found,  suggest  a  direct  communica- 
tion with  a  tuberculous  focus  in  the  lung  or  lymph  glands;  Eichhorst 
found  them  by  direct  examination  in  15  per  cent,  of  serous  pleurisies, 
though  inoculations  were  positive  in  62  per  cent,  (c)  So-called  primary 
pleurisy  which  is  non-tuberculous  is  usually  pnemnococcic.  {d)  ]\leta- 
and  parapneumonic  pleurisy  is  most  frequently  pneumococcic,  but  some- 
times streptococcic  and  staphylococcic. 

Symptoms. — Physical  findings  are  absolutely  essential  for  diagnosis 
and  all  subjective  symptoms  are  ambiguous  or  may  be  wholly  absent. 
In  the  main,  all  types  have  much  the  same  signs  which  difter  more 
quantitatively  than  qualitatively;  serous  pleurisy  nearly  always  shows 
friction,,  and  fibrinous  pleurisy  is  always  accompanied  by  some  exudation. 

Inspection. — (a)  Inspiratory  retraction  of  the  intercostal  spaces 
may  result  from  imperfect  ingress  of  air,  pain  or  adhesions.  Epigastric 
retraction  during  inspiration  is  due  to  contraction  of  the  diaphragm. 
(6)  The  patient  often  lies  during  the  dry  stage  on  the  sound  side  to  avoid 
pain  from  pressure  on  the  inflamed  surfaces;  later,  he  lies  on  the  diseased 
.  side  to  allow  freer  expansion  of  the  sound  lung,  especially  when  the  exti- 
date  is  large;  the  patient  may  sit  up  for  breath,  or  assume  the  diagonal 
decubitus,  (c)  Ectasia  (distention)  of  the  affected  side  occurs  especially 
in  children,  and  is  determined  by  mensuration  and  inspection.  The 
interspaces  are  obliterated,  the  costal  arch  is  immobile  during  respira- 
tion, the  skin  glistening,  the  spine  curved  toward  the  diseased  side,  the 
shoulder  higher  and  the  nipple  and  scapula  are  farther  from  the  median 


PLEURISY  455 

line.  (The  right  chest  is  normally  one  or  two  centimeters  larger.)  The 
sound  side  exceeds,  by  three  centimeters,  its  normal  dimensions  on 
account  of  compensatory  emphysema.  In  some  very  large  effusions 
the  writer  has  observed  an  apparent  retraction  of  the  diseased  side. 
(d)  Respiratory  momment  of  the  affected  side  is  decreased  or  absent 
both  in  dry  and  exudative  pleurisy.  Pain  alone  may  reflexly  decrease 
the  respiratory  expansion  and  variation  on  the  same  side  may  occur, 
there  being  more  movement  above  and  less  below.  The  frequency  of 
respiration  is  increased  from  lung  compression,  heart  luxation,  the  low 
diaphragm,  fever,  pain  or  paresis  of  the  intercostal  muscles,  {e)  The 
a;-rays  show  a  dark  shadow.  (/)  Inspection  reveals  cyanosis,  dislocation 
of  the  apex  and  occasionally  edema  {v.  i.).  {g)  Absence  of  Littens  yheno- 
menon  and  {h)  rarely  pulsation  of  the  effusion,  (i)  C.  L.  Greene  describes  a 
rhythmic  lateral  displacement  of  the  heart  most  marked  in  medium-sized 
effusions.  The  heart  approaches  the  affected  side  in  inspiration  and  moves 
outward  in  expiration,  movement  often  amounting  to  two  inches,  measured 
by  fluoroscopic  examination,  percussion  of  the  free  cardiac  border,  or  by 
inspection  of  the  apex. 

Palpation  confirms  inspection,  (a)  An  up-and-down  friction-rub 
is  felt;  it  increases  on  pressure,  which  also  increases  the  pain  and  ten- 
derness, and  it  is  the  more  readily  distinguished  the  coarser  the  rub. 
The  friction  develops  before  the  effusion,  is  often  present  with  it  and 
after  it  is  absorbed.  The  rub  is  due  to  roughening  of  the  pleura,  which 
loses  its  glistening  appearance  and  looks  like  glass  upon  which  one  has 
breathed;  the  two  raw  pleural  surfaces  scrape  on  each  other.  It  may 
last  a  few  hours  or  days,  even  disappearing  when  the  patient  takes  a 
deep  breath;  or  it  may  last  for  months  or  even  years.  (6)  Pressure  on 
a  tender  interspace  may  cause  a  sudden  contraction  of  the  rectus  muscle 
on  the  side  of  lesion,  (c)  Vocal  fremitus,  normally  greater  on  the  right 
side,  varies  according  to  the  level  at  which  it  is  tested,  (i)  Above  the 
effusion  it  is  normal,  (ii)  Near  the  spine  over  the  compressed,  relaxed 
lung  it  is  increased,  (iii)  Below  it  is  weak  or  absent,  from  exudation  of 
thick  fibrin  or  fluid,  though  less  change  is  observed  in  dry  than  effusive 
pleurisy.  The  condition  of  the  lung  and  the  bronchial  secretion  are 
important,  whence  before  testing,  the  patient  should  cough  and  take  a 
few  deep  breaths.  The  results  are  irregular  in  cases  of  loculated  effusion 
and  of  adhesions  bringing  the  lung  closer  to  the  chest  wall  in  given  places. 
(d)  By  tapping  with  the  finger  tips  the  increased  resistance  is  clearly  pal- 
pated, (e)  Edema  of  the  chest  wall  on  the  diseased  side  may  be  inflam- 
matory in  serous  and  purulent  pleurisy,  or  mechanical  (and  more  intense) 
from  pressure  on  the  azygos  or  hemiazygos  veins.  (/)  Fluctuation  is 
extremely  rare,  (g)  Palpation  determines  the  dislocated  apex  beat,  the 
dislocated  liver  or  spleen,  the  bulging  of  the  diaphragm  and  sometimes  a 
furrow  between  the  diaphragm  and  liver  (Stokes). 

Percussion  is  negative  in  dry  pleurisy,  except  when  a  very  thick 
fibrin  causes  some  dulness  and  weak  breathing;  after  an  effusion  has 
resorbed,  the  residual  plastic  lymph  maintains  the  dulness.  In  effusion 
(a)  dulness  is  found  typically  between  the  fifth  and  eighth  ribs  in  the 
left  axilla  or  over  the  liver  and  posteriorly  on  the  right  side.    Dulness 


456  DISEASES  OF   THE   PLEURA 

also  results  from  old  adhesions,  or  atelectasis  of  the  lung.  As  in  pneumo- 
thorax, emphysema  of  the  lungs  and  calcification  of  the  ribs  may  some- 
what obscure  the  dulness  of  an  effusion.  In  doubtful  cases  the  apparently 
sound  side  should  be  percussed  first.  Thirteen  ounces  of  fluid  are  neces- 
sary-in  the  adult  for  recognition  and  four  ounces  in  children,  and 
sometimes  six  ounces,  which  produce  a  dulness  two  fingers  in  height, 
may  be  recognized,  especially  in  children  and  women  having  thin  tho- 
racic walls.  The  effusion  must  be  one  inch  thick  to  produce  dulness. 
Before  percussion  the  patient  should  breathe  deeply  several  times  to 
eliminate  partial  collapse  of  the  lung  and  accumulated  bronchial  secre- 
tion. Percussion  is  absolutely  essential  to  diagnosis.  Not  merely  the 
audible  dulness  should  be  regarded,  but  also  the  ijalpable  sense  of  resis- 
tance, on  light  percussion.  In  larger  effusions,  the  distinct  flatness,  at 
first  located  posteriorly,  increases  along  the  spine  and  laterally  in  the 
axilla,  and  in  massive  exudates,  may  reach  above  the  clavicles. 

The  dulness  is  highest  posteriorly  as  the  patient  lies  on  the  back. 
\Yhen  he  sits  the  line  of  dulness  describes  a  parabolic  curve  (courbe  de 
Damoiseau  or  the  Garland-Ellis  line)  which  is  lowest  behind  and  due 
to  the  uneven  thickness  of  the  chest  wall  or  to  adhesions.  If  the  fluid 
should  effuse  with  the  patient  out  of  bed,  the  upper  level  would  be 
horizontal.  Dulness  is  found  one  or  two  centimeters  higher  than  the 
fluid,  due  to  plastic  exudate,  (b)  Right-sided  effusions  merge  with  the 
liver  dulness,  but  the  lower  limit  of  left-sided  effusions  can  usually  be 
determined  because  they  invade  Traube's  seviilunar  space,  which  lies 
between  the  heart's  apex  above  and  tenth  rib  below,  representing  the 
supplementary  pleural  space  and  is  designated  as  the  "half -moon" 
space  because  of  the  curve  at  its  upper  portion,  produced  by  the  apex; 
its  tympanitic  note  is  decreased  or  replaced  by  flatness  in  left-sided 
effusions  (without  adhesions).  Dulness  here  may  not  be  confused  with 
the  spleen,  for  there  is  no  respiratory  excursion  in  pleurisy,  and  the 
dulness  lies  more  toward  the  heart  than  toward  the  spleen,  (c)  lies- 
jnratory  excursion  and  Littens  sign  are  absent,  (d)  Change  of  the  upper 
line  of  dulness  with  change  of  position,  emphasized  by  most  writers, 
cannot  be  established,  because  of  adhesions  at  the  upper  level;  the 
patient  must  lie  hours  in  another  posture  before  any  alteration 
occurs. 

The  following  findings  are  less  important :  (e)  A  vertical  strip  of  tym- 
jxtny  along  the  spine,  often  measuring  3  cm.  wide,  may  be  detected  in  a 
large  exudate,  due  to  compression  of  the  lung.  Tympany  in  the  lower 
left  chest  results  from  the  gaseous  stomach  and  intestines.  (/)  Tympany 
over  an  upper  lobe  from  compression  or  relaxation  of  the  lung,  was 
observed  by  Avenbriigger  and  Skoda — the  Skodaic  note,  (g)  "  Cracked- 
pot''  resonance  occasionally  appears  on  short,  forcible  percussion  over 
the  upper  lobe,  and  results  from  sudden  expulsion  of  air  through  the 
rima  glottidis.  {K)  William's  tracheal  note  is  observed  on  the  left  more 
than  on  the  right  side  and  most  clearly  in  the  first  and  second  interspaces. 
It  is  obtained  chiefly  when  the  entire  side  is  dull  and  is  due  to  transmission 
of  percussion  vibration  from  the  fluid  to  the  trachea,  giving  a  tympanitic 
note.      (/)    Grocco's  .sign  is  a  small  triangnlar  dulness  on  the  sound  side 


PLEURISY  457 

along  the  vertehrce,  due  to  displacement  of  the  mediastinum  and,  with 
it,  the  sound  hmg,  which  is  pushed  away  from  the  vertebral  column 
by  fluid  in  the  lower  chest;  it  also  occurs  in  subphrenic  abscess,  cysts 
or  ascites;  Koranyi  first  described  this  sign  in  1897  and  Grocco  in  1902. 
(j)  Dislocation  of  other  organs.  There  is  no  parallelism  between  the 
amount  of  exudate  and  the  amount  of  luxation,  w^hich,  of  course,  is 
absent  if  the  organs  are  adherent.  The  average  increase  of  intrathoracic 
pressure  is  10  mm.  mercury  (0  to  26).  The.  heart  is  usually  dislocated 
in  toto  and  seldom  suffers  change  of  the  direction  of  its  axis.  The  right 
ventricle  pulsates  to  the  right  of  the  sternum,  even  at  the  right  nipple 
line,  in  left-sided  effusion.  In  right-sided  effusions  the  apex  is  pushed 
to  the  left  and  downward,  for  the  diaphragm  is  lower.  The  liver  is  less 
easily  displaced  than  the  heart,  but  in  right-sided  effusions  is  pushed 
down  (especially  in  empyema)  and  the  left  lobe  tipped  somewhat  upward ; 
both  lobes  are  dislocated  downward  in  massive  pleurisies.  In  left-sided 
effusions  the  spleen  is  dislocated  downward  and  forward,  undergoes  some 
torsion  and  may  stand  perpendicular  to  the  costal  arch. 

Auscultation. — This  is  most  important  in  dry  and  effusive  pleurisy. 
(a)  The  friction-rub  may  be  hard  or  soft,  is  superficial,  i.  e.,  close  to  the 
ear  and  resembles  the  sound  made  by  scratching  the  finger  upon  the 
ear  or  the  crunching  of  snow^  under  the  shoe;  it  often  develops  in  the 
first  twelve  hours.  It  is  most  frequent  during  inspiration,  but  is  very 
often  detected  in  expiration,  but  seldom  during  expiration  alone.  It 
may  disappear  after  several  long  breaths  w^hich  smooth  the  pleural 
roughening.  It  may  be  increased  by  pressure  and  its  duration  is  subject 
to  no  law;  Gerhardt  heard  a  pleural  rub  which  lasted  six  years.  It  is 
heard  most  frequently  over  the  anterolateral  portion  of  the  chest,  and  is 
detected  more  clearly  with  the  stethoscope  than  with  the  naked  ear, 
but  may  be  heard  at  a  distance  of  several  feet,  as  in  a  case  seen  with 
Dr.  H.  M.  Richter.  It  may  rarely  be  present  in  miliary  tuberculosis 
and  in  tumors  of  the  lung  or  pleura  without  actual  pleurisy.  It  usually 
becomes  less  clear  when  exudation  develops,  and  its  reappearance  indi- 
cates absorption  or  extension.  (6)  The  breath  sounds  are  modified  not 
only  by  the  effusion,  but  also  by  the  condition  of  the  lung,  and  the 
conditions  of  conduction  in  the  pleura  and  thoracic  walls.  In  general, 
and  especially  in  men  and  children,  the  respiratory  sounds  are  weake7ied 
even  in  fibrinous  pleurisy,  from  repressed  breathing  and  perhaps  from 
pain  alone;  cog-wheel  breathing  is  common.  In  moderate  effusions 
three  zones  are  observed:  (i)  Absence  of  breathing  in  the  lower  parts 
from  compression  of  the  lung  by  the  exudate,  which  lessens  the  conduc- 
tion of  the  vesicular  sounds;  (ii)  bronchial  breathing  in  the  middle 
zone  from  moderate  collapse  of  the  alveoli  of  the  lung,  with  fair  con- 
duction through  the  bronchi;  (iii)  an  upper  zone  of  sharp  vesicular 
breathing.  In  larger  effusions  the  lower  zone  extends  higher  and 
bronchial  breathing  may  be  heard  near  the  clavicle  or  between  the 
scapula  and  spine.  In  the  largest  effusions  the  breathing  is  indistinct 
everywhere  (with  metallic  bronchial  breathing  when  the  lung  is  wholly 
collapsed) .  (c)  The  voice  sounds  are  not  heard  over  the  fluid  or  over  very 
thick,  plastic  exudate.    They  may  persist  where  islets  of  lung  adhere  to 


458  DISEASES  OF   THE  PLEURA 

the  chest  wall,  (d)  Bronchial  breathing  and  increased  fremitus  may 
be  present,  especially  in  children  with  empyema,  under  the  following 
conditions:  if  the  bronchi  are  patent,  if  there  is  no  great  fibrin  deposit 
on  the  pleura  and  if  the  lungs  are  retracted  but  not  absolutel}^  com- 
pressed. The  bronchial  breathing  may  sometimes  be  as  intense  as  in 
pneumonia.  In  adults  increased  fremitus  may  be  observed  between 
the  spine  and  scapula  where  the  lung  is  compressed,  (e)  Bronchophony 
depends  upon  the  same  conditions  as  bronchial  breathing.  (/)  Egophony, 
which  is  an  exaggerated  bronchophony,  was  described  by  Laennec;  it 
is  found  chiefly  in  middle-sized  effusions,  usually  at  the  level  of  the 
fluid;  in  large  effusions  it  is  rare,  the  compression  being  too  great.  It 
is  caused  by  the  voice  sounds  passing  through  the  compressed  smaller 
bronchi  to  the  chest  wall ;  it  may  be  present  when  the  exudate  is  increas- 
ing or  decreasing  at  a  given  point,  {g)  Baccelli's  symptom  of  the  ''whis- 
pering voice,"  which  he  thought  was  more  frequent  in  serous  effusions, 
also  occurs  in  other  forms  of  pleurisy,  in  induration  of  the  lungs,  pneu- 
monia, hydrothorax  and  cavities,  (h)  A  toide  propagation  of  the  heart 
tones— if^  consolidation  is  excluded — suggests  dislocation  of  the  heart 
by  an  effusion.  Murmurs  may  result  from  bending  of  the  large  vessels 
by  dislocation  of  the  heart,  as  well  as  accidental  murmurs  resulting 
from  a  heart  weakened  by  toxemia. 

Diagnostic  puncture  determines:  (a)  the  existence  of  pleurisy, 
excluding  pneumonia,  hypostasis,  tumor,  etc.;  (b)  the  character  of  the 
fluid;  and  (c)  the  prognosis.  It  is  indicated  in  all  doubtful  cases.  Punc- 
ture with  aspiration  is  also  an  important  therapeutic  measure.  Negative 
results  may  result  from  a  thick,  fibrinous  exudate,  from  failure  to  reach 
an  encapsulated  effusion,  as  in  interlobar  pleurisy,  and  from  the  mem- 
brane being  pushed  in  before  the  needle.  In  dry  taps,  after  withdrawal 
of  the  needle,  examination  should  be  made  to  see  that  no  fibrin  or  cells 
plug  the  needle.  If  a  plug  is  obtained  it  should  be  examined  under 
the  microscope.  No  carbolic  acid  or  alcohol  should  remain  in  the  syringe 
or  needle,  which,  by  coagulating  the  serum,  may  explain  some  dry 
punctures.  The  puncture  should  be  made  with  a  large  needle.  Positive 
results:  when  the  needle  is  introduced,  resistance  due  to  a  callous  pleurisy 
or  indurated  lung  may  be  felt.  After  introducing  the  needle,  the  point 
may  be  freely  movable,  as  in  a  cavity.  In  rare  cases  serum  may  be 
obtained  from  a  high  puncture  and  from  a  lower  one  a  cellular  deposit, 
the  cells  settling  to  the  bottom;  oftener  puncture  in  different  localities 
shows  serum  in  one  and  pus  in  another  sac — Galliard's  polymorphous 
pleurisy.  A  pocket  of  sterile  effusion  often  indicates  a  contiguous  encap- 
sulated empyema  or  a  lung  abscess.  Bacteriological  examinations  made 
with  20  to  30  c.c.  of  the  serum  give  frequent  positive  results.  The 
special  chemical,  bacteriological,  cellular  and  other  characteristics  will 
be  discussed  under  individual  forms. 

X-EAY  Findings. — It  is  usually  stated  that  fluid  first  accumulates 
under  the  lung,  between  it  and  the  diaphragm.  Englebach  and  Carmen 
found  this  was  the  case  in  but  25  per  cent,  of  cases;  in  another  25  per 
cent,  the  fluid  stood  like  a  vertical  column  and  in. 34  per  cent,  laterally 
— nearer  the  chest  wall  than  the  mediastinum;  the  column  was  oblique 


PLEURISY  450 

in  K)  per  cent.  The  .r-rays  confirm  the  lack  of  mobility  on  change  of 
position  and  show  how  adhesions  may  prevent  luxation  of  organs^  inva- 
sion of  Traube's  space,  respiratory  excursion,  etc.  Small  or  deep  pockets 
of  fluid  near  the  diaphragm  or  in  the  interlobar  fissures  are  thus  detected 
which  may  escape  physical  examination. 

Symptoms. — Symptoms  may  be  absent  (latent  pleurisy);  if  present 
they  are  not  distinctive  and  there  is  no  relation  between  them  and  the 
physical  findings,  (a)  The  temperature  rise  is  usually  gradual  and 
without  a  rigor.  Temperature  is  no  positive  index  as  to  the  character 
of  the  fluid.  For  weeks  there  may  be  no  temperature,  even  in  purulent 
exudates,  especially  in  marantic  and  diabetic  subjects  and  in  terminal 
infections.  When  present  it  is  more  frequently  subcontinuous  or  remit- 
tent than  continuous.  The  average  elevation  is  101°  to  102°.  Exacer- 
bations of  fever  are  ominous,  expecially  when  no  change  occurs  in  the 
physical  findings.  Recovery  is  not  expected  until  the  temperature  has 
been  normal  for  some  time,  (b)  The  i^^^Jse  is  increased;  it  is  sometimes 
of  the  paradoxical  type  or  unequal  in  the  two  radials.  (c)  Dyspnea 
seldom  attends  pleurisy,  for  effusions  may  attain  enormous  proportions 
without  respiratory  difficulty,  particularh'  when  they  are  gradual  in  de- 
velopment. Urgent  dyspnea  is  usually  referable  to  coincident  pneu- 
monia, pericarditis,  arteriosclerosis,  nephritis  or  bilateral  pleuritis.  {d) 
Pain  is  usually  an  initial  symptom.  It  is  in  no  way  proportional  to  the 
physical  findings;  it  may  be  absent  when  auscultation  shows  a  marked 
rub.  Its  character  is  usually  dull,  tearing,  stabbing  and  sometimes  very 
severe,  crampy  or  colicky.  The  pain  is  pleural  (Cruveilhier)  and  is  present 
in  the  diseased  side,  well  down  over  the  ribs,  liver,  epigastrium  or  low 
in  the  back,  and  sometimes  may  radiate  to  the  sound  side,  into  the 
arm,  spine  or  abdomen,  especially  in  children,  in  which  case  it  may 
simulate  appendicitis,  {e)  Coughing,  an  early  and  frequent  symptom, 
results  most  often  from  pleural  irritation.  It  may  occur  after  tapping 
or  change  of  posture.  It  is  usually  unproductive.  (/)  Other  symptoms 
are  anorexia,  vomiting,  headache,  and  difficult  swallowing  due  to  involve- 
ment of  the  foramen  esophageum;  the  sweats  of  pleurisy  rank  third  in 
importance  after  those  of  sepsis  and  rheumatism.  The  urine  is  scanty 
but  increases  during  resorption,  when  peptonuria  and  transient  albumin- 
uria are  often  found.  The  skin  may  be  pale  and  cachectic  from  purulent 
accumulations,  red  from  high  temperature,  cyanotic  from  poor  oxygena- 
tion or  suddenly  pallid  from  hemorrhage  into  the  pleura,  when  also  there 
is  a  sudden  increase  of  fluid.  Emaciation  is  common  in  chronic  tuber- 
culous or  purulent  pleurisy. 

Special  Forms. — 1.  Cilvracter  of  the  Infi^iaumation. — In  790  cases 
Eichhorst  found  serous  pleurisy  in  81,  fibrinous  in  12,  purulent  in  5, 
ichorous  and  hemorrhagic  each  in  1  per  cent. 

(a)  Serous  pleurisy  is  the  prototype  of  pleuritis.  The  fluid  is  lemon- 
colored.  Its  specific  gravity  ranges  between  1.015  and  1.023,  which 
characterizes  inflammation.  Albumin  amounts  to  3  to  7  per  cent.; 
sugar  is  frequently  present.  The  fluid  clots  after  puncture.  All  pleuritic 
exudates,  serous  and  otherwise,  contain  white  and  red  blood  cells  and 
endothelial  cells,  which  may  show  fatty  degeneration. 


460  DISEASES  OF   THE  PLEURA 

Cytodiacjnosis.—WidaX,  Sicard  and  Revault  (1900)  insisted  that  lym- 
phocytes  are  characteristic  of  primary  pleural  tuberculosis  and  afford 
diagnostic  data  long  before  the  results  of  inoculation  are  available;  the 
fluid  must  be  examined  before  it  coagulates;  in  other  pleurisies  the  poly- 
morphonuclears prevail  and  that  over  50  per  cent,  lymphocytes  indi- 
cates tuberculosis;  the  "lymphocytic  formula"  proves  tuberculosis,  the 
"polymorphonuclear  formula"  indicates  pyogenic  infection  or  pleurisy 
secondary  to  well-developed  phthisis  and  the  "endothelial  formula" 
denotes  irritation,  transudation  or  malignancy.  The  tuberculous  nature 
of  pleurisy  is  established  by  inoculation  tests  (positive  in  66  to  94  per 
cent.),  by  apical  or  other  involvement,  by  the  finding  of  tuberculosis 
in  cases  of  sudden  death  in  the  course  of  pleurisy,  by  the  usually  intensely 
positive  ophthalmoreaction  (see  page  164)  and  by  the  fact  that  25  to  33 
per  cent,  of  cases  become  obviously  tuberculous.  It  is  well  to  suspect 
the  tuberculous  nature  of  all  so-called  rheumatic  pleurisies  and  carefully 
watch  the  sputum  and  lungs.  The  leukocytes  are  not  much  increased 
in  the  blood. 

(6)  Fibrinous  pleurisy  usually  shows  some  fluid,  serous  or  purulent, 
if  systematic  punctures. are  made. 

(c)  Purulent  pleurisy  (empyema)  usually  begins  as  a  serous  exudate 
which  soon  becomes  purulent.  In  contrast  to  serous  pleuritis  two-thirds 
of  this  group  are  secondary :  (i)  the  streptococcic  form,  which  is  observed 
chiefly  in  adults,  in  which  the  thin  fluid  separates  on  standing  into  an 
upper  serous  and  a  lower  denser  layer,  with  slight  fibrin  formation;  and 
(ii)  the  pneumococcic  form,  which  is  more  common  in  children;  the 
fluid  is  more  homogeneous  and  viscid,  like  "laudable"  pus,  flbrin  forma- 
tion is  abundant  and  the  odor  peculiar;  it  is  more  often  accompanied 
by  endocarditis,  pericarditis  and  meningitis,  and  is  more  often  febrile 
and  more  susceptible  of  spontaneous  recovery.  In  Netter's  series  of 
empyema  the  streptococcus  was  causal  in  47  per  cent.,  the  pneumococcus 
in  39,  the  tubercle  bacillus  in  11  and  the  staphylococcus  in  3  per  cent. 
Over  80  per  cent,  of  juvenile  empyemas  are  pneumococcic.  It  is  remark- 
able that  the  pneumococcus  has  far  less  pyogenic  propensities  in  the 
lung  than  in  the  pleura.  Microscopically,  various  bacteria  are  present, 
polymorphonuclear  and  often  fatty  white  cells,  and  sometimes  choles- 
terin  and  Charcot-Leyden  crystals.  Greater  visceral  luxation  and  dis- 
tention of  the  chest  than  in  any  other  type  may  occur;  Krause  reported 
22  pounds  of  pus.  Leukocytosis  and  hectic  fever  are  mentioned  under 
symptoms. 

Empyema  pulsans  (Walshe);  Sailer  collated  95  cases  in  1904;  95  per 
cent,  of  all  pulsating  effusions  are  purulent;  93  per  cent,  are  left-sided. 
A  pulsating  tumor  as  large  as  the  fist  may  be  noticed,  which  usually 
decreases  during  inspiration,  or  the  effusion  may  simply  pulsate  behind 
the  ribs;  in  either  case  the  pulsation  may  be  expansile,  and  usually 
lies  between  the  second  and  fourth  ribs,  anteriorly,  but  may  be  seen 
lower  or  even  in  the  back.  Pulsation  is  probably  propagated  from  the 
aorta.  The  apparent  conditions  for  pulsation  in  an  empyema  are  cardiac 
energy,  massive  exudation  and  paresis  of  the  intercostal  muscles.  Empy- 
ema pulsans  may  be  confused  with  aneurysm,  which  latter  is  much 


PLEURISY  461 

slower  in  its  evolution,  is  much  oftener  located  above  and  to  the  right, 
and  has  its  o^tti  signs,  miu-mur  and  thrill;  it  may  be  confused  with 
pulsating  abscess,  pneumonia,  gangrene  or  tumor  of  the  lung.  The 
pulsation  ceases  after  aspiration.  Expansile  pulsation  of  the  chest  wall 
has  been  observed  ■u'ithout  any  organic  change  (Lafleur  and  Edwards). 

Empyema  may  rupture  externally,  empyema  necessitatis,  usually 
along  the  sternum  or  lower  ribs.  Gravitating  abscesses  may  result, 
as  pulsating  tumors  in  the  groin  and  loin,  confusable  with  aneurysm 
or  spinal  caries.  Rupture  into  the  air  passages  may  cause  suffocation 
during  sleep;  25  per  cent,  of  postpneumonic  empyemas  rupture  into 
the  bronchi.  Fistulse,  hectic  fever  and  amyloidosis  are  frequent  sequelfe. 
Hippocrates  knew  of  the  "mouthful"  expectoration  and  also  the  fact 
that  pus  may  penetrate  the  lung  like  a  sponge  without  perforation 
or  pneumothorax  (perforation  into  the  lung  without  pneumothorax  is 
caused  by  a  small  opening  which  allows  the  escape  of  fluid  into  the  lung 
but  not  of  air  into  the  pleura,  because  of  higher  tension  in  the  exudate). 
Empyema  may  rupture  into  the  pericardium,  peritoneum,  esophagus, 
stomach,  etc.  HelKn  (1905)  found  114  cases  of  bilateral  empyema 
recorded  in  the  literature;  67  per  cent,  occurred  in  males  and  90  per 
cent,  in  young  persons  under  fifteen  years  old;  the  mortality  was  30 
per  cent. 

(d)  Putrid  pleurisy  is  usually  associated  with  gangrene  of  the  lung, 
pneumothorax,  esophageal  carcinoma,  appendicular  abscess  and  kindred 
lesions.  The  fluid  is  extremely  fetid;  fat,  leucin,  tyrosin,  cholesterin 
and  sometimes  hematoidin  crystals  are  found;  the  colon  bacillus  and 
other  gasogenic  bacteria  are  frequently  present. 

(e)  Hemorrhagic  pleurisy  is  usually  serofibrinous  and  the  exudate  is 
tinged  with  blood.  Five  to  six  thousand -red  cells  per  c.mm.  are  necessary 
to  produce  a  reddish  tinge.  Its  character  is  seldom  suspected  before 
puncture,  (i)  ]\Iost  cases  are  tuberculous  and  Dieulafoy  speaks  of  them 
as  having  "hemoptysis  into  their  pleurse."  After  puncture  more  fluid 
is  frequently  formed  but  recovery  is  possible,  (ii)  Some  cases  are  can- 
cerous; hemorrhagic  pleurisy  is  found  in  but  12  per  cent,  of  pulmono- 
pleural  cancer;  pain,  dyspnea,  luxation  and  rapid  pulse  are  frequent 
symptoms;  the  fluid  is  dark  red  and  contains  little  fibrin;  a  case  of  Desnos 
was  punctured  thirty  times  in  six  months,  (iii)  Some  cases  occur  in 
liver  cirrhosis,  in  nephritis  and  in  hemorrhagic  fevers  or  exanthemata; 
profuse  hemorrhage  into  the  pleura  was  called  pleural  hematoma  by 
\Yintrich  and  pachypleuritis  hemorrhagica  by  Chouppe. 

(/)  Chyliform  pleurisy  (v.  i.  Chtlothorax)  . 

2.  LoCATiox  OF  THE  EXUDATE. — (o)  Pleuritis  diaphragmatica  produces 
notable  subjective  disturbance,  as  pain  which  may  resemble  angina 
pectoris,  pain  with  tenderness  in  the  epigastrium,  between  the  tenth  rib 
and  the  xiphoid ;  tenderness  in  the  lower  interspaces  near  the  spine ;  ten- 
derness over  the  cervical  portion  of  the  phrenic  nerve,  with  pain  reflected 
along  the  acromial  branches  of  the  cervical  nerves  to  the  shoulder.  An 
inspiratory  spasm  of  the  upper  part  of  the  rectus  muscle;  dysphagia 
from  inflammation  of  the  foramen  esophageum;  if  left-sided,  vomiting 
and  singultus  may  be  noted,  and  if  right-sided,  icterus  is  not  uncommon. 


402  DISEASES  OF  THE  PLEURA 

Cough  may  occur  spontaneously  or  on  pressure.  Dyspnea  is  usually 
great,  the  temperature  is  generally  normal,  the  lower  chest  moves  but 
little,  the  respiratory  murmur  is  very  weak  and  friction  may  be  heard 
over  the  liver  or  in  Traube's  space.  If  there  is  no  exudate  the  diaphragm 
may  remain  high.  Fluid,  accumulating  between  the  diaphragm  and 
lung  without  reaching  the  chest  wall,  causes  no  dulness.  Fibrinous  is 
more  common  than  serous  effusion. 

(6)  Interlobar  pleurisy  occurs  most  frequently  in  pneumonia  or  tuber- 
culosis. Previous  pleurisy  may  favor  this  localization  by  obliterating 
the  general  pleural  space.  As  Laennec  noted,  it  is  almost  always  sup- 
purative. Its  early  diagnosis  is  uncertain,  for  the  fever,  rales,  hemoptysis, 
cough  and  dyspnea  suggest  a  lesion  of  the  lung,  e.  g.,  lung  abscess  from 
which  differentiation  is  sometimes  impossible;  tenderness  is  frequently 
elicited  along  the  interlobar  fissure;  later  a  zonular  surface  dulness  is 
found  conforming  to  the  fissure,  bounded  above  and  below  by  a  normal 
or  somewhat  over-resonant  note.  The  heart  may  be  pushed  to  the  right 
in  left-sided  localization,  but  the  liver  is  not  luxated  in  right-sided  locali- 
zation. Interlobar  pleuritis  may  be  shown  clearly  by  the  a:;-rays.  Large 
effusions  may  break  internally,  pus  suddenly  appearing  in  the  sputum, 
but  spontaneous  recovery  is  infrequent.  Puncture  may  infect  the  lung 
during  the  withdrawal  of  the  needle.  The  outlines  of  the  lobes  are  shown 
in  Figs.  33-35. 

(c)  Mediastinal  pleurisy  is  most  often  tuberculous  or  pneumococcic, 
and  more  frequently  purulent  than  serous.  The  symptoms  of  lung 
compression  are  less  distinctive  than  those  of  the  compression  of  medias- 
tinal tissues.  There  may  be  dyspnea,  dysphagia,  intrathoracic  oppres- 
sion, a  pertussis-like  cough,  enlarged  thoracic  veins,  deviation  of  the 
trachea,  and  dulness  between  the  scapula  and  spine;  the  a'-ray  picture 
may  be  suggestive.  The  sudden  onset  and  febrile  course  differentiate 
it  from  aneurysm,  tumor  and  adenopathies.  Without  operation  the 
outlook  is  unfavorable. 

(d)  Peri-  (para-)  pleuritis  is  inflammation  outside  of  the  parietal 
pleura,  and  is  usually  purulent.  Most  cases  are  actinomycotic.  Fistulse 
and  the  evacuation  of  the  characteristic  sulphur  granules  are  common. 
The  symptoms  are  more  local  and  irregular  than  those  of  pleurisy; 
fluctuation  is  more  frequent;  heart  dislocation  and  lung  compression 
are  rare;  the  respiratory  excursion  is  free,  and  heavy  percussion  elicits 
lung  resonance  beneath  the  dulness.  Metastatic  inflammation,  perfora- 
tion and  burrowing  are  common. 

3.  Pleurisy  in  Children. — In  children  pleurisy  is  attended  by  more 
toxemia,  higher  temperature,  pulse  and  respiration.  Bronchial  breath- 
ing is  more  frequent;  there  is  less  dulness,  less  luxation  and  less  friction. 
It  often  follows  pneumonia,  where,  in  the  majority  of  cases,  the  empyema 
is  more  benign;  tuberculosis  is  less  frequently  causative  in  children. 

Issue. — 1.  Resorption. — Even  purulent  pneumococcic  pleurisy  may 
exceptionally  resorb  in  part  without  operation  or  rupture,  leaving 
inspissated  caseous  accumulations.  Serous  pleurisies  may  be  absorbed 
after  three  to  six  months,  during  which  time  persistent  friction  is  common 
over  the  lower  chest.    A  proteolytic  ferment  in  the  white  cells  dissolves 


PLEURISY 


463 


the  fibrin  and  the  serum  is  taken  up  by  the  lymph-  and  bloodvessels. 
Dieulafoy  reports  a  case  of  serous  pleurisy,  in  good  health  after  ten  years, 
which  was  tapped  over  100  times  and  230  liters  removed. 

2.  Adhesions. — ^The  thickness  of  pleural  adhesions  is  more  important 
than  their  extent.     Universal  obliteration  of  the  pleural  sac  by  thin 


Fig.  33 


Fig.  34 


Fig.  35 


Figs.  33,  34,  and  35. — Cuts  from  Dieulafoy,  showing:  Fig.  33,  the  posterior  surface  of 
the  lungs  and  their  interlobar  fissures;  Fig.  34,  the  lateral  aspect  of  the  left  lung;  and  Fig. 
35,  that  of  the  right  lung. 


adhesions  is  of  no  consequence.  Compensatory  emphysema,  pain, 
thoracic  oppression,  obliteration  of  the  complementary  pleural  space, 
dulness,  decreased  vocal  fremitus  and  breathing,  failure  of  Litten's 
phenomenon  and  stagnation  of  bronchial  secretion  may  occur  when  the 
adhesions  are  thick,  and  stasis  may  ensue.     Peritonitis,  mediastinitis 


464  DISEASES  OF   THE  PLEURA 

and  obliterative  pericarditis  may  complicate  the  case.  In  some  instances 
the  pleura  calcifies  or  ossifies,  leaving  a  deposit  measuring  3  cm.  or  more 
in  thickness. 

3.  SuDDEX  DEATH  may  result  after  exertion,  coughing,  urination  or  defe- 
cation; it  results  chiefly  from  such  extreme  venous  compression  that  the 
venous  trunks  can  return  little  blood  to  the  heart.  Less  frequent  causes 
are  cardiac  paralysis  or  thrombosis,  pulmonary  edema,  and  rarely  bend- 
ing of  the  aorta,  pulmonary  embolism,  rupture. of  fluid  into  the  bronchi, 
which  may  drown  the  patient  during  sleep,  and  death  from  hemo-  or 
pneumothorax  or  brain  embolism. 

4.  Retractio  thoracis  is  characterized  by  increased  resistance, 
decreased  fremitus,  decreased  circumference  of  the  affected  side  and 
often  by  bronchiectasis.  The  percussion-note  is  dull  and  the  breathing 
is  usually  decreased,  but  sometimes  bronchial.  The  causative  factors 
are  atmospheric  pressure,  retraction  of  the  pleural  scars,  or  pleurogenous 
interstitial  pneumonia,  also  known  as  pleuritis  deformans,  which  some- 
times lobulates  the  lung.  Retraction  is  generally  a  slow  process  but  the 
writer  has  seen  marked  deformity  develop  in  three  weeks. 

5.  Changes  in  Other  Organs. — Retraction  may  raise  the  liver 
and  the  lung  may  shrink  away  from  the  heart,  the  spleen  and  the  heart 
may  lie  higher  and  Traube's  space  may  be  increased.  Organs  displaced 
by  exudate  may  in  rare  cases  remain  luxated  after  the  exudate  is  absorbed. 
Pleural  callosities  may  produce  recurrent  laryngeal  paralysis  which  may 
also  follow  pressure  by  an  exudate  or  adenopathy.  Other  complications 
are  acute  and  chronic  infiltration  in  the  lung;  extension  to  other  serous 
surfaces;  septicopyemia;  stasis  in  the  liver,  stomach,  extremities,  etc.; 
chronic  nephritis;  amyloid  degeneration  and  various  visceral  or  miliary 
tuberculosis.    Scagliari  reports  47  cases  of  brachial  paralysis. 

Diagnosis. — The  physical  findings  only  are  final;  symptoms  are  most 
unreliable.  Diagnosis  of  the  malady  is  the  first  step,  and  the  second  is 
the  determination  of  its  cause. 

Differentiation. — 1.  Pleuritis  sicca  is  recognized  only  by  feeling  or 
hearing  the  friction,  (a)  The  crepitant  rale  is  largely  inspiratory,  and 
is  heard  as  a  number  of  small  crackles  at  the  end  of  inspiration;  it  is 
altered  or  removed  by  coughing  and  deep  inspiration,  but  the  pleural 
rub  is  increased  by  pressure  and  deep  breathing.  It  may  disappear 
after  a  number  of  deep  inspirations,  which  make  the  two  surfaces  tem- 
porarily smooth,  (h)  It  must  be  differentiated  from  sacculated  breathing 
and  the  physiological,  bilateral  crackling  in  the  chest  muscles  on  deep 
breathing,  (c)  Intercostal  neuralgia  is  intermittent,  occurs  in  typical 
attacks  and  is  limited  to  the  interspaces;  Valleix's  points  are  present  at 
the  angle  of  the  ribs,  in  mid-axilla  and  anteriorly,  and  correspond  to  the 
exit  of  the  three  perforating  branches  of  the  nerve.  Intercostal  neuralgia 
is  increased  less  on  deep  breathing,  {cl)  In  caries  of  the  ribs  pain  is  local- 
ized directly  over  one  rib  and  not  between  the  ribs,  (e)  Differentiation 
from  rheumatism  of  the  thoracic  muscles  may  be  difficult,  for  both  affec- 
tions induce  pain  on  breathing,  tenderness  and  disturbed  breathing; 
there  may  be  a  history  of  exposure  or  repeated  attacks;  there  is  no 
fever  or  cough;  movement  increases  the  pain  more  than  in  pleurisy. 


PLEURISY  465 

(/)  The  rub  in  pericarditis  (q.  v.)  more  distinctly  depends  upon  the  cardiac 
movements.  In  pleurisy  along  the  left  border  of  the  heart,  over  the 
lingual  lobe,  on  holding  the  breath  the  pleuritic  rub  is  heard  near  the 
heart,  but  decreases  after  a  few  heart  beats.  On  deep  inspiration  the 
pleural  rub  ceases  and  the  pericardial  rub  is  increased;  pericarditis  most 
commonly  produces  a  rub  over  the  conus  pulmonalis  arteriosus. 

2.  Pleuritis  humida  (pleuritis  effusiva)  must  be  distinguished  (a)  from 
piiemnonia  (page  74).  (6)  Tumors  of  the  lung  produce  a  characteristic 
exudate;  this  is  often  brown,  sometimes  chyliform,  and  contains  fat 
globules  and  large,  degenerated  cells  which  may  show  mitoses;  the 
glands  above  the  clavicle  may  be  enlarged,  as  well  as  those  in  the  medias- 
tinum, which  produce  recurrent  laryngeal  paralysis.  Tumor  particles 
are  rarely  obtained  by  puncture  or  in  the  sputum,  and  are  only  found 
in  carcinoma,  for  sarcoma  rarely  ulcerates.  A  trocar  rather  than  a 
needle  should  be  used.  Unverricht  observed  the  development  of  car- 
cinoma at  the  seat  of  puncture.  In  tumors  there  is  less  displacement, 
less  invasion  of  Traube's  space  and  less  widening  of  the  chest  than  in 
pleurisy,  arid  the  breathing  is  often  bronchial,  the  flatness  intense  and 
the  fremitus  increased,  (c)  Hydrothorax  (q.  v.),  usually  described  as 
bilateral,  may  be  unilateral  (right-sided),  especially  in  disease  of  the 
liver,  kidneys  and  heart.  The  fluid  readily  shifts  its  level  on  change  of 
posture,  which  does  not  occur  in  pleurisy.  The  claim  that  salicylic 
acid,  iodine  and  potassium  iodide  pass  readily  into  transudates  and 
but  slowly  into  exudates,  is  disproved.  In  hydrothorax  the  specific 
gravity  is  below  1.014,  the  albumin  is  1  to  3  per  cent,  and  the  sediment 
shows  few  white  cells  and  some  endothelial  cells.  Cytology,  etc.,  may 
point  to  hydrothorax,  while  inoculation  reveals  tuberculosis,  (d)  The 
presence  of  hemothorax  is  determined  only  by  puncture. 

3.  Circumscrihed  pleurisy  requires  differentiation  (a)  from  pericarditis; 
pleurisy  shows  a  more  irregular  outline,  the  apex  beat  is  not  altered  and 
there  is  no  pericarditic  friction.  (6) ,  Lung  cavities  show  dulness  when 
full  of  secretion  and  resonance  when  it  is  voided;  the  fluid  obtained  by 
puncture  (under  a  wrong  diagnosis)  has  a  higher  specific  gravity  and  a 
larger  percentage  of  fat.  (c)  Differentiation  from  splenic  tumors  is 
determined  by  respiratory  excursion  and  palpation  of  the  lower  edge  of 
the  spleen,  {d)  Liver  enlargements  rarely  occur  solely  upward,  save  in 
in  echinococcus  and  in  abscess  of  the  convexity;  these  are  prone  to  occur 
anteriorly,  and  pleurisy  more  frequently  posteriorly.  In  tumors  of  the 
liver  there  is  usually  respiratory  excursion,  (e)  Subphrenic  abscess 
(v.  Localized  Peritonitis)  may  be  intraperitoneal  (as  from  liver  abscess) 
or  extraperitoneal  (e.  g.,  perinephritic) .  The  liver  stands  higher  in  the 
chest  because  of  the  paretic  diaphragm.  There  may  be  a  history  or 
physical  signs  of  an  abdominal  disease.  The  needle  reaches  the  pus  only 
when  thrust  deep  in  the  lower  interspaces.  The  pus  frequently  has  a 
fecal  odor.  The  manometer  shows  increased  pressure  during  inspiration 
and  decreased  pressure  during  expiration,  the  converse  of  the  findings 
in  pleural  effusion.  (/)  Abscess  of  the  liver:  Pleurisy,  serous  or  suppura- 
tive, may  complicate  abscess  of  the  liver.  Difi^erentiation  is  easy  when 
abscess  of  the  convexity  is  located  forward;  when  it  is  situated  poste- 

30 


466  DISEASES  OF   THE  PLEURA 

riorly,  aspiration  alone  will  distinguish  it;  the  pus  shows  liver  cells, 
amebse,  cholesterin  or  bile,  (g)  43  cases  of  pleural  echinococcus  are 
reported;  11  per  cent,  of  hepatic  cysts  reach  the  lung  and  pleura. 

Course  and  Prognosis. — 1.  The  course:  Acute  cases  last  two,  subacute 
three  to  eight  and  chronic  eight  or  more  weeks.  The  onset  is  no  index 
of  the  issue.  No  cycle  is  seen  in  any  form  of  pleurisy.  Friction  along 
the  lowest  limits  of  the  pleura  and  in  front  rarely  attends  great  effusions 
and  therefore,  after  the  exclusion  of  tuberculosis,  carcinoma  or  pyemia, 
the  prognosis  is  relatively  good.  In  the  average  case  dry  pleurisy  precedes 
and  succeeds  exudation.  Persistence,  recurrence  and  exacerbations 
render  the  prognosis  unfavorable.  The  author  has  seen  recovery  of 
secondary  carcinomatous  pleurisy. 

2.  The  immediate  mortality  is  under  5  per  cent.,  and  depends  upon 
the  etiology  and  the  nature  of  the  fluid.  Fibrinous  pleurisy  is  the  most 
favorable  type,  except  when  it  occurs  at  the  apex  of  the  lung.  The 
outlook  in  effusive  forms  is  most  favorable  in  metapneumonic  serous  or 
purulent  pleurisy;  next  most  favorable  in  serous  pleurisy  due  to  the 
staphylococcus,  less  favorable  in  staphylococcus  empyema,  and  least 
favorable  in  tuberculous,  fetid  or  putrid  forms.  It  is  usually  poor  in 
hemorrhagic,  chyliform,  peracute  and  bilateral  (generally  hemorrhagic 
or  purulent)  effusions.  It  is  more  favorable  in  effusions  relatively  rich 
in  solid  constituents;  effusions  containing  little  solids  are  apt  to  recur. 
Since  Hippocrates,  the  belief  has  prevailed  that  right-sided  are  less 
favorable  than  left-sided  effusions.  Sudden  death  is  not  infrequent. 
The  author  saw  3  cases  in  one  year. 

3.  Opinions  vary  as  to  the  idtimate  prognosis;  87  per  cent,  of  cases 
become  tuberculous  in  one  or  two  years  (Fiedler);  33  per  cent,  die  in 
five  years  (Bars);  15  per  cent,  die  of  tuberculosis;  90  per  cent,  are  in 
good  health  after  two  to  five  years;  and  80  per  cent,  are  healthy  after 
five  years  (Cabot). 

Treatment. — In  fibrinous  pleurisy,  or  in  the  fibrinous  or  first  stage  of 
exudative  pleurisy,  pain  is  the  main  indication;  morphine  may  be  given 
in  severe  cases,  especially  with  hard  coughing;  the  ice-bag,  poultices,  cups 
and  hot  fomentations  give  little  relief;  blisters  cause  as  much  discomfort 
as  the  disease  itself;  the  pleura  should  be  splinted  by  four  strips  of  zinc 
oxide  adhesive  plaster  two  inches  wide,  overlapping  the  median  line  before 
and  behind  by  about  three  inches,  and  running  around  the  chest  horizon- 
tally 'and  obliquely;  these  should  be  applied  firmly  during  expiration, 
that  the  lung  in  its  lower  part  and  the  pleural  surfaces  may  be  well 
immobilized.  Personal  experience  with  the  salicylates  has  not  been 
satisfactory.     The  patient  should  he  kept  in  bed. 

,  In  serous  pleurisy  the  patient  should  be  kept  in  bed  and  the  cough 
and  fever  treated  expectantly.  Laxatives  are  given  solely  to  obviate 
straining  at  stool  which  may  induce  cardiac  weakness;  they  do  not 
reduce  the  effusion.  If  at  the  end  of  the  second  week  the  effusion  remains 
stationary,  various  measures  are  indicated;  Scliroth's  treatment  limits 
the  fluid  ingested  to  one  quart  daily,  but  the  method  gives  no  results, 
as  exudation  is  an  active,  not  a  passive,  process;  tincture  of  iodine  is 
seldom  beneficial,  and  when  old  is  distinctly  a  local  irritant;  potassium 


PLEURISY  467 

iodide,  digitalis,  drastics  to  produce  copious  evacuations,  cotton  jackets 
and  sweats  are  useless,  and  pilocarpine  is  dangerous.  Transudates  may 
be  removed  in  this  way  but  not  exudates. 

Aspiration. — Trousseau's  indications  were  (a)  the  vital  indication, 
when  life  is  threatened  by  a  large  exudate;  (6)  moderate  effusions  with 
slow  resorption,  and  (c)  persistent  or  residual  exudates.  The  author 
believes  that  early  pimchire  and  aspiration  are  indicated  in  every  case, 
where  two  quarts  or  more  (2000  or  2500  c.c.)  of  fluid  are  effused, 
whether  the  temperature  is  still  high  or  not,  and  whether  dyspnea  is 
present  or  not;  this  amount  of  effusion  causes  dislocation  of  the  heart, 
liver  or  spleen,  compression  of  the  lung,  torsion  of  the  large  vessels,  or 
ectasia  of  the  chest;  high  intrathoracic  pressure  may  cause  sudden 
death,  sometimes  without  warning  symptoms.  Early  puncture  does 
not  irritate  the  pleura  or  favor  recurrence  or  suppuration.  Puncture 
was  first  performed  by  Hippocrates  and  exploited  by  Schub  and  Skoda 
(1841),  but  aspiration  dates  from  Bowditch  of  Boston  (1848). 

Method  of  Aspiration. — After  the  usual  surgical  antisepsis,  a  small 
trocar  or  large  aspirating  needle  is  introduced,  which  has  an  elbow  con- 
necting with  a  rubber  tube,  to  siphon  the  fluid  to  a  vessel  below  or 
connecting  with  a  bottle  which  can  be  exhausted  by  a  pump.  There  is 
no  rule  as  to  the  site  of  puncture,  which  must  be  governed  by  the  physical 
signs;  adhesions  which  hold  the  lung  to  the  surface  vitiate  any  set  law; 
fluid  is  usually  obtained  low  down  in  the  chest  between  the  scapular 
and  postaxillary  lines.  The  trocar  is  introduced  perpendicularly  to 
the  chest  wall  and  not  obliquely,  in  order  to  avoid  injuring  the  intercostal 
artery  lying  above  the  rib,  as  a  result  of  which  the  author  twice  saw 
fatal  hematoma  and  hemothorax.  Hypodermics  should  be  at  hand, 
against  a  possible  syncope.  The  pump  is  necessary  in  but  10  per  cent, 
of  cases,  for  the  fluid  can  usually  be  siphoned  readily ;  a  tube  is  attached 
to  the  needle  or  trocar,  filled  with  boric  acid  solution,  clamped  with  an 
artery  forceps  and  undamped,  after  its  lower  end  is  placed  in  a  basin  con- 
taining the  same  solution  and  held  at  a  lower  level.  The  fluid,  if  pumped, 
should  be  withdrawn  gradually;  caution  is  necessary  lest  air  be  pumped 
the  wrong  way,  i.  e.,  into  the  pleura.  The  blood-pressure  dm-ing  aspira- 
tion should  be  controlled  by  the  sphygmomanometer.  The  amount 
removed  need  not  be  great,  as  moderate  relief  of  intrapleural  tension 
often  promotes  absorption;  it  is  estimated  arbitrarily  at  one  quart 
(1000  c.c.)  to  three  pints  (1500  c.c).  Complete  or  nearly  complete  evacua- 
tion may  cause  the  accidents  enumerated  below  and  is  thought  by  Litten 
to  induce  miliary  tuberculosis.  Aspiration  should  be  discontinued  when 
the  exudate  becomes  bloody  from  lung  injury,  when  friction  develops, 
when  pain  is  felt  or  when  from  congestion  of  the  relaxed  lung  coughing 
begins.  Repetition  of  puncture;  a  second  puncture  is  necessary  in  25 
per  cent,  and  a  third  in  5  per  cent,  of  eft'usions.  Favorable  results  are 
relief  of  pressure  on  the  lung  and  absorption  of  the  exudate,  strengthen- 
ing of  the  pulse,  and  return  of  luxated  organs  to  their  place.  Unfavorable 
results  are  (a)  syncope  due  to  cerebral  anemia  from  reflux  of  blood 
to  the  expanding  lung  which  contained  little  blood  before  it  was  relieved 
by   the   puncture,    a   relatively   uncommon   occurrence;  (6)  pulmonary 


468  DISEASES  OF  THE  PLEURA 

edema — albuminous  expectoration — which  is  due  to  the  sudden  with- 
drawal of  too  much  fluid  (2  to  5  liters)  at  one  tapping;  it  should  take 
a  half-hour  to  evacuate  one  and  a  half  quarts  or  1500  c.c.  (Frantzel) ; 
edema  pulmonum  is  treated  (and  prevented)  most  successfully  by  hypo- 
dermics of  morphine  gr.  |;  Sears  records  10  deaths  from  simple  punc- 
ture; Capps  and  Lewis  ascribe  sudden  death  or  syncope  to  the  irritation 
of  a  pleural  reflex;  (c)  sudden  death  from  pulmonary  embolism  or 
cerebral  embolism;  the  latter  results  from  discharge  of  clots  from  vessels 
in  the  relaxing  lung,  and  causes  the  so-called  pleuritic  hemiplegia;  (d) 
injury  to  the  heart,  liver  or  spleen;  (e)  pneumothorax  and  subcutaneous 
emphysema  may  occur.  Doubtless  some,  if  not  most,  instances  of 
pneumothorax  after  tapping  are  primary  pneumothorax  with  secondary 
pleurisy;  the  tapping  opens  up  the  closed  point  of  rupture  and  pneumo- 
thorax again  dominates  the  clinical  picture.  (/)  The  author  twice 
witnessed  an  extensive  hemothorax  and  subcutaneous  hematoma  after 
pleural  puncture,  in  which  the  trocar  was  impatiently  thrust  in  and 
out  during  an  unsuccessful  thoracocentesis.  Naunyn  writes  of  death 
following  puncture  of  an  atheromatous  intercostal  artery,  (g)  Fibrinous 
bronchitis  has  followed  paracentesis,  (h)  The  needle  has  been  broken 
by  moving  the  patient  during  tapping,  (i)  Anaphylaxis  has  followed 
tapping.  When  repeated  punctures  fail  the  advisability  of  operation 
should  be  considered,  as  in  empyema.  Various  modifications  are  sug- 
gested: Holmgren  advises  two  openings,  one  to  admit  air  and  the  lower 
to  withdraw  fluid;  others  inject  nitrogen  to  replace  the  fluid  withdrawn, 
adrenalin  to  constrict  the  vessels,  etc. 

Gilbert's  autoserotherapy  consists  of  aspirating  1  c.c.  (10  to  20  c.c), 
but  before  the  needle  is  withdrawn  entirely,  reinjecting  the  fluid  into 
the  subcutaneous  tissues;  the  results  are  uncertain. 

Empyema  in  all  cases  necessitates  operation  (practised  by  Euryphon 
and  after  him  by  Hippocrates).  Rarely,  patients  may  recover  spon- 
taneously. A  day  or  two  before  operation  aspiration  is  indicated  when 
the  fluid  is  under  high  tension.  Some  surgeons  advocate  treating  tuber- 
culous empyema  without  operation,  as  Volkmann  treated  other  cold 
abscesses.  The  mortality  in  Velpeau's  cases  was  100  per  cent,  and 
Dupuytren  himself  "  chose  to  die  of  empyema  at  the  hands  of  God  rather 
than  to  die  at  the  hands  of  man  under  operation."  In  Schede's  series 
the  mortality  of  tuberculous  empyema  was  77  per  cent.,  of  metastatic 
32  per  cent.,  of  metapneumonic  13  per  cent,  and  of  primary  8  per  cent. 

After-treatment  is  directed  toward  prevention  of  thoracic  retraction, 
to  which  end  gymnastics  and  deep  breathing  are  essential.  A  patient 
having  suffered  from  a  "primary"  effusive  pleurisy  should  be  treated 
as  one  with  latent  tuberculosis. 

PNEUMOTHORAX. 

Definition. — Pneumothorax  is  an  accumulation  of  gas  or  air  in  the 
pleural  sac.  It  was  named  by  Itard  of  Paris  (1803)  and  was  described 
fully  by  Laennec  (who  in  1819  made  the  first  diagnosis)  and  Skoda. 
Hippocrates  described  succussion.    As  it  excites  pleurisy  in  90  per  cent. 


PNEUMOTHORAX  469 

of  the  cases,  the  following  varieties  are  distinguished:    l^yo-,  sero-  and 
hemopneumothorax. 

Etiology. — 1.  Diseases  of  the  lung  and  pleura  cause  about  95  per  cent, 
of  all  cases.  In  Biach's  collection  of  918  cases  in  Vienna,  pulmonary 
tuberculosis  caused  77  per  cent.,  gangrene  7  per  cent.,  empyema  5,  trauma 
3,  bronchiectasis  and  abscess  each  1  per  cent.,  the  etiology  was  unknown 
in  2  per  cent,  and  the  remaining  4  per  cent,  were  due  to  emphysema, 
infarct,  thoracocentesis,  echinococcus  and  contiguous  disease  perforating 
into  the  pleura,  as  gastric  or  esophageal  ulceration  or  caries  of  the  ster- 
num, (a)  Acute  is  more  important  than  chronic  tuberculosis  in  which 
there  are  protecting  pleural  adhesions;  pneumothorax  develops  in  5 
per  cent,  of  tuberculous  cases,  (b)  Ulcerative  lesions  of  the  lung  may 
erode  the  pleura  and  admit  air  (v.  s.).  (c)  Trauma  or  stab  wounds 
occur  far  less  frequently  than  one  would  expect,  and  here  hemopneumo- 
thorax is  the  type.  (For  "pneumothorax  following  paracentesis,"  see 
page  468.)  (d)  Empyema  may  rupture  into  the  lung  without  allowing 
ingress  of  air  from  the  opposite  direction,  (e)  Rupture  of  a  healthy 
lung  by  tearing  away  of  the  lung,  as  pleural  adhesions  give  way  in 
coughing,  muscular  straining  or  violent  coughing  is  very  exceptional. 

2.  Perforative  lesions  in  the  mediastinum,  esophagus,  peritoneum, 
stomach  or  colon  and  subphrenic  abscess  are  uncommon  causes  {v.  s.). 

3.  The  view  held  by  Oppolzer  and  Biermer  that  pneumothorax  may 
occur  spontaneously  (without  rupture)  has  received  confirmation  by 
discovery  of  the  Bacillus  aerogenes  capsulatus  and  other  gasogenic 
organisms  (Welch,  Lewy).  It  is  always  possible,  however,  that  the 
point  of  rupture  in  the  lung  has  healed;  the  fact  remains  that  air  enters 
the  pleura  chiefly  from  the  lung  or  from  a  gas-containing  organ. 

Pneumothorax  occurs  largely  in  adults  and  four  to  seven  times  as 
frequently  in  males  as  in  females.  Cozzolino  (1906)  found  only  41  cases 
in  children;  of  these  but  40  per  cent,  were  tuberculous. 

Pathology. — When  the  chest  is  opened,  air  or  gas  escapes  with  a  force 
sufficient  to  blow  out  a  candle.  The  volume  of  air  may  exceed  2000 
c.c,  and  its  tension,  studied  first  by  Wintrich  and  Weil,  collapses '  the 
lung — overcoming  the  normal  negative  pressure  of  3  to  6  mm.  Hg., 
due  to  its  elasticity — dislocates  the  heart  and  mediastinum  and  depresses 
the  diaphragm  and  subphrenic  organs.  The  gas  may  be  odorless  or 
fetid.  The  pathological  and  clinical  findings  vary  (a)  as  the  gas  is  encap- 
sulated or  occupies  the  entire  pleural  cavity;  (b)  as  the  air  is  aseptic 
(producing  a  pure  pneumothorax,  or  one  with  slight  exudation)  or  is 
infected  by  the  organisms  of  the  primal  disease  which  excite  serous, 
purulent  or  putrid  pleurisy;  (c)  as  the  air-containing  cavity  is  "closed," 
"open"  (into  a  bronchus,  or  sometimes  also  externally)  or  possesses  a 
valve,  allowing  passage  of  air  in  one  but  not  in  the  opposite  direction 
{v.  i.). 

Symptoms. — The  onset  is  usually  sudden,  occurring  spontaneously  or 
following  coughing  or  exertion;  it  is  characterized  by  sudden  pain  in 
the  side,  cyanosis,  dyspnea  and  collapse,  due  to  reflex  action  on  the 
vagus;  the  onset  may  resemble  angina  pectoris,  pulmonary  embolism  or 
abdominal  perforation;  there  may  be  sudden  evacuation  of  pus  from  the 


470 


DISEASES  OF   THE  PLEURA 


breaking  into  the  lung  of  an  empyema;  urticaria  occasionally  develops; 
decreased  diuresis,  albuminuria,  stasis  and  subcutaneous  emphysema  are 
sometimes  observed.  The  onset  may  be  insidious — with  no  symptoms 
and  with  only  physical  signs;  indeed  pneumothorax  sometimes  con- 
stitutes an  unexpected  postmortem  finding.  In  other  instances  the 
history  or  coiu"se  may  justify  a  presumptive  diagnosis,  as  in  a  case 
clearly  tuberculous;  and  in  still  other  cases,  a  small,  latent  caseous 
focus  may  burst  and  thus  produce  its  first  symptom. 

Physical  Findings. — 1.  Ixspectiox. — (a)  The  ajfeded  side  is  distended 
2  to  -i  inches  and  immobile,  and  contrasts  sharply  with  the  widely  moving 
sound  lung,  (b)  The  inierspaces  are  ohiiterated.  (c)  The  heart  and  liver 
or  spleen  are  dislocated,     (d)  There  is  dyspnea  and  cyanosis,     (e)  The 


I  II 

Fig.  36. — I.  Left-sided  effusive  pleurisy,  showing  relative  heart  dulness  (A),  effusion 
(B),  liver  flatness  (C),  and  fluid  impinging  on  Traube's  half-moon  space,  of  which  but  a 
small  part  remains  resonant  (D).  In  larger  effusions  reaching,  e.  g.,  up  to  the  dotted  black 
line,  the  relative  heart  dulness  may  be  pushed  over  to  the  dotted  line  (over  C).  II.  Left- 
sided  pneumothorax  marked  by  tympany  (T,  T),  pushing  over  the  mediastinum  and  also 
the  heart  to  the  right,  and  pushing  down  the  left  lobe  of  the  Hver  and  the  spleen. 

attitude  is  characteristic;  the  patient  most  often  lies  07i  the  affected  side 
to  afford  ample  play  to  the  sound  lung;  sometimes  there  is  orthopnea 
and  if  the  point  of  rupture  opens  into  the  lung  or  bronchus  a  peculiar 
decubitus  may  be  assumed  in  order  to  drain  the  pleura.  (/)  The  .r-rays 
show^  the  lung  flattened  near  the  spine,  the  diaphragm  depressed  and 
motionless,  and  the  shadow  of  the  effusion. 

2,  Palpation. — (a)  Vocal  fremitus  is  absent,  unless  adhesions  hold  the 
lung  to  the  chest  wall,  (b)  The  chest  icall  feels  resistant  and  (c)  some- 
times splashing,  fluctuation  or  a  "pillow  sensation"  is  noted,  (d)  The 
dislocated  apex  beat  and  the  edge  of  the  liver  or  spleen  are  felt. 

3.  Percussion. — ^Results  vary  according  to  the  tension  of  the  gas  and 
chest  wall:  (a)  In  open  pneumothorax  the  note  is  tympanitic  or  even 
metallic  when  percussion  is  made  on  a  solid  object,  as  a   coin;  this 


PNEUMOTHORAX  471 

hriiit  (V (train  is  found  in  75  per  cent,  of  cases;  cracked-pot  resonance  and 
Wintrich's  change  of  note  may  be  elicited  when  the  mouth  is  opened. 
(6)  In  closed  imeumothorax  the  note  is  full  and  loud;  it  is  tympanitic 
when  there  is  moderate  pressure  and  the  intercostal  muscles  are  relaxed; 
again  the  note  may  be  dull  if  the  tension  is  great  or  if  the  chest  muscles 
are  spasmodically  contracted,  as  in  sudden  pneumothorax  (vagus  reflex 
action),  (c)  Flatness  over  the  lower  thorax  usually  results  from  pleural 
effusion.  The  author  has  seen  tympany  over  the  entire  side,  in  great 
pleural  effusion.  Skoda  said  that  the  fluid  is  twice  as  much  as  we  antici- 
pate, {d)  On  change  of  posture  a  changing  level  of  the  fluid  is  readily 
elicited,  the  gas  being  found  above,  like  a  spirit-level,  and  the  fluid  below. 
(e)  The  j^itch  over  the  gas-distended  part  changes  with  change  of  posture 
(Biermer's  change  of  note).  It 'becomes  deeper  as  the  patient  sits, 
because  the  vertical  dimension  of  the  chest  is  increased  by  the  pushing 
down  of  the  diaphragm.  (/*)  The  heart  dulness  is  replaced  by  resonance 
in  left-sided  pneumothorax,  and  is  found  to  the  right  of  the  sternum;  in 
right-sided  pneumothorax  the  luxation  is  less  and  toward  the  left  axilla. 
{g)  The  liver  or  spleen  dulness  is  pushed  well  doumward. 

4.  Auscultation. — (a)  The  breath  sounds  are  usually  absent  in  the 
closed  variety  of  pneumothorax,  and  this,  with  ectasia  and  hyperreson- 
ance,  is  most  characteristic.  In  the  open  and  sometimes  in  the  closed 
form,  the  breath  sounds  are  bronchial,  amphoric  or  metallic,  the  voice 
sounds,  especially  under  the  clavicle,  are  metallic,  and  coincident  rales 
in  the  bronchi  are  also  metallic.  Amphoric  sounds  were  referred  by 
Laennec  to  a  fistula  but  probably  are  due  to  the  air  acting  as  a  sounding 
board.  (6)  Air  passing  through  the  point  of  rupture  may  produce 
curious  snapping  or  whistling  sounds;  the  point  of  rupture  is  oftenest 
between  the  second  and  fourth  interspaces  and  the  mammary  and  axil- 
lary lines,  (c)  The  gutta  cadens  (the  metallic  "falling  drop")  may  be  due 
to  rales  or  dripping  of  fluid  from  fibrin  shreds  as  the  posture  is  changed. 
(d)  The  Hippocratic  splashing  {succussio  Hippocratis)  was  carefully 
described  by  Laennec  and  is  elicited  by  placing  the  ear  to  the  chest  and 
sharply  shaking  the  patient;  in  one  of  James's  cases  it  was  heard  over 
a  large  clinical  amphitheatre;  three  patients  called  the  author's  attention 
to  a  "splashing  in  the  chest";  it  is  heard  in  three-quarters  of  the  cases, 
usually  before  dulness  develops,  (e)  The  heart  tones  may  be  metallic, 
and  the  heart's  action  may  even  cause  splashing  sounds.  Hellin  collected 
54  cases  of  double  pneumothorax;  it  is  not  incompatible  with  life. 

Diagnosis. — The  ectasia,  resonant  note,  suppressed  or  amphoric  breath- 
ing, luxations  and  succussion  are  characteristic. 

Type. — Dislocation  occurs  in  all  types,  though  it  varies  in  degree,  (a) 
In  the  opeji  form  Wintrich's  change  of  note,  metallic  sounds,  fistula 
murmur,  periodic  expectoration  of  large  amounts  of  pus,  or  of  methyl 
blue  injected  into  the  pleura,  moderate  cardiac  and  other  dislocations 
and  no  manometric  increase  of  the  tension  in  the  pleura  are  distinctive. 
(6)  The  closed  type  is  distinguished  by  increased  manometric  tension, 
absence  of  breath  sounds,  marked  ectasia,  change  of  note  on  sitting  but 
not  on  opening  the  mouth  and  marked  luxations,  (c)  In -the  valvular 
form  air  may  enter  the  pleural  cavity  but  cannot  escape  back  and  there- 


472  DISEASES  OF  THE  PLEURA 

fore  pus  cannot  be  voided.  Some  of  the  auscultatory  findings  of  the 
open  type  are  noted.    The  manometer  shows  increased  pressure. 

Differentiation. — (a)  Cavities  may  be  simulated  by  circumscribed 
pneumothorax,  but  the  interspaces  are  sunken,  the  fremitus  is  increased 
when  the  cavities  are  empty,  luxation  is  absent  and  the  Hippocratic 
succussion  and  coin  sound  are  extremely  rare.  (6)  Pleurisy  can  be  dis- 
tinguished on  careful  examination,  (c)  Meteorism  is  at  once  excluded 
by  filling  the  stomach  or  colon  with  water,  {d)  Diaphragmatic  hernia 
is  very  frequently  confused  with  pneumothorax;  out  of  481  cases  only 
12  were  recognized.  The  rr-rays  determine  the  condition.  Respiratory 
excursion  is  present  and  the  tympany  and  metallic  sounds  are  accom- 
panied by  symptoms  of  incarceration,  as  vomiting,  colic,  obstipation  and 
indicanuria.  The  intestines  push  the  heart  to  the  right.  Ninety  per 
cent,  of  cases  are  left-sided,  (e)  Pyopneumothorax  subphrenicus  (q.  v. 
under  Peritonitis,  Localized  Forms),  results  from  abdominal  lesions, 
such  as  cancer,  ulcer,  appendicitis,  disease  of  the  gall  tracts,  etc.,  whose 
histories  are  suggestive.  Thoracic  symptoms,  as  cough,  sputum  and 
dyspnea,  are  not  conspicuous  early  in  the  process  and  the  lungs  may 
show  perfect  excursion.  The  manometric  pressure  is  increased  during 
inspiration  and  decreased  during  expiration;  the  converse  is  true  in 
pneumothorax.  By  the  .-c-rays  the  diaphragm  is  above  the  fluid,  while 
in  the  pneumothorax  it  is  below  the  fluid. 

Prognosis. — The  prognosis  varies  with  the  cause,  the  condition  of  the 
lungs  and  the  character  of  the  fluid.  Cases  in  a  healthy  lung  foflowing 
exertion,  trauma  or  infarct  are  relatively  favorable.  The  closed  and 
open  are  more  auspicious  than  the  valvular  type.  In  tuberculosis, 
pneumothorax  seems  to  arrest  the  tuberculous  focus  if  it  is  small  and  if 
no  mixed  infection  occurs;  even  in  these  cases  complete  recovery  is 
infrequent.  Eichhorst  observed  one  case  which  lasted  for  five  years. 
Gabb's  case  recovered  and  relapsed  four  times,  the  attacks  being  two  to 
four  years  apart.  West  observed  a  mortality  of  70  per  cent.,  of  which 
three-quarters  died  within  two  weeks,  nine-tenths  in  less  than  a  month 
and  one  case  in  twenty  minutes. 

Treatment — The  results  are  disappointing.  (a)  Narcotics  and  stimu- 
lants are  imperative  at  the  time  of  the  rupture,  for  collapse,  dyspnea 
and  cyanosis,  (b)  Aspiration  is  of  most  value  in  the  serous  forms;  early 
aspiration  may  open  a  healing  fistula  by  relieving  the  pressure  which 
closed  it.  As  a  rule  aspiration  is  resorted  to  only  when  pressure  menaces 
the  heart  and  lungs,  and  when  pyothorax  threatens  sepsis,  (c)  The 
radical  operation  is  indicated  in  putrid  or  purulent  pneumothorax. 
Leyden  reported  66  per  cent,  and  Richardiere  50  per  cent,  of  recoveries. 

HYDROTHORAX. 

Definition. — Hydrothorax  is  a  serous  transudation  into  the  pleura. 

Etiology. — (a)  Stasis,  from  cardiac,  pulmonary  or  vascular  factors, 
is  a  frequent  cause.  In  failure  of  the  right  heart  the  superior  cava  is 
imperfectly  drained,  which  congests  the  azygos  and  hemiazygos,  leading 
in  turn  to  pleural   transudation.     It  may  occur  alone  but  is  oftener 


CHYLOTHOBAX  473 

part  of  a  general  dropsy.-  Local  venous  obstruction  from  mediastinal 
tumor  or  aneurysm  may  induce  hydrothorax.  (6)  Blood  and  vascular 
changes  resulting  ftom  multitudinous  anemic,  marantic  or  cachectic 
states,  as  nephritis,  cancer  and  blood  diseases.  The  chief  factors  are 
cardiac  and  renal. 

Symptoms  and  Diagnosis. — 1.  The  symptoms  of  hydrothorax  do  not 
include  pain  or  fever.  The  condition  accentuates  the  dyspnea  attending 
the  causal  stasis  or  cachexia.  The  amount  of  fluid  varies  from  ounces 
to  quarts  (or  even  to  two  gallons). 

2.  The  physical  signs  are  those  of  moderate  effusive  pleurisy,  except 
that  the  rub  is  absent,  the  fluid  shifts  with  change  of  posture  and  pro- 
duces a  moderate  compression  of  the  lungs  and  luxation  of  the  heart, 
liver  and  spleen.  The  transudate  is  usually  described  as  bilateral,  but 
in  over  half  the  cases  it  is  unilateral  (adhesions  obliterating  the  opposite 
pleura)  and  often  right-sided,  in  cardiac,  renal  and  hepatic  disease,  by 
pressure  on  the  azygos  or  pulmonary  veins  by  the  dilated  heart  or  cava 
or  the  luxated  root  of  the  lung. 

3.  The  fluid  is  clear,  slightly  green,  possibly  moderately  blood-tinged 
if  it  develops  during  the  death  agony,  and  shows  a  specific  gravity  of 
1.010  to  1.015;  at  the  most  it  develops  only  light  delicate  flocculi  of 
fibrin;  the  albumin  ranges  between  1  and  3  per  cent.  Centrifuging 
brings  down  only  a  few  leukocytes,  endothelial  cells  and  red  disks,  but 
no  bacteria.  Right  hydrothorax  may  prove  very  obstinate,  because  a 
low  grade  of  inflammation  eventually  supervenes. 

The  treatment  is  causal;  aspiration  often  prolongs  life. 

HEMOTHORAX. 

Blood  effusion  into  the  pleura  is  a  rare  malady.  It  may  be  caused  by 
trauma,  scurvy  or  allied  blood  diseases,  aneurysmal  rupture,  ulceration 
of  the  pulmonary  or  pleural  veins  and  by  various  necrosing  lung  diseases. 
It  may  occur  with  pleurisy,  pneumothorax  or  thoracocentesis.  Its 
symptoms  are  essentially  those  of  hydrothorax;  it  is  suspected  only  by 
a  sudden  onset  with  signs  of  acute  anemia,  and  is  proved  only  by  the 
exploring  needle.  Its  treatment  is  symptomatic,  stimulants,  ice  applied 
to  the  chest,  horse  serum  for  hemostasis  or  operation  for  trauma. 

CHYLOTHORAX. 

A  very  rare  affection,  in  which  true  chyle  or  chyliform  fluid  is  found 
in  the  pleura.  Its  etiology  is  disputed;  (a)  in  genuine  cases  chyle  con- 
taining sugar  is  found  (though  sugar  has  been  found  in  many  forms  of 
serositis  and  in  most  transudates);  only  60  cases  are  recorded.  In  11 
cases  (of  which  4  died  and  9  were  right-sided),  traumatic  rupture  of  the 
thoracic  duct  has  been  found.  In  others  the  duct  was  obstructed  by 
thrombosis  of  the  subclavian  vein  or  by  glands  and  tumors.  (6)  In  a 
second  group,  the  pseudochylous  (chyliform  or  adipose),  there  is  no 
chyle  and  the  milky  appearance  is  due  to  fatty  or  minute  albuminous 
granules  held   in   suspension.     This   variety   is   chiefly   tuberculous  or 


474  DISEASES  OF   THE  MEDIASTINUM 

carcinomatous.  It  has  been  thought  that  old  empyemas  may  become 
chyhform.  The  characters  of  both  forms  of  fluid  will  be  considered 
under  chylous  and  adipose  ascites,  with  which  they  are  frequently 
associated. 

PLEURAL    TUMORS. 

Pleural  tumors  are  nearly  always  secondary  by  contiguity  or  metas- 
tasis to  pulmonary,  mediastinal  or  extrathoracic  growths.  Carcinoma 
and  sarcoma  are  the  most  frequent  forms;  enchondroma,  lipoma,  hyper- 
nephroma and  dermoids  are  very  uncommon.  Of  primary  endothelioma 
of  the  pleura,  50  cases  are  reported,  but  it  is  considered  by  some  as 
solely  inflammatory;  clinically  it  presents  the  picture  of  chronic  pleurisy 
plus  occasional  metastatic  deposits  in  the  liver,  lungs,  kidneys,  muscles 
and  lymph  glands.  The  signs  are  those  of  lung  tumor  plus  those  of 
pleurisy;  the  diagnosis  of  primary  tumor  is  impossible. 


DISEASES  OF  THE  MEDIASTINUM. 

MEDIASTINAL   TUMORS. 

Mediastinal  tumors  are  very  rare.  They  are  usually  primary.  Sar- 
coma is  the  most  common  form  and  then  carcinoma;  lipoma  (7  reported 
cases),  substernal  struma,  thymic  growths,  fibroma,  myoma,  osteoma, 
enchondroma,  echinococcus,  dermoid  (64  cases  collected  by  Christian, 
1908),  teratoma,  gumma,  tubercle,  leukemic,  pseudoleukemic  and 
chloromatous  adenopathies  are  rarer  forms.  Sixty  per  cent,  occur  in 
males  between  twenty  and  thirty  years  of  age. 

Symptoms. — Symptoms  develop  gradually.  1.  Local  signs:  (a) 
Bulging  may  be  present  in  the  jugulum  or  under  the  sternum,  especially 
in  lymphosarcoma,  (h)  There  may  be  pulsation,  imparted  by  the 
heart,  aorta  or  its  branches;  it  is  rarely  expansile,  (c)  The  tumor  or 
secondarily  involved  glands  may  be  palpable  deep  in  the  jugular  notch. 
The  vocal  fremitus  varies,  (d)  The  sternum  may  be  exquisitely  tender 
from  erosion,  (e)  Dulness  may  be  elicited  under  or  near  the  sternum, 
or,  if  the  posterior  mediastinum  is  involved,  in  the  back;  the  dulness 
may  blend  with  the  heart,  suggesting  aneurysm  or  effusive  pericarditis, 
though  far  more  irregular.  (/)  Sometimes  there  is  bronchial  breathing, 
or  if  the  bronchi  are  closed  the  breath  sounds  may  be  absent. 

2.  Compression  sympioms,  as  in  aneurysm,  may  predominate  in  tumors 
of  the  posterior  and  middle  mediastinum,  though  local  physical  findings 
may  be  slight  or  absent,  (a)  Paroxysmal  asthma  and  orthopnea  are 
common;  dyspnea  is  the  earliest  and  most  frequent  symptom,  due  partly 
to  compression  of  the  vagus  and  partly  to  tracheal,  cardiac  and  pleuritic 
involvement.  Other  vagus  symptoms  are  brazen  cough  from  paralysis 
of  the  vocal  cords,  tachy-  or  bradycardia,  hiccough,  vomiting  or  esopha- 
geal spasm.    (6)  The  trachea  or  bronchi  may  be  compressed  from  without 


MEDIASTIXITIS  475 

or  occluded  by  growth  into  their  himina,  in  wliich  case  the  symptoms  of 
tracheal  or  bronchial  stenosis  may  be  pronounced.  Tracheal  tugging 
and  shrinking  of  one  side  of  the  chest  (instead  of  bulging)  may  be  noted, 
perhaps  with  dulness  of  the  right  apex.  The  sputum  may  contain  blood, 
tumor  tissue  or  hair.  The  larynx  may  show  lateral  deviation,  (c)  The 
arteries  of  the  neck  may  show  a  systolic  stenotic  murmur,  but  the  veins 
are  more  often  compressed,  especially  the  innominates  or  the  superior 
cava,  which  cause  bilateral  or  unilateral  edema  and,  less  often,  cyanosis 
of  the  face,  neck  and  arms;  enlargement  of  the  veins  on  the  thorax 
indicate  the'  collateral  circulation,  (d)  The  heart  may  be  compressed 
and  dislocated,  downward  and  outward  if  the  growth  emanates  from  the 
anterior  mediastinum,  forward  if  from  the  posterior  mediastinum.  Dis- 
location of  the  liver  and  spleen  are  less  common,  (e)  Compressive 
dysphagia  may  cause  death  from  inanition.  (/)  Inequality  in  the  pupils 
is  uncommon.  Neuralgia,  muscular  paralysis  or  even  spinal  paraplegia 
may  result.    Boring  pain  is  rare. 

Diagnosis. — A  diagnosis  is  positive  from  the  signs  or  presumptive 
from  the  symptoms.  Dyspnea,  ectasia,  irregular  substernal  dulness, 
venous  stasis,  bronchial  stenosis,  heart  luxation  and  the  skiagram  make 
the  diagnosis  probable;  puncture  may  withdraw  tissue  or  dermoid 
material;  the  sputimi  sometimes  voids  tumor  particles,  booklets  or 
hair.  Deep  anem-ysm  (g.  v.)  is  difficult  to  eliminate.  The  irregular 
dulness  excludes  pericarditis.  Tumors  of  the  lung  and  pleura  produce 
less  pressure  symptoms,  though  such  differentiation  is  rather  academic. 

Prognosis  and  Treatment. — The  prognosis  is  unfavorable,  as  death  from 
inanition,  compression,  exhaustion  or  pneumonia  results  within  a  few 
months.  Benign  tumors  run  a  longer  course,  sometimes  five  to  seven 
years,  or  even  forty  in  Lebert's  dermoid.  Treatment  is  palliative.  A 
few  successful  operations  are  reported;  in  20  operated  cases  of  dermoid, 
70  per  cent,  recovered  (R.  S.  ^Morris). 

MEDIASTINITIS. 

Acute  inflammation  is  uncommon,  but  may  follow  A'arious  local 
lesions,  as  pleurisy,  pericarditis,  pneumonia,  acute  lymphadenitis  and 
kindred  processes,  by  contiguity  or  by  metastasis,  (a)  Acute  non- 
suppurative cases  begin  with  chill,  fever,  pain  in  the  mediastinum  and 
tenderness  anteriorly  over  the  sternum  or  high  in  the  back;  there  may 
be  edema  over  the  sternum;  dysphagia,  dyspnea  and  vague  cardiac 
symptoms  may  develop.  A  presumptive  diagnosis  is  made  from  acute 
inflammatory  symptoms  with  mediastinal  localization.  The  prognosis 
is  grave  and  the  treatment  is  symptomatic;  an  ice-bag  should  be  applied 
over  the  sternum  and  opiates  should  be  given  for  pain,  (6)  Of  medias- 
tinal abscess,  Hare  (1899)  collected  115  cases  in  most  of  which  the 
anterior  mediastinum  was  affected.  Acute  cases,  most  often  traumatic 
or  sequential  to  eruptive  diseases,  were  more  frequent  than  chronic 
cases,  which  were  usually  tuberculous  (r.  ^Mediastinal  Pleurisy). 

Symptoms. — The  symptoms  are  mediastinal,  as  in  simple  acute  medias- 
tinitis,  and  general  or  septic.    A  throbbing  retrosternal  pain  is  common 


476  DISEASES  OF   THE  MEDIASTINUM 

and  dyspnea  may  result  from  pressure  by  large  pus  pockets.  Edema, 
fluctuation,  pointing  or  rupture  in  the  upper  interspaces  or  in  the  jugular 
notch  may  be  noted.  Fatal  hemorrhage  may  follow  simultaneous  erosion 
of  the  aorta  and  bronchus.  Internal  rupture  also  occurs  into  the  air 
passages,  esophagus  or  pleura,  or  deep  burrowing  to  the  abdomen.  The 
exploring  needle  is  of  great  diagnostic  aid  in  doubtful  cases.  Auvray 
(1904)  found  in  the  literature  36  operations  with  33  recoveries. 

(c)  Chronic  mediastinitis  is  discussed  under  Adhesive  Pericarditis. 

MEDIASTINAL   HEMORRHAGE. 

Small  hemorrhages  of  no  clinical  importance  may  occur  in  icterus, 
hemorrhagic  blood  diseases  or  acute  infections.  Larger  hemorrhages 
may  follow  trauma  or  erosion  of  the  large  vessels,  both  of  which  over- 
shadow the  mediastinal  incident. 

INTERSTITIAL  EMPHYSEMA. 

(See  Differentiation  of  Emphysema.) 


SECTION  lY. 

DISEASES  OF   THE  DIGESTIVE  TMGT. 


DISEASES  OF  THE  MOUTH. 

CATARRHAL   STOMATITIS. 

Etiology. — Simple,  acute  stomatitis  is  the  most  frequent  form.  In 
children  it  may  develop  with  dentition,  rude  cleansing  of  the  mouth 
and  digestive  disorders,  especially  in  the  poorly  nourished;  it  is  part  of 
the  exanthemata  and  syphilis.  In  adults  it  results  from  hot  food,  alcohol, 
tobacco,  iodine,  mercury,  arsenic,  etc.,  acidulous  vomiting,  carious 
teeth,  throat  disease,  uncleanliness,  etc. 

Symptoms. — Symptoms  are  chiefly  redness,  swelling  and  increased 
secretion,  and  in  the  acute  forms  pain  which  makes  eating  difficult.  The 
increased  and  usually  acid  saliva  irritates  the  lips  or  chin  if  it  flows 
over  them.  The  gums  are  turgid  (gingivitis)  and  the  tongue  broadened, 
lax  and  indented  by  the  teeth,  as  is  also  the  buccal  mucosa.  The  tongue 
is  coated.  Vesicles  sometimes  form  and  break  down  into  small  erosions. 
The  whitish  areas  sometimes  seen  are  epithelial  thickening.  Fever, 
thirst  and  general  symptoms  are  absent,  except  in  some  infantile  cases. 
Acute  stomatitis  lasts  but  a  week  or  two.  Transient  stomatitis  is  physio- 
logical in  the  newborn. 

Treatment. — In  children  the  mouth  should  be  gently  washed  after 
each  nursing.  Boracic  acid  is  excellent  and  safe.  In  adults  the  teeth 
should  be  cared  for.  Cold  water  or  ice  mitigates  pain.  Tincture  of 
myrrh  and  of  rhatany  (equal  parts)  are  excellent.  Stronger  antiseptics 
may  be  used  in  adults  but  children  may  swallow  them;  for  instance, 
2  per  cent,  chlorate  of  potash,  or  1  per  cent,  phenol;  erosions  may  be 
touched  with  1  per  cent,  silver  nitrate. 

STOMATITIS   ULCEROSA. 

Etiology. — Its  bacteriology  is  unknown.  In  some  cases  the  micro- 
organisms of  Vincent's  angina  are  found.  Epidemics  may  occur  in 
asylums  or  prisons.  It  may  be  induced  by  malnutrition,  uncleanliness, 
oral  or  dental  disease,  phthisis,  leukemia,  diabetes,  toxic  factors  (mer- 
cury) and  dentition.  (See  Acute  Pharyngitis  and  Diagnosis  of 
Diphtheria.) 


478  DISEASES  OF  THE  MOUTH 

Symptoms. — The  symptoms  are  those  of  catarrhal  stomatitis  phis 
necrosis  and  ulceration.  The  gums,  especially  about  the  incisors  and 
canines,  are  red,  swollen  and  spongy;  they  bleed,  secrete  pus  and  ulcerate; 
over  the  ulcers  a  membrane  develops.  The  teeth  are  exposed  and 
loosened.  The  tongue  and  cheek  ulcerate  less  often  and  the  pharynx  is 
nearly  exempt.  The  breath  is  fetid,  the  saliva  is  increased,  the  sub- 
maxillary lymph  glands  and  salivary  glands  are  swollen  and  mastication 
is  almost  impossible.  Fever,  prostration  and  signs  of  sepsis  may  mark 
the  severest  cases.  Acute  cases  last  one  or  two  weeks  and  chronic  cases 
weeks  or  months. 

Varieties. — (a)  Mercurial  stomatitis  may  be  industrial  or  therapeutic. 
The  author  saw  a  case  in  which  five  grains  of  calomel  caused  necrosis  of 
the  tongue,  which  rotted  off  at  its  root.  (See  Intoxications.)  Mer- 
curial and  other  stomatitis  may  cause  "erosions"  of  the  enamel  in  the 
developing  teeth  of  children;  they  become  pitted,  discolored  and  trans- 
versely furrowed,  (b)  In  Riga's  disease,  described  by  Riga  (1881)  in 
South  Italy,  there  is  a  pearly  induration  between  the  tip  of  the  tongue 
and  frenum;  it  appears  with  the  first  dentition,  sometimes  ulcerates, 
is  occasionally  epidemic,  is  often  observed  with  the  status  lymphaticus 
and  is  invariably  fatal,  (c)  In  nursing  ivomen  ulcers  may  develop  from 
the  lymph  follicles  of  the  lip  and  cheek;  they  usually  indicate  mal- 
nutrition, sometimes  are  painful  and  respond  to  tonics  and  hygiene,  (d) 
Herpetic  or  jyemphigoid  stomatitis  is  seen  in  neurotics  and  is  frequently 
recurrent  (Jacobi's  stomatitis  chronica  neurotica),  (e)  Bednar  described 
(aphthous)  white  plaques  on  the  posterior  part  of  the  hard  palate  near 
the  alveolar  border  of  the  jaw,  which  may  ulcerate;  they  occur  in  the 
first  three  months  of  life,  and  are  apparently  due  to  sucking.  Fatal 
cases  are  due  to  hemolytic  streptococci.  (/)  Parrot's  ulcers  occur  in 
marantic  newborn  children  on  the  hard  palate  near  the  median  line;  they 
seldom  heal. 

Treatment. — Potassium  permanganate  1  to  1000  relieves  the  foetor 
ex  ore.  Necrotic  areas  may  be  touched  with  silver  nitrate  solution  or 
equal  parts  of  tincture  of  the  chloride  of  iron  and  glycerin.  Potassium 
chlorate  gargles  may  be  combined  in  children  with  gr.  x-xx  every  day 
internally  and  twice  the  amount  for  adults.  Opium  and  belladonna  are 
indicated  by  pain  and  salivation. 

APHTHOUS   STOMATITIS. 

Etiology. — It  may  occur  sporadically  or  epidemically.  It  is  probably 
contagious;  when  due  to  milk  it  ceases  on  its  withdrawal.  Besides 
the  causes  of  stomatitis  {v.  s.),  it  occurs  chiefly  in  children  between  ten 
and  thirty  months  old. 

Symptoms. — Fever,  thirst,  salivation  and  pain  in  the  mouth  precede 
the  round,  yellowish-white  and  slightly  elevated  areas  as  large  as  a  pea 
on  the  tongue  and  less  often  on  the  lip  and  buccal  mucosa.  The  mucosa 
is  slightly  reddened  about  them.  Attempts  to  scrape  them  off  produce 
bleeding.  They  are  areas  of  superficial  necrosis  into  which  exudation  of 
fibrin  and  round  cells  occurs  (stomatitis  fibrinosa  disseminata).    Vesicles 


GANGRENOUS  STOMATITIS  479 

are  no  part  of  the  process,  though  they  may  occur  on  the  skin  near 
the  mouth.  Occasionally  there  is  tumefaction  of  the  lymphatic  and 
salivary  glands.  They  last  one  or  two  weeks,  and  recurrence  is  frequent. 
The  treatment  is  that  of  stomatitis. 


PARASITIC    STOMATITIS. 

Etiology. —  Thrush,  muguet,  soor  or  stomatomycosis  o'idica  is  due  to  the 
Oidium  albicans,  closely  allied  to  the  saccharomyces,  which  consists  of 
branching  mycelia  and  ovoid  granular  and  refracting  spores.  It  occurs 
chiefly  in  young  or  marantic  children  whose  mouths  have  been  improperly 
cared  for,  especially  among  the  poor  and  in  institutions.  Thrush  may 
develop  in  tuberculous  and  diabetic  adults. 

Symptoms. — A  few  punctate,  whitish  spots  develop  on  the  tongue, 
cheek  and  soft  palate;  they  become  yellowish  as  the  areas  grow  or  fuse. 
The  fungus  is  at  first  deposited  on  the  epithelium,  between  the  layers  of 
which  it  proliferates  and  penetrates.  The  mouth  is  dry  or  moist  from 
increased  salivary  flow.  In  severe  cases  the  fungus  may  reach  the 
pharynx,  larynx,  esophagus  and  even  the  stomach  and  intestine.  It 
is  generally  limited  to  areas  with  flat  epithelium,  and  epithelia  of  the 
cylindrical  and  ciliated  order  usually  escape.  It  ma}',  in  exceptional 
cases,  cause  esophageal  occlusion,  bronchopneumonia,  cerebral,  renal, 
and  other  embolism.    The  outlook  is  good  except  in  marantic  subjects. 

Treatment. — Prophylaxis  is  most  essential  in  regard  to  sterilization  of 
bottles  and  ni'pjples  and  maintenance  of  the  general  health  by  fresh  air 
and  early  treatment  of  dyspeptic  disorders.  Stomatitis  may  persist 
until  a  wet-nurse  is  secured.  Cleansing  the  mouth  with  borax,  sodium 
bicarbonate  and  lime-water  is  most  effective.  If  unusual  extension  occurs 
a  teaspoonful  of  a  resorcin  solution  (1  to  200)  may  be  given  every  two 
hours. 

Stomatitis  may  in  rare  cases  result  from  the  sarcina,  leptothrix,  pneu- 
mococcus,  gonococcus,  etc. 

GANGRENOUS    STOMATITIS. 

Etiology. — Gangrene  of  the  cheek,  noma  or  cancrum  oris,  is  a  rare 
affection.  Of  Brun's  415  cases,  only  11  were  over  fifteen  years  of  age 
and  only  6  infants;  the  author  saw  noma  in  a  man  forty  years  old. 
INIore  cases  occur  in  girls.  Malnutrition  causes  some  cases;  50  per  cent, 
follow  measles;  typhoid,  scarlatina,  etc.,  are  less  frequent  factors.  An 
organism  resembling  that  of  diphtheria  (Bac.  necroseos)  and  those  of 
Vincent's  angina  may  be  seen. 

Symptoms. — Ulceration  of  the  gums  or  buccal  mucosa  near  the  angle 
of  the  mouth  is  followed  by  rapid  necrosis,  gangrene  and  extensive 
brawny  edema  of  the  face.  The  fetor  is  intense  and  much  tissue  is  fre- 
quently sloughed  off.  Perforation  of  the  cheek,  necrosis  of  the  jaw  and 
extension  to  the  throat,  orbit  or  ears  are  not  uncommon;  70  per  cent. 
die  within  a  week  with  septic  symptoms  as  fever,  weak  heart,  diarrhea, 


480  DISEASES  OF   THE   TOXGUE 

colitis  and  meningitis  or  lobular  pneumonia.    The  mortality  was  92  per 
cent,  in  Springer's  collation. 

Treatment. — Treatment  is  ineffectual.  A  full  diet,  alcohol  (salvarsanj 
and  disinfectants  applied  to  the  necrotic  focus  are  indicated;  excision, 
the  live  cautery  and  caustics  are  employed  ^^dthout  success  and  sometimes 
aggravate  the  necrosis. 


DISEASES  OF  THE  TONGUE. 

ECZEMA. 

In  eczema  the  epithelium  thickens  and  desquamates,  leaving  red, 
smooth  and  circular,  serpiginous  or  geographical  areas,  which  heal 
centrally  and  extend  peripherally.  It  may  cause  local  irritation  or  worry 
the  patient,  who  may  think  he  has  syphilis  or  cancer.  Again,  it  is  an 
accidental  finding.  Its  cause  is  unknown,  its  course  is  chronic  and  its 
treatment  by  silver  nitrate  is  quite  inadequate. 

LEUKOPLAKIA. 

Leukoplakia  ("psoriasis,  ichthyosis,  keratosis)  closely  resembles  the 
"geographical  tongue, '^  in  connection  T^dth  which  it  is  often  described. 
Irregular,  smooth,  pale  plaques  of  thickened  epithelium  measuring  1  or 
2  centimeters,  develop  on  the  tongue  and  less  often  on  the  lips,  cheeks 
or  tonsils.  Eighty  to  ninety-eight  per  cent,  occur  in  men;  tobacco, 
alcohol,  gout  and  gastric  disease  are  probable  factors;  Fournier's  experi- 
ence with  324  cases  convinced,  him  that  80  per  cent,  came  from  syphilis 
and  20  per  cent,  from  tobacco.  Its  symptoms  are  slight,  its  course  very 
chronic  and  its  treatment  uncertain;  salvarsan  is  suggested.  Sodium 
salicylate,  10  per  cent.;  chromic  acid,  5  per  cent.;  strong  silver  nitrate; 
corrosive  sublimate  (I  to  500  parts)  and  the  galvanocautery  are  recom- 
mended. Excision  is  necessary  for  papillomatous  or  epitheliomatous 
outgrowths  which  are  said  to  develop  in  one-third  to  one-half  the  cases. 

ACUTE    GLOSSITIS. 

Acute  glossitis  may  be  localized  or  diffuse,  and  ends  in  suppuration 
in  33  per  cent.  It  follows  burns,  erosions,  trauma  or  the  entrance  of 
pyogenic  cocci  tlirough  the  hmph  follicles.  The  painful,  swollen  tongue 
may  protrude  beyond  the  lips.  In  145  cases  the  mortality  was  3  per 
cent.  CBennett,  1906).  Eating,  speaking  and  oral  breathing  are  impos- 
sible.   Incision  is  indicated. 

GLOSSITIS    DESICCANS. 

Glossitis  desiccans  is  a  rare,  chronic,  intractable  affection  in  which 
deep  indentations  of  the  margins  of  the  tongue  and  consequent  lobulation 


PAROTITIS  481 

occur.  Melanoglossia  {nigrities  lingucB)  results  from  proliferation  of  the 
filiform  papillse  at  the  base  of  the  tongue  (melanotrichia  linguce,  black- 
haired  tongue);  50  cases  are  on  record;  the  hair  is  removed  by  a  10  per 
cent,  salicylic  acid  solution  or  by  curetting.  The  mucor  niger  may  cause 
a  black  coating  on  the  tongue. 


DISEASES  OF  THE  SALIVARY  GLANDS. 

PTYALISM,    SALIVATION,    HYPERSECRETION,    SIALORRHEA. 

Etiology. — The  chief  causes  are  (a)  disease  of  the  mouth,  stomatitis, 
dentition;  (6)  toxic  substances,  as  jaborandi,  tobacco,  mercury  and 
iodides;  (c)  nervous  affections,  as  trigeminal  neuralgia,  paretic  dementia 
or  hydrophobia;  a  distinction  is  drawn  between  oversecretion  and  lesions 
like  bulbar  paralysis,  in  which  the  saliva  cannot  be  swallowed;  {d) 
reflex  salivation,  which  may  occur  from  diseases  of  the  tympanum  through 
the  chorda  tympani,  from  gastro-intestinal  disease  (ulcer,  pancreatic 
lesions,  etc.)  by  way  of  the  vagus  and  sympathetic  nerves  and  from 
genital  conditions,  as  pregnancy. 

Symptoms. — A  pathological  salivary  flow  of  over  twelve  quarts  has 
been  recorded.  The  salivary  glands  are  tense,  swollen  and  hard.  The 
reaction  of  the  saliva  may  become  neutral  or  acid;  it  may  contain  ropy 
mucous  or  scattered  pus  cells;  the  ptyalin  and  potassium  sulphocyanide 
disappear.  The  saliva  may  trickle  into  the  larynx  during  sleep,  and  cause 
coughing;  it  may  flow  into  the  stomach  and  produce  vomiting  of  an 
alkaline  or  neutral  vomitus,  especially  in  the  morning;  it  may  stream 
from  the  lips  and  redden  the  skin. 

Prognosis  and  Treatment. — Both  depend  on  the  causal  affection.  In 
nervous  and  reflex  types  potassium  bromide  and  iodide  are  often  valuable. 
Severe  cases  necessitate  opium  and  belladonna. 

XEROSTOMIA. 

Hyposecretion  or  arrested  secretion  occurs  in  diabetes  insipidus  and 
mellitus,  in  some  cases  of  contracted  kidney  and  as  a  neurosis  or  a  neurotic 
symptom  (Hutchinson,  1888).  Women  are  more  often  affected  (80  per 
cent.).  The  mouth  is  dry,  red  and  glistening,  interfering  with  speaking, 
chewing,  swallowing  and  digestion  of  carbohydrates.  The  tongue  may 
cleave  to  the  roof  of  the  mouth.  Treatment  consists  in  painting  the 
mouth  with  iodine,  potassium  iodide  and  glycerin  (1,  10,  100  parts), 
pilocarpine  hydrochloride,  grain  -y2  to  \,  and  galvanism  to  the  parotid. 

PAROTITIS. 

Besides  specific  parotitis  (mumps),  infection  may  reach  the  salivary 
glands  by  way  of  their  ducts  or  the  blood  stream.    Acute  'parotitis  may  be 
31 


482  DISEASES  OF   THE  SALIVARY  GLANDS 

simple  or  oftener  suppurative  (staphylococcic).  (a)  Any  acute  infec- 
tion may  be  complicated  by  parotitis,  particularly  typhoid.  (6)  Paget 
drew  attention  to  diseases  of,  or  operations  on.  the  alimentary  and  genito- 
urinary tracts,  peritoneal  disease,  pancreatitis,  abdominal  trauma,  etc.; 
many  of  these  cases  are  clearly  attenuated  sepsis.  Zezas,  in  1910, 
collected  162  cases  of  postoperative  parotitis;  the  mortality  is  33  per 
cent,  (c)  Facial  neuritis  and  the  starvation  therapy  of  gastric  ulcer 
may  cause  parotitis. 

Chronic  imrotitis  sometimes  follows  epidemic  or  symptomatic  parotitis, 
poisoning  by  mercury  or  lead,  syphilis  or  chronic  nephritis.  Mikulicz 
described  a  "chronic  symmetrical  hypertrophy  of  the  salivary  and  lachry- 
mal glands,"  which  may  be  independent  or  symptomatic  of  pseudo- 
leukemia, leukemia,  etc.  There  is  a  round-cell  infiltration,  epithelial 
degeneration,  and  structures  like  giant  cells. 

Treatment. — In  acute  parotitis,  leeches,  cold  and  later,  hot  fomentations 
and  surgical  incision,  if  there  is  pus  formation,  are  indicated.  Chronic 
forms  respond  slowly  to  iodine  or  mercurial  ointment,  and  Mikulicz's 
disease  to  arsenic  and  a;-rays. 

ANGINA   LUDOVICI. 

Ludwig's  angina  is  a  streptococcic  infection  beginning  in  the  sub- 
maxillary gland,  and  extending  to  the  floor  of  the  mouth  and  the  cervical 
cellular  tissue  (Ludwig,  1836).  Trauma  may  be  its  immediate  antece- 
dent, but  most  cases  are  secondary  to  typhoid,  diphtheria  and  kindred 
infections.  The  inflammation  spreads  rapidly,  causing  fever,  redness, 
pain  and  swelling  under  the  tongue,  cellulitis  and  sometimes  gangrene 
in  the  neck  {cynanch'e  gangrceneuse) .  Mastication  and  deglutition  may  be 
impossible.  The  parotids  are  sometimes  invaded.  Resolution  is  very 
exceptional  and  external  pointing  of  pus  is  not  likely  to  occur,  whence, 
without  early  surgical  intervention,  septic  and  pyemic  complications  or 
laryngeal  and  pharyngeal  edema  or  phlegmon  (of  which  it  is  the  analogue) 
very  frequently  develop.    The  mortality  is  40  per  cent. 

SIALODOCHITIS   FIBRINOSA. 

Inflammation  of  the  salivary  ducts  with  formation  of  membrane 
(Kussmaul)  results  from  infection  ascending  from  the  oral  cavity  and  is 
characterized  by  fever,  tenderness,  pain  and  tumefaction  of  the  gland. 
The  duct  is  kept  patent  by  pressure  or  sounding. 

SIALOLITHIASIS. 

Stones  of  calcium  phosphate  or  carbonate  occur  usually  from  stagna- 
tion of  the  salivary  secretion  by  foreign  bodies,  bacterial  invasion  or 
stricture  following  ulceration.  Roberg  found  stones  in  Wharton's  duct 
fifty  times,  in  the  submaxillary  gland  twenty-eight  times,  in  Stenson's 
duct  six  times  and  in  the  parotid  gland  twice.  Bendixen  collected  216 
cases  (1908). 


CHRONIC   PHARYNGITIS  483 


DISEASES  OF  THE  PHARYNX. 


ACUTE    PHARYNGITIS. 

• 

Etiology. — ^Acute,  simple  angina  may  be  caused  by  (a)  rheumatism, 
cold  or  exposure;  (6)  infections,  either  acute  (measles,  scarlatina)  or 
chronic  (syphilis);  (c)  gout,  dyspepsia  or  smoking;  (d)  in  many  cases 
the  cause  is  obscure,  probably  always  mycotic;  no  single  virus  is  found. 
It  is  most  common  in  youth. 

Symptoms:  (a)  Local:  The  throat  is  red,  glazed  and  streaked  with 
mucopus  which  is  easily  wiped  away.  Swelling  or  vesicles  on  the  soft 
palate  and  uvula,  superficial  erosions,  and  swollen  mucous  follicles  are 
occasionally  seen.  In  some  cases  the  local  findings,  hidden  in  the  naso- 
pharynx, are  very  slight  in  proportion  to  the  local  pain  and  general 
symptoms.  A  scratching  sensation  in  the  throat  may  radiate  into  the 
posterior  nares  or  ear.  The  patient  hawks,  but  raises  little,  unless  there 
is  coincident  rhinitis  or  laryngitis.  Swallowing  is  rather  painful,  slight 
deafness  is  common,  the  speech  is  slightly  nasal  and  the  angular  lymph 
nodes  are  painful,  (b)  Constitutional  symytoms  are  usually  slight.  At  the 
onset  there  are  chilliness,  moderate  fever,  aching  in  the  muscles  and  in 
some  individuals  extreme  cutaneous  hyperesthesia,  which  may  be  falsely 
attributed  to  changes  in  the  deeper  parts  of  the  body.  With  or  without 
coincident  tonsillitis,  there  may  be  high  fever,  and  in  labile  individuals, 
marked  nervous  intoxication.  Herpes  facialis  occasionally  develops. 
Complications,  as  acute  endocarditis  or  nephritis,  are  very  uncommon. 
In  a  few  days  convalescence  is  complete. 

Treatment. — {a)  Local:  Painting  the  pharynx  with  a  20  per  cent, 
silver  nitrate  solution  affords  local  and  general  relief.  (6)  General: 
Dover's  powder  and  acetylsalicylic  acid,  each  ten  grains,  may  be  ex- 
hibited for  unusual  pain,  calomel,  followed  by  salines,  for  elimination 
and  a  1  per  cent,  phenol  gargle  for  the  throat. 

The  pneumococcic  sore  throat  may  be  suppurative,  pseudodiphtheritic, 
follicular,  like  tonsillitis,  erythematous  or  herpetiform;  its  onset  is 
severe,  it  produces  a  thicker  and  more  adherent  membrane  than  does 
the  streptococcus  and  the  prognosis  is  generally  poor. 

CHRONIC   PHARYNGITIS. 

Etiology. — (a)  Recurrent  pharyngitis;  (6)  tobacco  or  alcohol;  (c)  abuse 
of  the  voice,  as  in  clergymen,  venders,  etc.;  (d)  extension  from  chronic 
nasopharyngitis;  (e)  chronic  nephritis,  syphilis,  etc.  These  factors  are 
most  common  in  adolescence  and  middle  life. 

Symptoms. — The  nasopharynx  is  red  and  lined  with  turgid  venules; 
the  pillars  are  relaxed  and  the  drooping  uvula  may  tickle  the  tongue  or 
epiglottis,  causing  chronic  coughing.  The  sides  of  the  pharynx  may  show 
isolated  whitish  epithelial  thickenings  or  more  often,  reddish,  hyper- 
trophied  lymph  follicles  (pharyngitis  granulosa) .  The  pharynx  is  dry  and 
burning,   exciting   hawking   efforts   which   are   unproductive   and   may 


484  DISEASES  OF   THE  PHARYNX 

cause  morning:  vomiting.  Slight  bleeding  occasionally  causes  unneces- 
sary worry.  ]\Iiddle-ear  involvement  is  common,  through  the  Eustachian 
tube.  Pharyngitis  sicca  is  an  atrophic  type  and  marked  by  a  pallid  glazing 
of  the  pharynx  wall  and  crust  formation. 

Treatment. — (a)  The  causal  f actors,  as  straining  of  the  voice,  alcoholism 
or  smoking,  etc.,  are  corrected.  Alkaline  laxatives  are  frequently  bene- 
ficial. (6)  Galvanopuncture  of  the  turgid  veins  or  hyperplastic  follicles 
is  indicated;  improvement  is  probably  more  frequent  than  aggravation 
by  overzealous  treatment,    (c)  Local  medical  treatment  is  less  eflBcacious. 

J\ — Phenolis gr.  xx 

Acidi  tannici 3ss 

Glycerini 5ij 

Aquae  rosa q.  s.  ad.  gv 

M.  et  ft.  gargarismiis. 

S. — As  gargle,  properly  diluted. 

I^ — Tincturse  guaiaci 3iv 

Liq.  potassae 3ss 

Alcoholis 8J 

Aquae  cianamomi q.  s.  ad.  giv 

M.  et  S. — One  teaspoonful  in  one-half  glass  of  water  as  gargle. 

(d)  For  atrophic  pharyngitis  the  best  formula  is: 

li — lodi gr.  iij 

Potassii  iodidi 3ss 

Glycerini §j 

M.  et  S. — Massage  thoroughly  into  the  pharj^nx. 

PHLEGMONOUS    PHARYNGITIS. 

Angina  phlegmonosa  invades  the  submucosa  (Senator).  It  is  usually 
primary  but  may  be  metastatic.  The  throat  is  painful,  swollen  and 
edematous,  the  neck  enlarges  and  suppuration  occurs  with  high  fever, 
sepsis,  dysphagia  and  dyspnea,  especially  when  the  subject  lies  down. 
The  inflammation  may  be  hemorrhagic  or  necrotic.  Phlegmonous 
angina  is  the  analogue  of  suppurative  submucous  laryngitis  and  angina 
Ludovici.  Without  surgical  intervention  or  early  spontaneous  rupture 
into  the  throat,  death  occurs  from  septicopyemia,  mediastinitis  or  glottis 
edema. 

RETROPHARYNGEAL   ABSCESS. 

(a)  The  primary  form  occurs  in  children  under  two  years  of  age,  with 
dysphagia,  a  nasal  voice  and  retropharyngeal  suppuration,  as  a  visible 
protrusion  or  a  palpable  fluctuation  on  the  posterior  pharyngeal  wall; 
dyspnea,  cyanosis  and  inspiratory  retraction  of  the  chest  develop.  It 
is  primarily  a  lymphadenitis,  ih)  Secondary  types  are  less  common  in 
caries  of  the  cervical  spine,  diphtheria,  erysipelas,  scarlatina  and  suppu- 
rative inflammation  in  the  retropharyngeal  lymph  glands,  or  rarely  by 
metastasis.  Unless  surgical  measures  are  instituted  or  spontaneous 
rupture  occurs  early,  death  results  from  asphyxia,  mediastinitis,  glottis 
stenosis,  inhalation  pneumonia  or  sepsis.  After  incision  the  head  should 
be  prompt]>'  thrown  forward  to  obviate  occlusion  of  the  air  passages, 


ACUTE  FOLLICULAR  OR  LACUNAR  TONSILLITIS  485 

PHARYNGEAL   ULCERATION. 

Syphilitic  and  tuberculous  ulceration  have  been  considered.  Follicular 
ulcers  are  superficial  and,  like  all  ulcers  in  the  mucous  membrane  only, 
heal  without  a  cicatrix.  Ulceration  also  occurs  in  diphtheria  and  the 
diphtheroid  group,  due  chiefly  to  the  streptococcus.  Malignancy  too, 
causes  ulceration. 

Vincent's  angina  (see  page  85)  constitutes  2  per  cent,  of  all  anginas 
including  diphtheria.  It  occurs  especially  in  children  between  six  and 
ten  years,  medical  students  and  servants  in  anatomical  laboratories. 
Tobacco,  tuberculosis,  sj^philis,  scarlatina,  measles  and  the  eruption 
of  wisdom  teeth  are  predisposing  factors.  The  two  causative  organisms 
were  first  described  by  Rauchfus  (1893) :  (a)  The  fusiform  bacillus  has 
pointed,  sometimes  rounded  ends,  is  sometimes  bent,  measures  6  to 
12)U  in  length  and  may  be  flagellated;  (6)  the  spirillum  or  Spirochete 
darticola  is  long,  delicate  and  twisted.  They  stain  with  carbol-fuchsin 
but  not  by  Gram's  method. 

Symptoms. — In  the  first  period,  there  is  congestion  and  edema.  Then 
a  grayish-yellow  membrane  forms  which  is  friable,  cheesy  and  usually 
removable.  Under  the  membrane,  an  ulcer  develops;  it  is  usually 
single,  oval  and  has  an  irregular  edge  and  an  uneven  granulating  floor. 

The  general  symptoms  are  lassitude,  indigestion,  vomiting  or  epistaxis; 
fever  over  100°  is  uncommon  and  complications  rare  (albuminuria,  enter- 
itis or  noma).  The  breath  is  fetid  and  the  cervical  nodes  enlarge.  Lesions 
are  recorded  in  the  larynx  and  bronchi  alone.  Syphilis  and  diphtheria 
require  differentiation.  It  is  communicable  within  narrow  limits.  The 
affection  heals  under  applications  of  iodine,  pencilling  with  silver  nitrate 
and  gargles  of  hydrogen  peroxide  or  chlorate  of  potash.  Salvarsan  locally 
has  given  rapid  results.    Mercury  is  contra-indicated  (v.  page  226). 


DISEASES  OF  TONSILS. 

ACUTE    FOLLICULAR    OR   LACUNAR    TONSILLITIS. 

Definition. — An  acute  mycotic  parenchymatous  inflammation  of  the 
tonsils,  usually  attended  by  decided  constitutional  reaction. 

Etiology. — (a)  Bacteriologically,  the  streptococcus  is  the  most  frequent 
cause,  then  the  staphylococcus,  pneumococcus  and  diphtheria  bacillus 
(at  the  time  of  diphtheria  epidemics,  but  such  cases  are  a  subtype  of 
diphtheria).  (6)  The  virus  of  rheumatism  probably  gains  access  to  the 
blood  by  way  of  the  tonsils;  affections  associated  with  rheumatism,  as 
erythema  nodosum,  chorea  and  endocarditis  may  follow  acute  tonsillitis. 
Tonsillitis  may  begin  the  rheumatic  cycle,  as  described  under  Rheuma- 
tism in  Children,  or  it  may  appear  later  with  endocarditis,  pericarditis, 
arthritis  and  chorea.  Tonsillitis  is  contagious,  (c)  Cold  and  dampness  are 
directly  predisposing  causes,  largely  in  the  spring,     {d)  Tonsillitis  occurs 


486  DISEASES  OF   THE   TONSILS 

chiejQy  in  youth  and  adolescence,  (e)  Individual  predisposition  depends 
on  some  unknown  factor  and  one  attack  favors  recurrence,  (f)  Poor 
hygiene  and  possibly  sexual  activity,  especially  in  yoimg  married  people, 
may  be  conducive  to  tonsillitis  (Shepard) . 

Symptoms. — {a)  The  onset  occurs  with  chilliness  or  rigor,  severe  pains 
in  the  hack  and  limbs,  fever,  rising  within  a  day  to  103°  or  even  106° 
in  children  or  susceptible  adults,  pjain  in  the  throat,  particularly  on  swal- 
lowing, and  tenderness  of  the  glands  at  the  angle  of  the  jaw.  (h)  The 
to)isik  are  swollen  and  show  on  the  deeply  injected  surface  three  to  ten 
yellowish- white  points,  corresponding  to  the  lacunae;  these  crypts  con- 
tain bacteria,  epithelium  and  leukocytes  and  are  small  abscesses;  the 
tonsil  is  the  seat  of  serocellular  infiltration.  Occasionally  there  are  small 
superficial  areas  of  necrosis,  slight  erosions  or  even  membrane.  The 
voice  may  acquire  a  nasal  twang,  the  pain  increases  for  a  few  days  and 
the  angular  glands  remain  painful  and  tender,  whence  the  head  is  often 
held  rigidly  forward  and  the  jaws  are  opened  with  difficulty.  Pain  in 
the  ear  is  common,  (cj  The  comtitutional  symptoms  {v.  s.)  also  include 
anorexia,  coated  tongue,  hyperesthetic  skin,  depression,  accelerated 
pulse  and  respiration;  in  two  adult  cases  seen  by  the  -^Titer,  retraction 
of  the  neck  with  headache,  delirium  and  vomiting  was  mistaken  for 
meningitis.    Herpes  facialis  is  frequent. 

"Septic  Soee  Theoat.'" — English  ^^Titers  have  long  believed  that  milk 
conveys  streptococcic  tonsillitis;  such  epidemics  were  observed  in  Chris- 
tiana in  1908  and,  in  1911-12,  1043  cases  developed  in  Boston  T^nth  5  per 
cent,  mortality  and  10,000  cases  in  Chicago.  In  75-87  per  cent,  of  cases, 
infection  was  traced  to  certain  dairies,  where  bovine  mastitis  and  human 
sore  throat  prevailed.  The  disease  is  due  to  streptococci  Tof  a  type  half- 
way between  the  S.  pyogenes  and  S.  mucosus)  or  to  pneumococci.  The 
local  findings  are  tonsillitis  with  a  milky  gray  membrane ;  the  onset  is  severe, 
or  first  mild  with  later  severe  symptoms — fever  102-106°,  bradycardia 
(40-90),  prostration,  chill,  moderate  leukocytosis;  later  marked  lymphad- 
enitis, which  suppurates  in  about  10  per  cent.,  and  suppurative  tonsillitis 
in  5  per  cent. ;  and  finally  septic  generalization  in  the  severerst  types, 
with  peritonitis  particularly,  empyema,  meningitis,  arthritis  and  endo- 
carditis. 

Complications. — Complications  are  uncommon.  Acute  pericarditis, 
endocarditis,  functional  heart  murmurs,  febrile  albuminijria,  otitis  and 
er\'thema  (from  the  toxins  or  medicationj  are  not  very  infrequent.  Con- 
valescence is  complete  within  a  week,  though  marked  prostration  and 
considerable  residual  swelling  remain  for  some  time.  Repeated  attacks 
may  cause  chronic  nephritis  or  endocarditis. 

Diagnosis. — The  typical  case  cannot  be  confused,  (a)  Diphtheria 
produces  a  white  membrane,  with  a  pathognomonic  tendency  to  spread 
to  the  uvula,  soft  palate  or  pharynx;  it  leaves  bleeding  raw  points  when 
it  is  stripped  off;  it  recurs  after  removal;  it  sometimes  extends  to  the 
larynx;  it  is  followed  not  infrequently  by  paralysis,  responds  to  sero- 
therapy and  shows  the  Klebs-Loeffler  bacillus.  (6)  Tonsillitis  necrotica 
leaves  an  ulcer;  some  cases  showing  the  fusiform  bacillus  and  spirillum 
of  Mncent  and  others  are  alleged  to  be  diphtheritic;  in  some  cases  there 


SUPPURATIVE   TONSILLITIS  487 

is  much  fever,  in  others  none;  the  general  reaction  is  severe,     (c)  The 
possibihty  of  incipient  scarlatina  should  be  kept  in  mind. 

Treatment. — 1.  Prevention. — The  subject  should  be  hardened  by  cool 
baths  or  sponges,  and  tonsillectomy  should  be  performed. 

2.  Local  ^Measures. — After  cocainizing  the  throat,  a  small  probe, 
bent  at  right  angles  near  its  end,  is  introduced  into  each  swollen  crypt 
to  secure  free  drainage;  then  undiluted  Dobell's  solution  is  applied  on 
bits  of  cotton  to  each  crypt,  followed  by  20  per  cent,  silver  nitrate  solu- 
tion; the  results  are  often  immediate,  sometimes  abortive.  Squeezing 
out  the  crypts  with  a  spatula  is  painful.  Hot  fomentations  may  be 
applied  to  the  neck. 

3.  Constitutional  Treatment. — In  a  small  number  of  cases  sodium 
salicylate,  given  as  in  rheumatism,  affords  relief.  Hydrarg.  biniodide, 
gr.  y^,  every  fifteen  minutes  for  ten  doses  may  abort  the  process;  tr. 
guaiaci  ammoniat.,  TTLx-xl,  every  two  hours  is  unsatisfactory.  Ac. 
acetylsalicyliciun  and  Dover's  powder,  aa  gr.  x,  relieve  pain  in  the  throat, 
body  and  limbs.  Aconite  and  belladonna  are  beneficial  in  children  with 
high  fever,  but  less  so  in  adults;  they  are  given  as  in  coryza  or  influenza. 

SUPPURATIVE    TONSILLITIS. 

Etiology. — ^The  etiology  is  almost  identical  with  that  of  the  follicular 
type.  Suppurative  tonsillitis  is  most  common  in  adolescence,  and  for 
unknown  reasons  individual  disposition  is  an  important  factor. 

Symptoms. — The  symptoms  resemble  those  of  the  follicular  type  but 
are  more  severe  from  the  onset;  one,  or  less  often  both,  tonsils  are  greatly 
swollen,  tense,  edematous,  and  deep  red.  The  pain  often  radiates  to 
the  ears.  The  swollen  tonsils  may  come  in  contact;  one  swollen  tonsil 
may  reach  over  to  the  sound  side.  There  is  often  coincident  stomatitis, 
a  free  salivary  flow,  and  edematous  palate  and  uvula.  Swallowing  causes 
great  pain,  the  jaw  cannot  be  depressed  because  of  the  swollen,  painful 
angular  glands,  and  the  speech  is  nasal.  The  toxemic  prostration  is  often 
profound,  the  fever  ranges  between  103  and  105  degrees  and  the  pulse 
between  100  and  140. 

Incision  in  the  first  two  or  three  days  evacuates  only  blood  and  serum. 
In  a  few  days  fluctuation  is  felt  anterior  to  and  above  the  tonsil  (peri- 
tonsillar abscess).  Introduction  of  a  probe  into  the  early  incision  is 
followed  by  escape  of  pus  and  immediate  relief.  The  abscess  may  break 
spontaneoush',  usually  forward  and  rarely  toward  the  throat,  when,  in 
rare  cases,  suffocation  or  aspiration  pneumonia  may  follow.  Very  rarely 
ulceration  may  reach  the  carotid  wdth  fatal  hemorrhage.  IMinute  sup- 
purative foci  may  cause  septicemia. 

Treatment. — (a)  Tonsillectomy  is  indicated  after  an  individual  tendency 
is  manifested.  (6j  An  ice-bag  over  the  neck  is  beneficial.  Local  applica- 
tions are  uncertain.  It  is  good  practise,  early  in  the  course,  to  introduce 
a  knife,  with  extreme  care,  covered  with  adhesive  plaster  to  within  half  an 
inch  of  its  point,  above  and  inside  the  tonsil;  blood  and  serum  escape, 
tension,  edema  and  pain  are  relieved  and  the  later  abscess  more  readily 
points  toward  the  cut;  the  wound  is  opened  with  a  bhnit  probe  every 


488  DISEASES  OF  THE  TONSILS 

day.  (c)  Salicylates  help,  and  possibly  hasten  maturation.  Oinum  and 
coal-tar  products  relieve  the  pain  to  some  extent.  (fZ)  In  exceptional 
cases  intubation  or  tracheotomy  is  indicated,  because  of  great  swelling. 
(e)  The  diet  is  necessarily  liquid.  (/)  In  convalescence,  iron  and  strychnine 
overcome  the  resulting  prostration  and  anemia. 

CHRONIC    TONSILUTIS. 

Synonyms. — Chronic  inflammation;  tonsillar  hypertrophy;  hyperplasia 
of  the  pharyngeal  or  lingual  tonsils;  adenoids;  aprosexia. 

Etiology. — (a)  Repeated  acute  attacks  of  tonsillitis  cause  chronic  hyper- 
trophy in  some  cases,  and  in  others  the  tonsils  gradually  indurate  and 
shrink.  (6)  Waldeyer's  "Schlundring"  of  lymphadenoid  tissue  consists 
of  the  two  tonsils,  the  adenoid  tissue  in  the  nasopharyngeal  vault  {"ade- 
noids" in  the  common  acceptation)  and  the  lingual  tonsil.  Variously 
combined  hypertrophies  of  these  structures  may  be  noted,  occasionally 
as  congenital  growths,  but  most  frequently  from  the  third  year  until 
puberty.  Adenoids  are  found  in  1  per  cent,  of  children.  Rickets,  the 
lymphatic  constitution  and  acute  infections  involving  the  throat  pre- 
dispose. 

Symptoms. — 1.  Local  Changes. — (a)  From  the  enlarged  tonsil  may 
be  expressed  cheesy  plugs,  which  occasion  an  extreme  foetor  ex  ore;  calculi 
may  result  from  a  deposit  of  lime  salts.  The  pharyngeal  mucus  is 
increased,  sometimes  tinged  with  blood  and  expectorated  with  difficulty. 
(6)  Adenoids  occur  alone  or  with  tonsillar  hyperplasia.  They  are  papillo- 
matous, vascular  and  range  up  to  the  size  of  a  bean,  (c)  Hypertrophy 
of  the  "lingual  tonsil"  often  disturbs  deglutition.  Enlarged  tonsils  and 
adenoids  produce  the  following  changes  by  stenosing  the  posterior 
nares : 

2.  Sequences. — {a)  Oral  breathing  is  the  earliest  symptom  and  is 
first  noticed  at  night,  when  sleep  is  disturbed  by  night  terrors  {pamr 
nocturnus),  by  disordered  and  irregular  breathing,  for  a  time  stertorous 
and  then  interrupted,  asthmatic  seizures  or  Balne's  paroxysmal  cough. 
(6)  The  palatal  vault  is  high  from  atmospheric  pressure  in  the  mouth, 
and  the  transverse  measurement  between  the  upper  teeth  is  diminished; 
there  is  less  room  for  the  teeth  to  erupt,  (c)  The  anterior  nares  are  small 
and  retracted  and  the  voice  is  nasal  {rhinolalia  claustra) ;  the  consonants  n 
and  m  are  pronounced  with  difficulty.  Bloch  associated  oral  breathing 
with  stuttering.  The  sense  of  smell  or  taste  is  obtunded.  Hearing  is 
impaired  by  pressure  of  adenoids  on  the  Eustachian  tubes,  or  retraction 
of  the  tympana  from  low  atmospheric  pressure  in  the  nasopharynx,  {d) 
l^h&  fades  is  characteristic;  it  is  vacuous  and  apathetic,  the  nose  is  pinched, 
the  mouth  open  and  the  lips  swollen.  The  "adenoid  habitus"  may  be 
observed  as  a  stigma  of  degeneracy,  {e)  In  chronic  cases  the  cerebral 
reaction  is  slow,  the  memory  tardy,  the  disposition  sullen  and  the  power 
of  concentration  diminished  (aprosexia),  due  perhaps  to  some  cytotoxin 
elaborated  in  the  lymphoid  tissue.  (/)  Nervous  symptoms  embrace 
headache,  habit-spasm,  night  terrors  and  enuresis  nocturna.  {g)  Devel- 
opment is  sometimes  retarded,     {h)    Deformity  of  the  thorax  was  noted 


PLATE    XUI 


FIG.    1 


FIG.    2 


\ 


Types  o 


f  the  '^Adenoid"   Facies.     (Posey  and  Wright.) 


INFLAMMATION— NECROSIS— ULCERATION  489 

by  Dupuytren  (1828).  The  pigeon-  or  chicken-breast  is  the  most  common. 
The  sternum  juts  forward,  from  which  the  ribs  slant  sharply  backward; 
at  the  level  of  the  diaphragm  there  is  a  circular  depression,  and  inspira- 
tory retraction  is  caused  by  the  contraction  of  the  diaphragm.  The 
funnel-breast,  marked  by  a  deep  depression  of  the  lower  part  of  the 
sternum,  is  less  commonly  due  to  adenoids,  and  like  the  chicken-breast 
also  results  from  other  causes.  The  emphysema  chest  may  result  from 
adenoids,  (i)  Mouth-breathers  may  develop  collapse-induration  resem- 
bling apical  tuberculosis  (see  page  158).  (j)  The  cervical  lymph  glands  are 
enlarged  and  the  blood  evidences  decreased  hemoglobin,  increased  white 
cells  and  distinct  lymphocytosis.     (Plate  XIII.) 

Diagnosis. — The  oral  breathing,  adenoid  facies,  mental  disturbance, 
palpation  of  the  adenoids  in  young  children  and  their  rhinoscopic  detec- 
tion in  older  ones,  and  the  inspection  of  hyperplastic  tonsils  determine 
the  diagnosis.  In  the  prognosis  of  untreated  cases,  the  possibility  of 
deafness,  mental  deficiency,  retarded  growth,  arthritis,  endocarditis, 
nephritis,  asthma  and  emphysema  should  be  borne  in  mind.  Acute 
recurrent  tonsillitis,  diphtheria  and  other  infections  are  more  likely  to 
develop  and  produce  disproportionate  symptoms.  Rarely  the  hyper- 
plastic tissues  may  atrophy  spontaneously. 

Treatment. — The  general  health  should  be  maintained  by  out-door 
life,  an  ample  diet,  hydrotherapy  and  iron.  Hypertrophied  tonsils  should 
be  removed  when  they  harbor  chronic  infection,  or  when  growth  is 
retarded,  etc.  Adenoids  causing  symptoms  should  be  removed  early 
under  ether  anesthesia;  chloroform  frequently  causes  death  in  the  status 
thymicus  or  lymphoid  constitution.  Oral  breathing,  persisting  after 
operation,  is  a  habit  hard  to  break;  at  night  a  bandage  should  be  used 
to  close  the  mouth. 


DISEASES  OF  THE  ESOPHAGUS. 

INFLAMMATION,    NECROSIS,    ULCERATION. 

I.  Esophagitis. — This  is  an  uncommon  finding  at  autopsy.  Its  causes 
are  (a)  mechanical,  as  from  foreign  bodies,  strictures  or  dilatation  of 
the  esophagus;  (b)  chemical,  as  corrosive  poisons  or  acid  vomitus;  (c) 
hypostatic,  in  cardiac  or  pulmo;nary  affections;  (d)  rarely  extension 
from  pharyngeal  or  laryngeal  inflammation;  (e)  acute  infections,  as 
smallpox  and  diphtheria.  Esophagitis  is  physiological  in  the  newborn 
after  the  ingestion  of  the  first  meals  of  life.  Its  pathology  is  local  or 
diffuse,  acute  or  chronic  redness,  sw^elling  and  hypersecretion.  Special 
forms  are  follicular  catarrh,  sometimes  resulting  in  ulcers  or  retention 
cysts;  exfoliative  esophagitis;  the  fibrinous  form,  observed  in  acute 
infections  and  uremia;  genuine  diphtheria;  the  pustules  of  smallpox; 
the  toxic  form  from  caustics  or  acids;  only  12  cases  are  on  record  of  the 
single  bulging  submucous  abscess  or  diffuse  submucous  suppuration  which 
perforates  into  the  esophagus  which  then  presents  a  sieve-like  aspect; 


490  DISEASES  OF   THE  ESOPHAGUS 

forms  due  to  the  Oidium  albicans  or  ray  fungus.  In  chronic  cases  the 
epithehum  may  thicken  (leukoplakia)  or  hypertrophy  (papilloma). 

Symptoms. — Only  in  marked  cases  is  there  pain,  continuous,  substernal 
or  elicited  by  speaking,  or  movement  of  the  spine.  Dysphagia  is  constant 
in  marked  inflammations.  Mucus,  blood,  pus  or  eschars,  depending  on 
the  nature  of  the  inflammation,  are  brought  up  by  gagging  efforts.  Fever 
is  common  in  the  more  severe  types,  in  which  the  local  symptoms  are 
wholly  obscured  by  the  causal  diphtheria,  smallpox,  etc.  In  inflammation 
due  to  acids  or  alkalies,  the  history,  local  symptoms  and  eschars  in  the 
mouth  and  pharynx  are  distinctive. 

Treatment. — Treatment  is  palliative.  Narcotics  are  given  for  pain, 
demulcents  as  acacia  and  ice-cream  and  a  liquid  diet  for  local  irritation, 
or  nutrient  enemata  are  given. 

II.  Necrosis. — This  may  be  due  to  corrosive  poisoning;  pressure 
from  struma,  aneurysm,  sounds  left  in  the  esophagus  to  dilate  strictures; 
or  "bed-sores  of  the  gullet,"  described  by  Dittrich  (1850)  in  laryngeal 
perichondritis,  due  to  pressure  of  the  larynx  upon  the  gullet.  Esophago- 
malacia  is  softening  due  to  regurgitation  of  the  gastric  acid,  chiefly  after 
death,  or  during  the  death  agony. 

III.  Ulceration. — Aside  from  cancer,  follicular  ulceration,  caustic 
ulcers,  syphilis  and  tuberculosis,  there  is  the  peptic  ulcer  first  described 
by  Cruveilhier,  who  identified  it  with  ulcer  of  the  stomach.  Forty  cases 
were  collected  by  Tileston  (1908).  It  appears  in  four  conditions  (a) 
by  extension  from  the  round  ulcer  of  the  cardiac  orifice,  (b)  in  ulcers 
at  the  pylorus  or  duodenum,  which  produce  gastric  dilatation,  (c)  in 
multiple  hemorrhagic  infiltrations  of  the  esophagus,  stomach  and  duo- 
denum and  (d)  in  alcoholism  and  arteriosclerosis.  Its  chief  symptom  is 
dysphagia  (50  per  cent.) ;  its  pathology,  complications  and  treatment  are 
those  of  gastric  ulcer. 


STENOSIS    OR   STRICTURE   OF   THE   ESOPHAGUS. 

Stenosis  is  the  most  frequent  esophageal  disease.  The  esophagus  is  a 
closed  tube  only  in  its  cervical  segment,  and  its  cardiac  orifice  is  not 
physiologically  closed. 

Etiology. — (a)  Interstitial  factors,  i.  e.,  in  the  wall  of  the  esophagus,  are 
the  most  important;  cancer  causes  90  per  cent,  of  all  stenoses;  ulceration 
by  caustics  and  acids  comes  next;  then  stenosis  by  diverticula  or  pouches 
which,  bulging  out  of  and  beside  the  esophagus,  exert  upon  it  a  lateral 
compression;  rarer  ulcerative  stenoses  result  from  healing  gummata, 
tuberculous  lesions,  smallpox  and  peptic  and  diphtheritic  ulcers;  mus- 
cular spasm  causes  many  cases;  congenital  stenosis  or  atresia,  of  which 
Dickie  (1906)  collected  76  cases,  occurs  chiefly  as  a  cut  de  sac,  incom- 
plete development  or  fistulous  communications  with  the  trachea  or 
bronchi.  (6)  Extra-esophageal  factors,  compressing  the  tube  from  with- 
out, include  aortic  aneurysm  or  abnormal  branches  of  the  aorta;  vertebral 
tumor,  cold  abscess,  exostosis  or  deformation;  anthracotic  lymphadenitis 
and   malignant   lymphoma;  thyroid   or   thymic   enlargements;  medias- 


STENOSIS  OR  STRICTURE  OF   THE  ESOPHAGUS  491 

tinitis,  pericarditis  and  pulmonary  neoplasms.  (c)  Intra-esophageal 
factors  are  the  rarest,  as  foreign  bodies,  pedunculated  polyps, 
etc. 

Stenosis  occurs  chiefly  (a)  at  the  lower  third  of  the  esophagus,  (b) 
near  the  level  of  the  bifurcation  of  the  trachea  or  (c)  high  in  the  esopha- 
gus. The  stenosis  is  more  often  single  than  multiple  and  more  often 
annular  than  longitudinal;  it  varies  from  slight  stenosis  to  complete 
atresia.  Above  the  stenosis  the  tube  is  dilated  and  its  musculature  is 
hypertrophied  to  force  food  through. 

Symptoms. —  Dysphagia  may  be  secondary  to  aortic  aneurysm  and 
vary  from  time  to  time  with  the  pressure  exerted  upon  it;  in  cicatriz- 
ing ulcers  dysphagia  is  the  only  symptom.  In  advanced  stenosis  the 
food  and  later  the  fluids  regurgitate  after  a  short  time  if  the  stenosis  is 
low,  or  at  once  if  the  stenosis  lies  just  below  the  pharynx.  The  regur- 
gitated food  is  neutral,  often  fermented  and  contains  round  cells,  mucus 
or  blood,  but  never  HCl  nor  pepsin.  Esophageal  jjain  is  common. 
Singultus  is  frequent  when  the  lesion  lies  near  the  diaphragm.  Dyspnea 
may  result  from  pressure  upon  the  air  passages  by  the  dilated  portion 
of  the  esophagus  above  the  stricture. 

Signs  and  Diagnosis. — The  chest  should  be  examined  for  aneurysm, 
retrosternal  struma  and  lung  tumor  and  the  finger  should  be  introduced 
down  the  throat  to  exclude  lesions  situated  high  in  the  esophagus  or 
larynx.  Esophagoscopy  may  give  excellent  results  if  done  by  an  expert. 
Local  signs  are  elicited  in  three  ways: 

1.  Sounding. — A  soft  sound  is  far  less  dangerous  at  least  for  the 
first  examination  in  cases  of  acute  esophagitis,  aneurysmal  compression 
and  ulcerating  cancer;  as  there  may  be  other  strictures  lower  down,  the 
sound  should  be  passed  into  the  stomach.  The  length  of  the  esophagus 
is  10  inches  or  25  cm.;  from  the  upper  incisor  teeth  to  the  esophagus,  6 
inches  or  15  cm.;  from  the  teeth  to  the  cardia,  16  inches  or  40  cm.  (19.7 
inches  or  50  cm.).  The  length  of  the  cervical  portion  is  2  inches  or  5  cm., 
of  the  thoracic,  6f  inches  or  17  cm.-,  and  of  the  abdominal  part,  1|  inches 
or  3  cm.  From  the  teeth  to  the  level  of  the  tracheal  bifurcation  is  9 
inches  or  23  cm. 

2.  AuscuLTATiON.^Physiologically,  two  murmurs  are  heard  with  the 
stethoscope  six  to  eight  seconds  after  the  beginning  of  deglutition,  first 
a  short  and  then  a  longer  murmur.  In  marked  stenosis  the  swallowing 
sound  is  heard  at  a  point  just  above  the  lesion,  of  value  when  aneurysm 
is  suspected  and  sounding  is  feared.  In  the  cervical  part  the  noise 
results  from  the  movements  of  the  pharynx;  in  the  thoracic  segment, 
to  the  left  of  the  spine  from  the  first  to  ninth  dorsal  vertebra,  there  is 
a  delayed  first  murmur,  and  a  gurgling,  spurting  character  in  both  mur- 
murs; in  the  lowest  segment  the  murmurs  are  heard  above  the  cardia, 
at  the  tenth  dorsal  vertebra. 

3.  X-RAYS. — ^The  a;-rays  outline  the  dilatation  (v.  i.). 

Prognosis. — Cancerous  stricture  may  ulcerate,  relieving  the  local  symp- 
toms, though  cachexia  increases.  Strictures  from  caustics  often  improve. 
Where  the  cause  cannot  be  relieved,  the  same  symptoms  result  as  in 
esophageal  cancer  {q.  v.).    Perforation  into  the  lungs,  pleurae,  air  passages, 


492  DISEASES  OF  THE  ESOPHAGUS 

mediastinum  or  vessels  may  follow.     Aspiration  pnemiionia,  which  often 
becomes  gangrenous,  is  not  infrequent. 

Treatment. — The  remediable  etiological  factors  are  few.  Foreign 
bodies  can  sometimes  be  removed  by  long  forceps,  with  the  direction  of 
the  esophagoscope.  In  cancerous  and  aneurysmal  strictures,  dilatation 
by  sounds  is  attended  by  the  risk  of  perforating  the  esophagus.  Sounds 
should  be  introduced  beside  the  index  finger,  with  the  patient's  head 
thrown  slightly  backward;  severe  gagging  may  be  overcome  by  painting 
the  pharynx  with  cocaine,  though  it  is  often  as  much  psychical  as  esopha- 
geal. The  subject  should  first  swallow  some  olive  oil  to  facilitate  passage 
of  the  sound,  which  is  held  like  a  pen  and  pushed  with  exceeding  gentle- 
ness. Trousseau's  ivory  olive  points  are  excellent,  but  care  is  necessary, 
and  successively  larger  sizes  should  be  used.  Sounds  may  be  left  in 
the  esophagus  for  some  minutes  or  an  hour,  or  even  permanently,  but 
pressure  necrosis  may  then  result.  It  is  at  times  necessary  to  introduce 
filiform  bougies.  Silver  balls  (2  to  7  mm.  in  diameter)  with  threads 
attached,  may  be  swallowed  and  carefully  pulled  out  after  remaining 
in  over  night.  When  the  obstruction  is  high,  external  esophagotomy  is 
advisable.  After  opening  the  stomach,  dilatation  may  be  employed 
from  below.    Impermeable  strictures  call  for  gastrostomy. 

DILATATION.     DIVERTICULUM. 

Etiology. —  Dilatation  involves  the  entire  circumference;  diverticulum 
involves  but  part  of  it.  Secondary  dilatation  may  occur  above  stenosis 
of  the  esophagus  or  above  the  cardiac  end  of  the  stomach.  It  seldom 
extends  more  than  an  inch  and  a  half  (4  cm.)  above  the  stricture;  it 
may  follow  enteroptosis,  ulcer  or  pyloric  stenosis.  MarkecJ  dilatation 
above  the  cardia,  Luschka's  so-called  "fore-stomach"  is  a  local  form, 
usually  congenital.  The  diffuse  idiopathic  dilatation  results  from  cardio- 
spasm (Purton,  1821).  It  is  seen  chiefly  between  the  years  of  twenty  and 
forty.  Most  clinicians  incline  to  Meltzer's  view,  that  cardiospasm  is 
due  to  abolition  of  cerebral  inhibition  on  the  cardia;  Kraus  reports  a 
case  with  great  atrophy  of  both  vagi;  others  accuse  a  primary  esophagitis 
or  the  angular  insertion  of  the  esophagus  in  the  stomach.  Cardiospasm 
produces  a  great  hypertrophy  of  the  cardia  muscle,  even  six  times  its 
normal  thickness,  and  diffuse  total  dilatation  so  that  the  esophagus  may 
measure  46  cm.  instead  of  25  cm.  in  length,  or  30  cm.  in  circumference. 
Though  Zenker  collected  but  18  cases  in  1878,  in  1912  Plummer  published 
91  personal  cases.  The  mucosa  is  catarrhal,  thickened  or  eroded,  and  the 
muscularis  is  hypertrophied. 

Symptoms. — There  is  gradual  or  sudden  dysphagia,  which  may  be  over- 
come by  effort;  the  patient  feels  that  the  food  does  not  reach  the  stomach. 
Regurgitation  of  the  food,  especially  the  portion  last  swallowed,  occurs 
soon  after  eating  or  lying  down;  it  may  measure  two  quarts,  is  neutral, 
decomposed  if  retained  for  some  time,  and  contains  no  hydrochloric 
acid,  pepsin  or  rennet.  The  regurgitated  food  may  again  be  swallowed. 
Vomiting  is  impossible.  The  pressure  of  the  stagnant  food  or  fluid  in 
the  gullet  may  produce  dyspnea  or  palpitation.    The  sound  moves  freely 


DILA  TA  TION—DI VERTICUL  UM  493 

from  side  to  side,  but  meets  temporary  resistance  at  the  cardia,  though 
pressure  usually  overcomes  an  obstructing  cardiospasm.  One  sound, 
introduced  into  the  stomach,  may  recover  HCl,  pepsin,  etc.,  but  another, 
introduced  to  but  not  beyond  the  cardia,  recovers  fluid  or  food  T\dth  a 
neutral  reaction;  methylene  blue  solution  poured  through  the  first 
tube  returns  blue;  that  recovered  by  the  second  tube  is  colorless.  Dis- 
tention of  the  esophagus  with  water  gives  duhiess,  to  the  left  of  the  sixth 
to  the  ninth  dorsal  vertebra,  sometimes  above  the  left  costal  arch,  or 
even  in  the  epigastrium.  The  esophagoscope  reveals  the  dilatation;  a 
distinct  shadow  is  seen  by  using  the  a.'-rays  after  the  patient  has  eaten 
potatoes  mixed  with  bismuth.  The  second  swdloicing  bruit  may  be 
absent  or  sounds  like  fluid  running  into  fluid.  Marasmus,  constipation 
and  often  death  result,  but  the  clinical  course  may  cover  decades. 

Treatment. — Treatment  is  unsatisfactory.  Olive  oil  §ss  before  meals 
may  help  the  fluid  (or  the  sound)  to  pass  the  cardia.  Continued  use  of 
the  stomach-tube  may  cause  esophagitis;  its  life-long  use  is  often  re- 
quired. Lockwood's  pneumatic  bag  may  be  introduced  empty  on  a  sound 
into  the  stomach,  then  inflated  and  withdrawn  gently  through  the 
cardia.  Gastrostomy  and  rectal  feeding  may  be  indicated.  Operation 
should  not  be  delayed  too  long — entering  the  stomach  and  divulsing  the 
cardia. 

Dn^ERTicuLu:M  involves  only  an  arc  of  the  esophageal  circumference. 
Two  types  are  distinguished:  1.  Zenker  s  pressure  diverticulum  (pulsion- 
diverticulum)  of  which  Rosenthal  (1902)  collected  180  cases.  It  is 
found  chiefly  in  men  (77  per  cent.),  and  is  a  pouch  which  forms  on  the 
posterior  esophageal  wall,  near  its  junction  Tvith  the  pharynx,  and  con- 
sists only  of  the  mucosa  and  submucosa — a  bottle-shaped  esophageal 
hernia.  Its  onset  is  very  gradual,  for  the  muscle,  probably  congenitally 
weak,  yields  before  intra-esophageal  pressure,  trauma,  foreign  bodies 
and  the  stagnating  food.  The  early  symytoms  are  signs  of  pharyngo- 
esophagitis,  hawking  and  dysphagia,  and  food  entering  the  sac  rather 
than  the  esophagus;  the  axis  of  the  sac,  which  dips  between  the  gullet 
and  the  spine,  is  roughly  parallel  with  that  of  the  esophagus;  many  of 
its  symptoms  are  those  of  a  high  esophageal  stenosis.  The  food  stag- 
nates and  regurgitates  with  a  fetid  odor.  Cooper  describes  a  succussion 
splash.  In  .33  per  cent,  of  cases  a  tumor  appears  in  the  supraclavicular 
region,  which  is  dull  when  filled  with  food  or  tympanitic  when  dis- 
tended with  carbon  dioxide;  it  sometimes  can  be  smoothed  out,  whereon 
the  food  regurgitates.  The  murmurs  on  swallowing  are  protracted  in 
50  per  cent.  A  sound  usually  enters  the  sac,  and  another,  if  slightly 
bent,  enters  the  gullet,  which  differentiates  a  diverticulum  lower  in  the 
gullet,  which  is  even  less  common.  Examination  by  the  esophagoscope 
is  generally  negative,  but  the  .r-rays  show  a  characteristic  shadow.  There 
may  be  pressure  on  the  heart,  trachea,  vagus,  recurrent  laryngeal  nerve 
and  brachial  plexus.  The  clinical  course  is  protracted,  even  to  forty- 
nine  years,  and  the  evolution  is  inanition  in  over  50  per  cent.,  gangrene 
(15  per  cent.)  or  perforation  with  cervical  phlegmon.  Treatment  includes 
feeding  by  means  of  the  tube,  rectal  nutrition,  gastrostomy  and  surgical 
resection,  first  performed  by  von  Bergmann,  with  20  per  cent,  mortahty. 


494  DISEASES  OF   THE  ESOPHAGUS 

2.  liokitansky's  tr action-diver ticulum,  found  in  3.5  per  cent,  of  autopsies, 
is  due  to  extra-esophageal  traction,  which  draws  part  of  the  gullet  out  into 
a  funnel-like  form.  Over  80  per  cent,  are  due  to  indurative  periadenitis 
around  caseous  or  anthracotic  lymph  glands.  Cicatricial  mediastinitis 
from  pleuritis,  pericarditis  or  vertebral  disease  produces  the  same  effect. 
It  usually,  therefore,  occurs  at  the  level  of  the  tracheal  bifurcation; 
it  begins  early  in  life,  is  usually  single,  less  marked  on  the  anterior  or 
lateral  wall,  rarely  exceeds  5  to  10  mm.  in  depth  and  is  rarely  discovered 
except  with  the  esophagoscope.  Its  chief  danger  is  ulceration  at  its  apex 
and  perforation,  with  resulting  gangrene  of  the  lungs,  fatal  hemorrhage, 
pneumothorax  or  phlegmonous  mediastinitis. 

CANCER    OF    THE   ESOPHAGUS. 

Etiology. — Its  frequency  is  rated  at  0.25  to  1  per  cent,  of  autopsies, 
ranking  third  among  cancers  (stomach  33,  uterus  15,  and  esophagus  6 
per  cent.).  Scars,  ulceration  and  traction  are  promoting  causes;  75  per 
cent,  occur  in  males  and  80  per  cent,  between  the  fortieth  and  sixtieth 
year  and  8  per  cent,  occur  before  the  fortieth  year. 

Pathology. — Cancer  of  the  esophagus  is  single  and  primary;  cancer 
of  the  stomach,  pharynx  or  mediastinmn  rarely  involves  the  esophagus 
secondarily.  Most  cases  are  squamous  einthelioma,  arising  from  its 
pavement-epithelium;  scirrhous,  colloid  and  medullary  forms  are  rare. 
Most  cases  (57  per  cent.)  develop  in  the  lowest  third  of  the  esophagus, 
33  per  cent,  in  the  middle,  and  10  per  cent,  in  the  upper  third;  its  favorite 
sites  are  near  the  cardia,  tracheal  bifurcation  level  and  back  of  the  cricoid 
cartilage.  The  muscularis  sometimes  hypertrophies  above  the  cancer, 
where  some  dilatation  may  occur. 

Symptoms. — Signs  of  esophagus  stenosis  (v.  s.)  develop  in  varying 
grades;  stenosis  generally  advances  slowly  but  occasionally  is  sudden. 
It  may  lessen  as  the  cancer  ulcerates.  Its  symptoms  are  those  of  stenosis, 
as  dysphagia,  rather  indefinitely  located  pain,  regurgitation  of  food  and 
perhaps  also  of  bloody  mucus  or  necrotic  cancer  tissue.  Its  signs  are  also 
identical,  as  obstruction  on  sounding,  fluoroscopic  findings,  detection 
by  the  esophagoscope  of  a  papillomatous  or  ulcerated  neoplasm,  and 
rarely  tumor  particles  found  in  the  fenestrse  of  the  tube.  Salivation 
(Roger's  syndrome)  was  noted  in  22  cases.  Cachexia  develops;  con- 
stipation, indicanuria  and  acetonuria  are  frequent.  Extension,  by 
contiguity,  occurs  to  the  spine,  mediastinum  and  cardia,  or  in  60  per 
cent,  by  metastasis;  the  mediastinal  lymph  nodes  are  usually  invaded, 
the  supraclavicular  often,  and  upper  cervical  seldom. 

Complications. — There  may  be  pressure  on  the  recurrent  laryngeal, 
vagus,  mediastinal  vessels,  sympathetic  ganglia  or  brachial  plexus. 
Perforation  occurs  in  over  50  per  cent.,  most  often  into  the  air  passages, 
when  aspiration  pneumonia  or  gangrene  may  follow;  into  the  lung, 
pleura  (ichorous  pleurisy  or  pneumothorax  resulting),  aorta  (fatal  hem- 
orrhage), heart,  pericardium  and  mediastinum.  Pyemia,  tuberculosis 
and  thrombosis  occur  in  some  cases.  Death  is  usual  within  thirteen 
months,   with   emaciation^    subnormal   temperature,  small,  slow   pulse. 


MOTOR  AND  SENSORY  DISTURBANCES  OF  THE  ESOPHAGUS     495 

slow,  shallow  breathing,  flattened  abdomen  and  perhaps  acidosis, 
coma  and  fever. 

Diagnosis. — The  diagnosis  is  based  (a)  on  a  stricture  of  the  esophagus, 
which  in  90  per  cent,  of  all  cases  is  carcinomatous;  (6)  on  cachexia, 
nodes,  metastases  and  perhaps  tumor  particles  on  the  sound.  Other 
tumors,  as  lipoma,  myxoma,  myoma  or  fibroma  are  of  httle  clinical 
importance,  except  accessible  fibropapillomata  of  the  upper  gullet. 
Von  Hacker  (1908)  collected  21  cases  of  sarcoma;  81  per  cent,  were  in 
the  lower  thoracic  segment. 

Treatment. — The  treatment  is  that  of  stricture,  nutritive  enemata, 
feeding  by  the  stomach-tube,  gastrostomy  and  narcotics.  Less  than 
10  per  cent,  are  accessible  to  surgical  interference.  As  to  gastrostomy, 
45  per  cent,  do  not  live  longer  than  a  week  and  90  per  cent,  not  more 
than  one  hundred  days. 

PERFORATION,  RUPTURE;   HEMORRHAGE  OF  THE  ESOPHAGUS. 

1.  Perforation  may  result  from  causes  wdthin  or  without  the  esophagus. 
Internal  causes  include  ulcers,  foreign  bodies,  diverticula,  cancer  and  use 
of  the  sound;  external  causes  are  aneurysm,  gravitating  abscess,  lung 
cavities  or  gangrene,  suppurating  lymph  glands  or  trauma.  It  is  marked 
clinically  by  mediastinitis  and  cervical  cellulitis,  which  are  usually 
phlegmonous.  Esophageal  fistulse  may  communicate  w-ith  the  air 
passages,  from  which  by  the  laryngeal  mirror  fluid  or  food  is  seen  to  be 
expectorated;  a  communicating  tuberculous  cavity  may  become  flat 
when  the  patient  drinks  or  eats,  and  the  flatness  changes  to  tympany 
when  the  food  or  drink  is  expectorated;  this  is  tested  by  giving  the 
patient  milk,  which  will  be  brought  up  from  the  larynx.  Aspiration 
gangrene,  pneumopericardium,  pneumothorax  and  fatal  hemorrhage  are 
common  causes  of  death. 

2.  Spontaneous  rupture  (so-called)  is  a  very  rare  affection,  there  being 
only  39  cases  on  record  (Cohn,  1908).  It  is  often  confused  with  esophago- 
malacia,  in  which  the  rupture  is  not  longitudinal  or  clean-cut  as  in 
genuine  rupture.  The  flrst  case,  and  one  of  the  clearest,  was  reported 
by  Boerhaave  (1714);  in  all  cases,  except  Boerhaave's,  the  rupture 
was  longitudinal.  It  follows  overeating  or  severe  vomiting,  and  most 
victims  have  been  alcoholics.  There  is  great  and  sudden  pain  over  the 
lower  esophagus  (where  most  ruptures  occur)  and  over  the  xiphoid, 
hematemesis,  collapse  and  subcutaneous  emphysema.  Death  results 
from  collapse,  phlegmonous  mediastinitis,  pleuritis  or  pneumothorax. 

3.  Hemorrhage  may  follow  esophageal  ulceration,  external  or  internal 
trauma,  toxic  esophagitis,  softening  and  aneurysmal  or  other  perforations. 
Varicose  veins  in  the  lower  esophagus,  first  described  by  Le  Derberden 
(1837),  most  often  complicate  liver  cirrhosis,  less  often  syphilis  and 
pylethrombosis.  The  diagnosis  and  localization  of  the  bleeding-point  is 
only  suggested  by  the  history  and  previous  physical  findings.  Treatment 
consists  chiefly  of  absolute  quiet,  morphine  and  rectal  feeding. 

MOTOR    AND    SENSORY   DISTURBANCES   OF   THE   ESOPHAGUS. 

(See  Affections  of  the  Vagus  under  Nervous  Diseases.) 


496  DISEASES  OF   THE  STOMACH 


DISEASES  OF  THE  STOMACH. 


ACUTE  GASTRITIS  (ACUTE  CATARRH,  ACUTE  DYSPEPSIA). 

1.  Simple  Gastritis. — Etiology. — It  is  a  common  primary  and  secondary 
affection,  (a)  Its  most  important  mechanical  cause  is  improper  food 
or  improper  eating;  rich  food,  an  excessive  amount,  partial  mastication, 
washing  down  food  with  water,  hurried  eating  when  very  hungry,  articles 
containing  bacteria  or  ptomaines  and  excessive  ingestion  of  cold  water 
and  fruit  are  accessory  factors,  (h)  Thermal  factors  include  too  hot 
or  too  cold  foods,  especially  when  taken  on  an  empty  stomach,  (c) 
Chemical  causes;  aside  from  toxic  gastritis  {v.  i.),  alcohol  ranks  foremost; 
autotoxins  may  excite  acute  gastritis,  as  in  nephritis,  cholemia  or  gout. 
id)  Some  cases  are  clearly  infectious;  the  condition  may  occur  in  variola, 
typhoid,  grippe  and  pneumonia,  as  a  secondary  manifestation;  occasion- 
ally it  is  an  independent  febrile  affection,  as  in  the  Christiana  epidemic 
reported  by  Hausemann  (1880),  in  which  6000  persons  were  affected 
within  three  weeks  (Gartner's  Bacillus  enteritidis,  paratyphoid  bacillus 
or  Bacillus  botulinus).  (e)  Stasis  from  diseases  of  the  heart,  lung  or  liver, 
tuberculosis,  cancer,  chlorosis  and  affections  of  the  higher  alimentary 
mucosa  are  predisposing  factors.  In  some  cases  a  nervous,  familial  or 
even  hereditary  tendency  is  noted,  "the  delicate  stomach." 

Symptoms. — 1.  Digestive  Symptoms. — These  are  sometimes  absent, 
as  demonstrated  by  Beaumont  in  the  celebrated  St.  Martin  case  of 
gastric  fistula.  The  apijetite  is  usually  lost  or  perverted.  The  tongue 
is  thickly  coated  with  white  fur  and  dry  mucus.  The  mouth  is  dry  and 
there  is  a  disagreeable  taste  and  thirst,  even  though  the  salivary  flow 
be  increased.  Hiccough,  eructations,  a  sense  of  gastric  distention,  pressure 
or  pain  and  tenderness  over  the  stomach  are  common.  Nausea  and 
vomiting  characterize  the  more  marked  cases ;  the  vomitus  is  pale  yellow, 
bitter  and  contains  little  or  no  hydrochloric  acid,  though  lactic,  butyric 
and  fatty  acids  are  common;  there  is  much  mucus,  frequently  flecked 
with  blood.  Gastric  intolerance,  pain,  nausea  and  vomiting  summarize 
the  situation.  Few  uncomplicated  cases  come  to  autopsy;  the  mucosa 
is  red,  swollen,  smeared  with  adherent  mucus,  sometimes  slightly  eroded 
or  dotted  with  ecchymoses;  the  dilated  vessels,  seen  by  the  gastroscope 
or  through  a  gastric  fistula,  are  less  conspicuous  at  autopsy  for  the 
blood  leaves  the  organ  after  death;  microscopically  the  main  findings 
are  leukocyte  emigration,  granular  degeneration  and  swelling  of  the 
mucous  and  other  glandular  cells. 

2.  General  Symptoms. — Herpes  is  an  occasional  finding.  Constipation 
is  the  rule.  The  urine  is  scanty  because  of  the  vomiting;  it  deposits  a 
lateritious  sediment  and  sometimes  contains  indican  or  acetone.  Frontal 
headache,  vertigo,  intercostal  neuralgia  and  depression  are  common; 
convulsions  (acetonemia)  and  other  marked  nervous  manifestations  occur 
infrequently  in  sensiti\'e  individuals.  Fever  is  uncommon;  when  present, 
it  is  irregular  and  ephemeral. 


ACUTE  GASTRITIS  497 

Diagnosis. — With  fever  or  constitutional  symptoms  it  is  excellent 
practise  to  regard  acute  gastritis  as  a  symptom,  imtil  typhoid,  exanthe- 
matous  disease  or  nephritis  is  excluded.  Confusion  is  possible  with  a 
tabetic  crisis,  the  vomiting  of  pregnancy,  hysteria,  appendicitis  or  gall- 
bladder disease. 

Treatment. — (a)  Prophylaxis  embraces  the  etiological  factors.  (6) 
Complete  rest  of  the  stomach  is  the  first  indication;  no  rectal  feeding  is 
required  for  twenty-four  to  forty-eight  hours,  by  which  time  the  gastric 
equilibrium  is  restored;  warm  water  by  rectum  unloads  the  bowels  and 
allays  thirst,  (c)  If  gastric  irritation  persists,  the  stomach  is  washed  out 
by  the  stomach-tube  (using  warm  water  A^nth  sodium  bicarbonate);  lavage 
is  better  than  calomel,  salines  and  apomorphine  or  ipecac  which  irritate 
the  inflamed  mucosa.     Epigastric  fomentations  alleviate  pain. 

R — Phenolis gr.  iv 

Ac.  hydrocyanici  dil 3ss 

Bismuthi  subnitratis, 

Cerii  oxalatis aa      oiss 

Mucilaginis  acaciae q.  s. 

Aquae  menthEe  piperitse q.  s.  ad.      gij 

M.  et  fac  emulsum.  S. — One  teaspoonful  without  dilution  every  half  to  one  hour  for  six 
to  ten  doses,  or  till  vomiting  ceases. 

Opiates  give  relief,  but  secondary  nausea  is  an  insuperable  obstacle 
to  their  use.  (d)  In  convalescence,  dilute  hydrochloric  acid  TTlv-xv  and 
bitters  are  given  after  meals,  to  stimtilate  the  gastric  secretion.  The 
food  should  be  simple  and  thoroughh"  chewed. 

n.  Gastritis  Toxica  (Venenata,). — Etiology  and  Pathology. — Acute 
toxic  gastritis  is  caused  by  various  alkalies,  acids  and  metallic  poisons. 
Sulphuric  acid  produces  a  gray  eschar,  nitric  acid  a  yellow  one,  alkalies 
a  brown,  copper  a  greenish-blue,  silver  a  deep  black  eschar  and  phos- 
phorus produces  an  opaque,  milky  stain.  The  pathological  changes  are 
severest  in  places  with  which  the  corrosives  remain  longest  in  contact, 
as  the  pylorus  and  posterior  wall;  they  range  from  epithelial  desqua- 
mation and  catarrh,  to  hemorrhagic  infiltration,  diphtheroid  patches, 
suppuration  and  ulceration. 

Symptoms. — They  are  those  of  simple  gastritis,  but  more  severe; 
pain  is  intense  in  the  mouth,  throat,  esophagus  and  stomach,  and  the 
vomitus  is  often  bloody  and  the  epigastrium  tender. 

Prognosis. — The  outcome  varies;  fa)  collapse  after  a  few  hours  or 
(lays  is  frequent,  with  small  pulse,  shallow  breathing,  subnormal  tempera- 
ture, bloody,  albuminous  urine,  etc.  {h)  The  gastric  symptoms  subside 
and  death  occurs  later  from  blood  or  visceral  changes,  (c)  Stricture 
may  develop,  or  (d)  there  may  be  atrophy  of  the  secretory  glands. 

ni.  Phlegmonous  Gastritis. — Etiology. — Only  131  cases  are  reported 
since  Borel's  hi  Kj.jlj.  It  is  an  acute  suppurative  gastritis,  usually  caused 
by  the  streptococcus,  which  usually  enters  some  small  erosion  at  the  cardia 
and  infiltrates  the  submucosa  and  other  coats  dift'usely  or  circumscribes 
as  a  mural  abscess.  It  occurs  secondarily  (75  per  cent.)  in  sepsis,  acute 
infections,  or  in  local  diseases  as  gastric  cancer;  85  per  cent,  occur  in 
adult  males.  Alcoholism  and  traumatism  are  predisposing  factors. 
32 


498  DISEASES  OF   THE  STOMACH 

Symptoms. — Besides  an  acute  gastritis,  the  vomitus  sometimes  contains 
pus,  the  epigastric  pain  is  intense,  ^dth  meteorism  and  many  symptoms 
of  peritonitis,  ^vhich  is  a  most  common  comphcation.  In  a  few  cases  an 
epigastric  tumor  marks  the  circumscribed  variety.  Sepsis  causes  the  high 
fever,  the  pronounced  status  tj^hosus,  the  small  pulse,  occasional  icterus 
and  petechise. 

Diagnosis  and  Treatment. — A  diagnosis  is  almost  impossible,  the  out- 
come  is  fatal  in  96  per  cent,  during  the  second  week  and  the  treatment  is 
sjTiiptomatic,  viz.,  rectal  nutrition,  stimulation,  narcotics,  and  if  the 
affection  is  suspected,  operation.  Some  cases  heal  by  rupture  into  the 
stomach  ^dth  cicatrization. 

IV.  Diphtheritic  Gastritis. — Genuine  diphtheria  is  very  rare.  Diph- 
theroid gastritis,  caused  by  streptococcic  and  other  infections,  ma}' 
develop  after  gastritis  toxica,  pneumonia  and  kindred  maladies. 

V.  Parasitic  Gastritis. — ^This  rare  form  is  due  to  Oidium  albicans, 
favus,  anthrax,  larvse  of  insects  and  tinese. 

CHRONIC  GASTRITIS. 

Chronic  catarrh  is  characterized  pathologically  by  degeneration  of  the 
parenchymatous  and  infiltration  of  the  interstitial  tissue,  and  clinically 
by  mucus  formation  and  decreased  secretion. 

Etiology. — (a)  The  factors  are  those  of  acute  gastritis,  from  repeated 
attacks  of  which  chronic  inflammation  may  result.  Abuse  of  drugs, 
especially  cathartics,  alcoholism  and  improper  eating,  eating  hurriedly 
or  at  irregular  hours,  inadequate  mastication,  washing  doT^-n  the  food 
with  fluids,  excessive  use  of  coffee,  tea,  ice-water,  pastries  or  fried  foods 
are  salient  factors.  Chemng  and  smoking  tobacco,  stomatitis,  carious 
teeth  and  pyorrhea  are  important  causes.  ]Most  cases  occur  in  adult 
males.  (6)  It  often  accompanies  other  gastric  diseases,  as  cancer  or 
ectasia,  or  (c)  tuberculosis,  anemia,  stasis,  nephritis,  gout,  diabetes, 
sj^hilis,  amyloidosis,  etc. 

The  acid  form  is  usually  caused  by  excesses  in  eating,  drinking  and 
smoking;  the  subacid  form  by  the  abuse  of  spirits. 

Pathology. — ^The  pathological  changes  are  observed  chiefly  in  the 
pyloric  region.  The  A'essels  are  dilated,  imparting  a  reddish-bro^Mi 
color,  which  later  changes  to  gray.  The  mucosa  is  swollen,  lax  and 
covered  with  tenacious  mucus  or  sometimes  punctate  hemorrhages 
or  erosions.  In  a  few  cases  the  mucosa  is  rough,  even  papillomatous 
(gastritis  polyposa,  etat  mamellone).  The  muscularis  is  occasionally 
hypertrophied  near  the  pylorus.  Histologically,  the  glandular  cells 
show  granular,  fatty  or  mucoid  degeneration;  the  parietal  cannot  be 
distinguished  from  the  principal  cells,  the  glands  are  often  large  or 
cystic  and  the  tubules  show  ramifications;  the  glandular  structures 
may  completely  atrophy  (see  Achylia).  The  interstitial  tissues  show 
leukocytic  infiltration. 

Symptoms. — The  symptoms  begin  insidiously . 

1.  Oral  Syiiptoms. — The  tongue  is  generally  coated  with  moist  white 
fur,  reddish  at  its  tip  and  indented  on  its  edges,  which  (like  salivation) 


CHRONIC  GASTRITIS  499 

may  also  result  from  alcoholic  or  nicotine  stomatitis.  There  is  frequently 
a  bitter,  sour,  salty  taste  in  the  mouth  and  sometimes  a  marked  foBtor  ex 
ore.    The  throat  frequently  aches. 

2.  Gastric  Symptoms. — (a)  Gastric  pain  is  less  frequent  than  a  sense 
of  distention  or  pressure  after  eating,  or  sometimes  when  the  stomach 
is  empty;  actual  pain  is  characteristic  of  the  alcoholic  type.  Soup  and 
fluids,  unless  they  are  cold,  generally  cause  no  distress;  coarse  or  hard 
foods,  as  beefsteak,  bread,  smoked  meat,  cabbage,  hard-boiled  eggs  or 
cheese,  cause  distress.  (In  nervous  dyspepsia,  any  kind  of  food  may 
cause  discomfort.)  Tenderness  is  much  less  than  in  cancer  or  ulcer. 
(6)  Belching  indicates  atony.  Eructations  of  hydrochloric  acid  are 
rare,  (c)  Nausea  and  vomiting  are  infrequent,  except  in  alcoholics, 
in  whom  the  morning  vomiting  (vomitus  matutinus  potatorum)  consists 
chiefly  of  saliva  and  mucus  swallowed  during  the  night. 

3.  Gastric  Chemism. — Our  knowledge  dates  from  the  introduction 
of  the  stomach-tube  by  Kussmaul  and  Leube  and  especially  the  work  of 
Riegel,  Ewald  and  Boas.  After  washing  out  the  stomach  the  Ewald 
test  breakfast  is  given,  consisting  of  a  piece  of  dry  bread  and  a  cup  of 
weak  tea  without  sugar  or  cream.  In  an  hour  the  gastric  contents  is 
withdrawn  (the  patient  compressing  the  abdomen  and  straining)  by 
Ewald 's  aspiration  bag.  Innumerable  errors  result  from  confidence  in  a 
single  examination  and  assigning  undue  importance  to  the  gastric  chemism 
alone.    It  is  best  to  examine  the  contents  without  filtration. 

(a)  The  gross  examination  shows  coarse  particles  of  food  when  the 
hydrochloric  acid  is  absent  or  greatly  reduced,  or  fine  subdivision  when 
it  is  present  in  fair  amounts.  A  rancid  odor  denotes  fatty  acids,  and  a 
foaming  appearance,  fermentation.  Mucus  is  seen  in  practically  all 
cases;  most  clinicians  do  not  recognize  a  simple  gastritis  without  mucus 
formation,  though  Ewald  distinguishes  (i)  simple  gastritis  in  which  the 
acid  and  ferments  are  decreased;  (ii)  a  mucous  gastritis,  in  which  the 
acid  is  greatly  decreased,  the  ferments  are  present  and  there  is  much 
mucus;  and  (iii)  an  atrophic  gastritis  {xi.  Achylia).  Mucus  usually 
indicates  a  reduction  in  the  hydrochloric  acid.  Normally  there  is  little 
gastric  mucus,  though  rather  more  with  an  amylaceous  than  with  a 
proteid  diet.  Mucus  of  gastric  origin  is  intimately  mixed  with  the  food 
and  is  not  yellow,  nummular,  pigmented  or  mixed  with  air  or  cells,  as 
is  swallowed  mucus. 

{h)  The  HCl  is  reduced.  Of  Giinzburg's  solution  (2  gm.  phloroglucin 
and  1  gm.  vanillin  dissolved  in  30  c.c.  of  absolute  alcohol),  a  few  drops 
are  added  to  an  equal  amount  of  gastric  contents  and  heated,  without 
boiling,  in  a  porcelain  dish,  when  a  carmine-red  color  develops,  indi- 
cating free  hydrochloric  acid;  the  solution  should  be  kept  in  a  dark 
bottle  and  not  over  two  months,  for  it  deteriorates.  Boas's  test  gives 
the  same  reaction  and  is  less  expensive:  resorcin  0.5,  sugar  0.3,  dilute 
alcohol  q.  s.  ad.  10  gm. 

Total  free  HCl.  10  c.c.  of  gastric  contents  plus  a  few  drops  of  the  indi- 
cator (0.5  per  cent,  solution  of  dimethylamidoazobenzol  in  strong  alcohol) 
are  placed  in  a  beaker  and,  if  free  HCl  is  present,  the  yellow  color  imparted 
by  the  indicator  will  change  to  bright  red;  a  decinormal  solution  of 


-JIJIJ  DISEASES  OF   THE  STOMACH 

caustic  soda  is  then  added  drop  by  drop  until  the  color  of  the  indicator 
has  been  changed  from  red  to  bright  yellow;  the  number  of  c.c.  of  deci- 
normal  solution  used  is  multiplied  by  0.00365  and  again  by  10  to  give 
the  amount  of  free  HCl.  Often  the  result  is  expressed  in  terms  of  the 
number  of  c.c.  of  decinormal  solution  used;  /.  e.,  if  4  c.c.  were  employed, 
4  X  10  =  40,  the  free  HCl.    The  usual  amount  is  30  to  40. 

The  total  acidity  (HCl,  lactic  and  other  organic  acids,  acid  phosphates, 
albumins,  albumoses  and  peptones)  is  estimated  by  adding  two  drops 
of  a  1  per  cent,  alcoholic  solution  of  phenolphthalein  (as  an  indicator) 
to  10  c.c.  of  the  gastric  contents;  to  this  is  added,  drop  by  drop,  a  deci- 
normal solution  of  caustic  soda  until  the  red  color,  due  to  the  alkali 
acting  upon  the  phenolphthalein,  is  no  longer  even  deepened  in  hue  by 
it.  As  4  to  8  c.c.  of  the  decinormal  solution  are  usually  required, 
4  to  8  X  10  =  normal  total  acidity;  i.  e.,  40  to  80  expressed  in  terms 
of  the  decinormal  solution  (corresponding  to  0.15  to  0.25  per  cent.  HCl). 
In  most  cases  determination  of  the  total  acidity  is  sufficient.  The  bread 
of  the  test  breakfast  (phosphates  chieflyj  accounts  for  a  total  acidity  of 
from  5  to  8;  this  figure  indicates  that  the  gastric  glands  are  atro- 
phied. 

In  chronic  gastritis  the  hydrochloric  acid  is  found  decrea^sed  or  absent. 
A  few  cases,  usually  light  or  incipient,  show  a  total  acidity  of  40  to  50; 
this  form  is  called  gastritis  acida,  though  its  separation  as  a  t^'pe  is 
scarcely  justihable. 

(c)  Reyinet  and  yepsin  are  rarely  absent,  though  usually  decreased; 
25  c.c.  of  gastric  juice  w"ill  dissolve  0.05  gm.  of  serum  albumin  in  one 
hour,  of  fibrm  in  one  and  one-half  hours  and  of  egg  albumen  in  three 
hours.  A  few  drops  of  hydrochloric  acid  liberate  the  enzyme  (pepsin) 
from  the  pro-enzyme  (pepsinogen).  If  no  rennet  is  present  the  filtrate 
will  not  coagulate  milk. 

Lactic  acid  is  seldom  found.  Leukocytes  and  epithelial  cells  are  found 
at  times,  and  in  rare  cases  shreds  of  gastric  mucosa  (gastritis  exfoliativa, 
Parisier) . 

4.  Other  Symptoms. — (a)  Vertigo  e  stornacho  loeso,  gastric  vertigo,  is 
probably  neurasthenic  rather  than  gastric.  Dyspeptic  dyspnea  probably 
results  from  pressure  of  the  distended  stomach  on  the  heart.  Headache, 
physical  and  mental  depression,  intercostal  neuralgia,  tender  points 
between  the  shoulders  or  over  the  lower  cervical  spines  and  palpitation 
are  common  toxemic  symptoms,  (h)  The  bowels  are  constipated;  diarrhea 
and  tympany  at  times  result  from  marked  gastric  fermentation  or 
extension  of  the  catarrh  to  the  gut,  when  catarrhal  icterus  may  result. 
Boas  and  Schmidt  find  undigested  connective  tissue  in  the  movements. 
(c)  The  urine  is  reduced  and  shows  a  lateritious  deposit,  phosphates  and 
oxalates,  (d)  The  general  nutrition  is  maintained  if  the  intestines 
functionate  well,  (e)  The  motive  and  absorptive  power  of  the  stomach 
may  be  impaired,  normal  or  even  exaggerated,  the  food  being  hurried 
into  the  intestine. 

Diagnosis. — Its  cardinal  points  are  its  steady,  chronic  course,  the 
presence  of  mucus  and  decreased  secretion.  (For  its  differentiation,  v.  i. 
Ulcer. j 


CHRONIC  GASTRITIS  501 

Treatment. — 1.  Prophylaxis. — Recurrence  is  prevented  by  treatment 
of  the  causal  conditions. 

2.  Hygiene. — Hygiene  concerns  regularity  in  li\ing,  moderation, 
recreation,  rational  exercise  and  careful  mastication. 

3.  Diet. — Everyone  "has  the  stomach  he  deserves."  Slo\Miess  of 
eating,  drinking  only  after  meals  and  thorough  mastication  are  frequently 
curative  without  medicinal  treatment;  insalivation  of  the  food  is  vital, 
since  the  ptyalin  operates  for  nearly  an  hour  in  the  unchurned  contents 
of  the  cardiac  end  of  the  stomach.  As  Ewald  states,  "die  Diat  der 
Magen-Kranken  fangt  im  INIunde  an."  The  teeth  require  care,  as  pyorrhea, 
carious  teeth  and  fitting  of  proper  plates  Food  should  be  taken  in  moder- 
ate amounts,  and  the  stomach  given  sufficient  rest.  The  relish  of  food 
excites  the  flow  of  the  gastric  juice,  the  "appetite  juice"  (Pawlow). 

Kind  of  Food. — "Easily  digestible  food"  is  less  important  than 
careful  mastication  and  insalivation.  In  severe  or  alcoholic  cases  equal 
parts  of  milk  and  Apollinaris  water,  may  be  tried,  to  which  grains  x 
each  of  sodium  bicarbonate,  sodium  chloride  and  magnesium  oxide  are 
added.  Predigested  milk  is  indicated  in  severe  catarrh  with  much  mucus 
formation  or  atrophy.  The  diet  should  be  mixed,  but  proteids  are  superior 
to  carbohydrates,  which  are  prone  to  ferment.  The  proteids  given  are 
chopped  lean  meats,  scraped  beef,  boiled  mutton,  veal,  roasted  steak, 
broiled  tenderloin,  pigeon,  chicken  and  eggs  boiled  one  minute.  Beef- 
tea,  fresh  beef,  hard-boiled  eggs,  pork,  game,  fish,  warmed-over  (therefore 
hardened)  meat,  turkey,  goose,  duck,  smoked  or  cured  meat  (except 
bacon)  and  cheese  must  be  interdicted.  Carbohydrates  are  withheld  when 
there  is  obstinate  fermentation.  Those  allowed  are  arrow-root,  well- 
cooked  sago,  tapioca  or  rice,  white  bread,  zwieback  and  toast;  those 
occasionally  allowed  or  tried  later  are  mealy  potatoes,  spinach,  pea  or 
bean  soups;  those  forbidden  are  substances  containing  much  cellulose, 
as  hard  or  browm  bread,  oatmeal,  coarse  vegetables,  uncooked  green 
vegetables,  most  fruits,  pies  and  pastries.  Soups  (containing  meat  extract), 
dextrin,  maltose,  dextrose,  and  proteoses,  reaching  the  pyloric  region  and 
duodenum,  liberate  a  hormone  (gastrin),  which,  absorbed  and  carried 
by  the  blood  to  the  gastric  glands,  excite  secretion  from  them.  Carbo- 
hydrates should  be  eaten  before  the  proteids,  as  they  leave  the  stomach 
earlier.  Fats  are  a  necessary  part  of  the  diet,  especially  moderate  amounts 
of  butter  and  cream;  greasy  soups  are  injurious.  Liberal  quantities  of 
salt  may  be  used;  condiments  in  moderate  amounts  are  helpful.  Tea, 
coft'ee,  alcoholic  beverages  and  smoking  should  be  interdicted  or  re- 
stricted. 

4.  Gastric  Lavage. — Lavage  is  considered  when  there  is  formation 
of  mucus,  fermentation,  deficient  secretion  and  delayed  digestion,  but 
in  the  ^Titer's  experience  is  seldom  indicated  as  there  is  no  stagnation  of 
food.  ^lorning  lavage  is  best  for  removal  of  mucus,  and  lavage  before 
the  evening  meal  for  delayed  digestion  or  fermentation.  Warm  water 
is  used,  to  which  sodium  bicarbonate  (1  to  100)  is  added  to  dissolve  the 
mucus,  or  salicylic  acid  (1  to  1000)  to  modify  fermentation.  The  stomach 
is  washed  until  the  water  returns  clear.  ^Yhen  the  stomach-tube  is  contra- 
indicated,  the  patient  may  drink  before  breakfast  two  glasses  of  warm 


502  DISEASES  OF   THE  STOMACH 

water  to  which  a  teaspoonf  iil  each  of  sodium  chloride  and  sodium  bicarbon- 
ate has  been  added — essentiahy  the  same  as  drinking  the  Kissingen, 
Wiesbaden  and  other  waters.  Sodium  bicarbonate  acts  locally  and 
sodium  chloride  locally  and  systematically,  for  small  doses  increase  the 
hydrochloric  acid  and  large  doses  reduce  it.  Carbonated  waters  stimulate 
secretion  and  neutralize  abnormal  acids. 

5.  Medical  Treatment. — (a)  The  first  indication  for  hydrochloric  acid 
is  to  convert  pepsinogen  into  pepsin,  whence  it  is  useless  in  atrophic 
gastritis  save  as  it  stimulates  pancreatic  and  possibly  biliary  secretion. 
Its  second  indication  is  as  a  digestant;  we  employ  20  drops  of  the  dilute 
acid  every  thirty  minutes  until  Sj-ij  have  been  given;  it  dissolves 
the  glutin  covering  on  vegetables  and  some  connective  tissue  in  meats. 
Its  third  indication  is  as  an  antizymotic,  which  Boas  holds  is  its  sole 
indication;  it  should  not  be  given  until  about  half  an  hour  after  meals, 
during  which  period  the  saliva  is  acting  upon  the  carbohydrates;  its 
fourth  indication  is  its  appetizing  action.  (6)  Pepsin  should  be  given 
as  a  powder,  for  solutions  rapidly  deteriorate  and  are  strongly  alcoholic; 
many  forms  on  the  market  are  inert.  Pancreatin  is  usually  ineffective. 
Taka-diastase  is  beneficial  in  some  cases,  (c)  Bitters,  best  exhibited 
before  meals,  increase  the  appetite  and  flow  of  saliva,  gastric  and 
probably  also  the  pancreatic  juice.  Strychnine  and  nux  vomica  are 
the  best  drugs  and  are  expecially  valuable  in  alcoholic  cases;  bitters  are 
given  in  solution,  as  their  taste  is  their  chief  mode  of  action. 

I^ — StrychninaB  sulphatis gr.  j 

Acidi  nitrohydrochlorici 3j 

Tr.  gentianse  comp §iv 

M.  et  S. — One  teaspoonful  half  an  hour  after  meals  in  half  a  glass  of  water. 

Condurango  bark  (fluidextract  5  ss)  is  prepared  by  macerating  the  bark 
in  cold  water.  Some  bitters,  as  gentian,  may  irritate  the  stomach  and 
induce  diarrhea,  (d)  Antifermentatives  often  cause  irritation.  Phenol 
gr.  j,  creosote  lUj,  thymol  gr.  ss-j,  resorcinol  gr.  ij-v,  after  meals, 
act  on  the  stomach  and  salol  gr.  x  and  betanaphthol  gr.  x  (in  capsule 
because  of  its  bitterness)  are  intestinal  antiseptics,  (e)  Gastric  sedatives 
are  seldom  indicated  except  in  the  hyperacid  type  (see  page  55) .  Silver 
nitrate  is  sedative,  astringent  and  alterative,  but  may  cause  nephritis 
or  argyria;  it  is  given  in  pill  form,  half  an  hour  before  meals,  gr.  I  (per- 
haps with  small  doses  of  opium  or  belladonna).  Zinc  oxide,  gr.  iij-v, 
before  meals,  is  valuable  in  alcoholic  gastritis.  Extract  of  belladonna, 
gr.  J,  relieves  pain,  especially  in  hyperacid  gastritis.  In  pyrosis  of  fatty 
and  other  organic  acids,  alkalies  may  be  employed,  sparingly,  sodium 
bicarbonate,  creta  preparata  and  magnesium  carbonate,  each  grains  x, 
after  meals.  Spasm  from  gas,  erosions  near  the  pylorus,  or  overloading 
of  the  stomach  is  modified  by  tincture  of  asafetida  5jj  extract  of  bella- 
donna gr.  I  and  subnitrate  of  bismuth  gr.  x.  (/)  Faradization,  massage 
and  hydrotherapy,  are  less  valuable  than  in  gastric  atony  and  sensory 
neuroses  of  the  stomach.  Cathartics  cause  irritation  and  constipation 
recurs;  hot  water,  colonic  flushings  and  perhaps  the  mildest  saline 
aperients  are  indicated. 


ACHY  LI  A  503 

Achylia  Gastrica. — Etiology. — The  term  \\'as  introduced  by  Einhorn 
to  designate  total  suppression  of  gastric  digestion.  Achylia  occurs 
secondarily  in  cancer  of  the  stomach,  various  gastritides,  cancer  of  distant 
organs,  diabetes,  pernicious  anemia,  tabes  and  as  a  functional  disorder. 
In  rare  cases  it  develops  as  a  seemingly  primary  affection,  possibly  as  a 
congenital  condition.  It  occurs  oftenest  in  middle  or  advanced  life. 
Atrophy  of  the  stomach  was  described  by  H.  Jones,  Flint  and  Fen- 
wick. 

Pathology. — Pathologically  two  main  forms  exist,  (a)  cirrhosis  ventriculi, 
in  which  the  stomach  is  very  small  and  its  walls  measure  several  centi- 
meters in  thickness,  and  (6)  phthisis  ventriculi,  in  which  the  walls  are  thin 
or  "wasted"  and  the  stomach  is  lax  or  dilated.  The  glandular  structures 
are  wasted  (anadenia).  In  neurotic  achylia  there  is  no  anatomical 
change. 

Symptoms. — Symptoms  may  be  absent  if  gastric  motility  is  good  and 
the  intestinal  glands  are  normal.  If  the  same  process  exists  in  the  gut 
diarrhea,  marasmus  and  death  result. 

1.  Gastric  Symptoms. — None  are  pathognomonic.  Pain  may  be 
absent,  moderate  or  in  some  cases  lancinating,  like  that  of  hyperchlor- 
hydria.  The  appetite  is  variable.  When  vomiting  is  present  the  vomitus 
contains  coarse,  poorly  digested  particles. 

2.  Test  Meal. — The  recovered  food  is  coarse;  the  total  acidity 
corresponds  to  the  amount  in  the  food  ingested.  No  HCl  is  found 
(achlorhydria),  no  pepsin  (therefore  no  peptones),  no  rennet  (therefore 
no  coagulation  of  milk),  no  blood  and  according  to  most  writers  no  mucus; 
mucus  may  be  due  to  metaplasia  of  the  gastric  mucosa  to  one  resembling 
that  of  the  intestine,  the  cells  of  which  secrete  mucus;  as  they  in  turn 
atrophy  the  mucus  disappears.  Lactic  acid  is  found  but  rarely.  The 
gastric  motor  poiver  is  usually  increased  and  the  stomach  is  emptied  in 
less  than  an  hour.  In  the  contracted  cirrhotic  form,  a  sound  is  introduced 
into  the  stomach  with  difficulty,  hydrochloric  acid  is  present,  the  stomach 
cannot  be  distended  with  gas  and  its  capacity  is  enormously  decreased; 
in  the  phthisic  form  ectasia  may  occur. 

3.  Other  Symptoms. — Headache,  vertigo  and  constipation  are  the 
rule;  in  some  cases  diarrhea  may  be  the  sole  salient  symptom,  simulating 
an  intestinal  lesion;  these  morning  movements  are  inoffensive  and  usually 
painless.  Symptoms  like  those  of  pernicious  anemia  or  like  gastric  cancer 
mark  some  cases. 

Prolonged  observation  may  be  necessary  to  exclude  the  atrophic  gas- 
tritis of  cancer  and  amyloid  gastric  disease.  In  one  instance  the  autopsy 
showed  only  atrophic  gastritis,  whereas  clinically  hematemesis,  achylia, 
lactic  acid,  edema,  ascites  and  extreme  emaciation  had  led  to  a  suspicion 
of  cancer. 

Prognosis. — Life  may  be  prolonged  for  years  by  compensating  intestinal 
digestion,  but  recovery  is  impossible  after  atrophy  develops. 

Treatment. — Treatment  is  necessarily  palliative.  Thorough  masti- 
cation of  food  is  imperative.  Cellulose  is  to  be  avoided  and  thick,  plain, 
leguminous  purees  should  be  given.  Butter  is  well  tolerated.  The 
meals  should  be  small  and  given  every  three  or  four  hours.    HCl  should 


504  DISEASES  OP  THE  STOMACH 

be  given  in  full  doses  (TTlxx-xxx),  stimulating  the  pancreatic  flow  and 
controlling  the  pylorus  (thus  averting  diarrhea) .  Water  relieves  the  pain, 
which  resembles  hyperchlorhydria. 

DILATATION  OF  THE  STOMACH;  MOTOR  INSUFFICIENCY. 

Gastrectasia  is  only  a  symptom,  and  is  understood  as  a  more  or  less 
lasting  dilatation  with  motor  insufficiency. 

I.  Acute  Dilatation. — Acute  dilatation  was  first  fully  described  by 
Fagge  (1883);  217  cases  are  recorded  (Laffer,  1908). 

Etiology. — (1)  Most  cases  follow  abdominal  trauma  or  anesthesia, 
affecting  the  vagus  (45  per  cent.);  gall-bladder  operations  are  the  most 
frequent  type.  The  two  cases  seen  by  the  writer  were  in  women  operated 
on  for  fibroids  of  the  uterus.  (2)  It  may  follow  acute  infections  as  pneu- 
monia or  typhoid;  or  (3)  mechanical  causes;  in  one  of  Kolisko's  autopsies 
the  author  saw  an  enormously  dilated  stomach  in  a  man  who  on  a  wager 
had  taken  a  large  number  of  charged  siphons.  Unconscious  aerophagia 
is  Mathieu's  explanation.  (4)  Traction  or  obstruction  of  the  superior 
mesenteric  artery  in  the  duodenal  mesentery  is  the  most  favored  etiological 
factor,  though  no  proof  exists  that  it  is  not  a  result  rather  than  cause. 
(5)  Most  cases  occur  between  twenty  and  thirty  years  of  age. 

Symptoms.- — The  stomach  is  enormously  distended;  there  is  vomiting 
of  brown  or  black  material  which  often  runs  out  of  the  mouth,  may  be 
very  copious,  sometimes  offensive  and  rarely  fecal.  Succussion  sounds  are 
frequent.  The  abdomen  is  greatly  distended  and  often  painful.  There 
is  much  collapse. 

Prognosis  and  Treatment. — Sixty-four  per  cent,  die,  usually  within  five 
days.  The  indications  are :  the  knee-chest  position  or  lying  on  the  face 
or  the  right  side;  interdiction  of  all  food  and  fluid;  early  and  frequent 
use  of  the  stomach-tube,  which  may  be  left  permanently  in  the  stomach; 
rectal  feeding;  atropine  (under  which  the  writer  observed  one  recovery), 
or  eserine  gr.  4^0;  salt  solution  under  the  skin,  and  other  measures 
for  shock;  gastrostomy  or  gastro-enterostomy  is  contra-indicated. 

II.  Chronic  Dilatation  and  Motor  Insufficiency. — ^Various  grades  of 
distention  and  atony  may  occur;  dilatation  may  be  associated  with 
increased  power  of  the  gastric  musculature  or  with  atony;  and  motor 
insufficiency  (inability  of  the  stomach  to  propel  food  into  the  intestine) 
is  not  necessarily,  though  very  often,  associated  with  dilatation  of  the 
stomach.  Dilatation  and  motor  insufficiency  are  most  prevalent  in 
middle  or  advanced  life. 

Etiology. — 1.  Pyloric  Stenosis. — Its  causes  are  twofold,  malignant 
and  benign.  It  is  most  often  cancerous,  but  may  follow  round  or  corrosive 
ulcers,  gastritis  leading  to  hypertrophy  of  the  pyloric  musculature 
(stenosing  gastritis),  benign  tumors,  as  pedunculated  polyps,  and  con- 
genital stenosis.  (In  pyloric  obstruction  in  nurslings,  the  cause  is  either 
pylorospasm  or  hypertrophy  of  the  pyloric  musculature,  from  its  repeated 
irritation.)  It  may  also  result  from  congenital  duplicature,  volvulus 
of  the  stomach,  angular  bending  of  the  fixed  pylorus  or  from  chole- 
c\stitis.     Garre  collected  25  cases  of   tuberculous  pyloric  obstruction. 


DILATATION  OF   THE  STOMACH  505 

Stenosis  of  tlie  duodenum  produces  essentially  the  same  results  as  pyloric 
stenosis  and  may  follow  duodenal  ulcer,  di\-erticulum  or  twisting.  The 
pylorus  may  suffer  compression  stenosis  from  tumors  of  the  liver,  colon, 
kidney  or  pancreas.  Pyloric  stenosis  may  be  associated  with  intestinal 
stenosis  (chiefly  from  round  ulcer).  Temporary  or  permanent  pyloric 
spasm  from  fissure,  erosion,  ulcer,  hyperchlorhydria  or  from  appendicitis 
may  cause  obstruction.  The  pathological  sequence  of  pyloric  stenosis  is 
retention  of  food  within  the  stomach  and  hypertrophy  of  its  musculature 
in  attempts,  sometimes  partially  successful  and  at  other  times  vain, 
to  force  the  food  through  the  narrow  or  closed  pylorus.  Dilatation  of  the 
stomach  may  be  considered  as  a  disturbed  compensation,  analogous 
to  hypertrophied  and  dilated  bladder  from  prostatic  enlargement  or 
h\^ertrophy  with  dilatation  in  obstructive  valvular  disease.  In  all 
three  instances  the  hypertrophied  muscle  eventually  degenerates. 

2.  ^Muscular  Weakness. — Motor  insufficiency,  atony  or  myasthenia 
gastrica  constitutes,  in  contrast  with  the  first  group  of  causes,  a  functional 
and,  generally  speaking,  a  more  reparable  type,  (a)  Atony  dependent  on 
general  causes  may  occur  in  acute  infections,  anemia,  rickets  and  neuroses. 
The  tendency  may  be  acquired  or  congenital.  (6)  Atony  may  result 
from  gastric  conditions,  as  cancer,  gastritis,  hypersecretion,  peritoneal 
adhesions,  cholecystitis  with  pyloric  adhesions,  diaphragmatic  pleurisy 
and  diastasis  of  the  recti  muscles.  Overloading  the  stomach  with  heavy 
meals,  indigestible  foods,  vegetables,  carbohydrates,  beer,  milk  in  large 
quantities,  much  water  ingested  with  heavy  meals,  as  in  diabetics, 
swallowing  of  foreign  bodies  by  insane  subjects,  etc.,  may  develop 
muscular  insufficiency.  The  stomach  is  usually  enlarged  and  shows  a 
lax,  often  wasted  and  thinned,  musculature  but  seldom  contains  residual 
food. 

Symptoms. — The  symptoms  differ  greatly,  ranging  from  absolute  pyloric 
stenosis  to  the  least  motor  weakness,  and  are  partly  mechanical,  partly 
chemical. 

1.  Gastric. — (a)  The  appetite  is  variable;  the  tongue  is  sometimes 
coated,  sometimes  clean,  (h)  There  is  usually  thirst  and  dryness  of  the 
throat,  most  frequently  in  hypersecretion,  (c)  Singultus,  pyrosis  of 
fatty  acids,  oppression  over  the  stomach  and  eructation  of  gas  are 
frequent.  Gases  are  never  formed  without  motor  insufficiency;  they 
include  hydrogen  sulphide,  hydrogen,  oxygen,  nitrogen,  carbon  dioxide 
and  even  inflammable  gases,  (d)  Vomiting  is  cdways  present  in  pyloric 
obstruction  and  marked  motor  insufficiency.  It  occurs  easily  and  is 
often  rather  belched  up  than  vomited.  It  frequently  occurs  during  the 
night  or  at  intervals  of  days;  five  quarts  may  be  evacuated.  Large 
amounts  argue  directly  for  stagnation  and  dilatation.  The  vomitus  is  acid, 
sour  and  often  greatly  decomposed.  Three  layers  are  noted:  a  brownish 
foam,  a  grayish-brown  fluid  and  a  sediment  of  food,  stones  and  seeds,  which 
may  have  lain  for  days  in  the  stomach.  Gas  often  bubbles  up  as  the 
vomitus  stands.  If  gastric  juice  only  is  found,  it  indicates  hypersecretion 
with  motor  insufficiency.  Chemically,  butyric  acid,  peptones  and,  in 
cancer,  lactic  acid,  are  found;  when  the  obstruction  lies  in  the  duodenum 
below  the  papilla  of  the  common  duct,  bile  is  also  present,     ^licro- 


506  DISEASES  OF   THE  STOMACH 

scopically  undigested  meat  or  starch,  in  benign  stenosis  sarcinee  and  in 
cancer  the  Oppler-Boas  bacilh  and  yeast  are  found.  HCl  is  absent  in 
cancer,     (e)  Pain  is  cramp-hke,  boring  or  burning. 

2.  Motility  and  Resorptiox. — (a)  The  chemism  depends  on  the 
causal  affection  (see  Ulcer,  Cancer,  Hyperchloehtdel\,  Htper- 
SECRETiox).  Hyperchlorhydria  and  hypersecretion  are  usually  present 
except  in  malignancy  and  are  sequential  rather  than  causative,  (h) 
Motility  is  best  tested  by  Leuhes  test  dinner,  consisting  of  13  ounces  beef 
soup,  7  ounces  beefsteak,  one  or  two  ounces  bread  and  7  ounces  water, 
which  should  leave  the  stomach  physiologically  in  not  more  than  seven 
hours;  jam  is  added,  for  seeds  are  a  ready  index  of  stagnation.  If  food 
is  found  later,  stagnation  is  present;  if  found  in  the  morning  when 
Leube's  meal  has  been  given  at  night,  there  is  great  stagnation  and 
fermentation.  Fluid  is  not  absorbed  by  the  stomach,  whence  the  measure 
of  its  residual  amount  is  important.  There  is  more  fluid  in  the  stomach 
than  was  ingested,  which  is  accounted  for  by  hypersecretion,  transu- 
dation, mucus  and  perhaps  regurgitation  from  the  intestine  or  hemor- 
rhage. (Other  tests  are  less  reliable — the  oil  test,  administering  100  c.c. 
of  olive  oil,  70  to  80  per  cent,  of  which  should  leave  the  stomach  in  two 
hours;  and  the  salol  and  potassium  iodide  tests.)  In  general  a  homo- 
geneous chyme  means  that  the  motor  function  is  normal;  coarse  particles 
occur  when  there  is  motor  insufficiency. 

3.  Physical  Signs. — (a)  Inspection  in  a  good  light  is  very  important. 
A  A'isible  prominence  of  the  dilated  organ  may  be  seen  below  the  navel, 
sometimes  showing  clearly  the  abnormally  low  upper  and  lower  cur\'a- 
tures,  the  upper  curvature  ncA'er  being  seen  normally.  In  obstruction  a 
peristaltic  wave  passing  from  left  to  right  or  an  antiperistaltic  wave  in 
the  opposite  direction  often  tells  the  whole  story.  Peristalsis  disappears 
when  the  gastric  musculature  is  exhausted  or  infiltrated,  e.  g.,  by  carci- 
noma. "Stift'ening""  of  the  stomach  is  an  infallible  sign  of  pyloric  stenosis. 
The  .T-rays  show  the  outline  of  the  viscus  after  ingestion  of  bismuth, 
hyperperistalsis,  stasis,  etc.  (see  Ulcer  and  Cancer),  (b)  Palpation  con- 
firms the  above  findings  and  also  elicits  splashing  {clapotage)  of  gas  and 
water  in  the  stomach;  it  occurs  in  healthy  stomachs.  The  hand  may 
palpate  the  final  gush  of  gastric  contents  into  the  gut,  or  outline  a  tumor 
(adhesions,  callus,  pyloric  spasm,  cancer j.  (c)  Percussion:  The  normal 
vertical  dimension  of  the  stomach  is  10  to  1-i  cm.  and  its  average  capacity 
1600  c.c.  Filling  the  stomach  T\ith  water  and  percussing,  with  the  patient 
standing,  outlines  both  the  lesser  and  greater  curvatures,  which  may 
reach  to  the  pubes.  Siphoning  the  water  and  then  distending  the  stomach 
with  carbon  dioxide,  replaces  the  flatness  by  tympany,  though  distention 
is  dangerous.  ^Yhen  doubtful,  the  colon  may  be  distended  Ts-ith  gas  or 
fluid.  The  greatest  distention  is  at  the  fundus.  The  note  changes  with 
change  of  posture,  the  fluid  being  in  the  lower  and  the  gas  in  the  upper 
parts;  the  most  experienced  have  confused  enormously  dilated  stomachs 
with  ascites  and  ovarian  cysts  and  have  introduced  a  trocar;  in  Jadon's 
case  the  stomach  contained  45  quarts.  Leube  palpated  the  lower  end 
of  the  stomach  by  means  of  a  rigid  sound;  this  practise  is  abandoned. 
((J)  Auscultation  elicits  the  splashing  which  may  be  heard  by  the  patient. 


DILATATION  OF  THE  STOMACH  507 

and  sometimes  metallic  heart  tones,  crepitation,  hissing  of  gas  or  a  drip- 
ping sonnd  as  the  patient  drinks. 

Complications. — (a)  Constipation  is  the  rule,  because  less  fluid  passes 
the  pylorus;  in  the  exceptional  diarrhea,  sarcinse  may  be  found  in  the 
stools.  (6)  The  urine  is  often  alkaline,  its  chlorides  lessened  and  its 
amount  reduced  as  a  result  of  acid  vomiting;  acetone  and  diacetic  acid 
are  occasional,  (c)  The  skin  is  dry  and  emaciation  common,  even  in 
benign  forms  because  food  is  imperfectly  absorbed  or  lost  to  the  organism 
by  fermentation  and  possibly  by  tissue-destroying  toxins,  {d)  Auto- 
intoxication may  develop,  causing  headache,  vertigo,  drowsiness,  psy- 
choses, polyneuritis,  tetany,  slow  pulse  and  dyspnea.  Tetany  (Neu- 
mann and  Kussmaul)  occurs  oftenest  in  hypersecretion  or  stenosis  from 
cancer  or  ulcer;  88  per  cent,  of  cases  die. 

Diagnosis. — The  vomiting,  impaired  motility,  as  shown  by  Leube's  test 
dinner,  the  visible  outlines,  a^-rays,  and  the  low  lesser  curvature  which 
is  not  seen  normally,  distinguish  gastrectasia  easily;  its  cause  may  be 
determined  with  difficulty  only.  The  stomach  may  be  physiologically 
large  (megalogastria) ,  but  then  there  is  no  motor  insufficiency,  no  vomiting 
and  no  stagnation.  Gastroptosis  will  be  considered  later.  Stenosis  may 
be  intermittent,  latent  and  misinterpreted  (stenose  meconne  du  pylore) ; 
a  test  of  the  digesting  or  fasting  stomach  may  reveal  nothing  between 
the  attacks  when  muscular  compensation  is  good.  The  degree  of  stasis 
is  determined  by  washing  out  the  stomach  at  varying  times  after  the  test 
dinner.  Retention  of  food  after  twelve  hours  almost  certainly  indicates 
ulcer  or  cancer.  In  pyloric  stenosis  there  is  greater  dilatation  than  in 
simple  motor  insufficiency  (or  atony)  and  marked  peristalsis  always 
indicates  obstruction.  The  benign  must  be  differentiated  from  the 
malignant  type;  benign  pyloric  obstruction  runs  a  more  remittent,  longer 
course,  over  two  years,  even  fifteen  years;  HCl  and  the  ferments  are 
always  present,  often  increased  and  sarcinse  are  often,  and  lactic  acid 
seldom,  present;  there  is  more  supernatant  fluid  and  the  total  acidity 
runs  70  to  100  or  over,  and  the  free  HCl  50  to  80;  while  in  cancer  the 
march  of  symptoms  is  progressive  and  achlorhydria,  cachexia,  anemia 
with  leukocytosis,  hydrops,  pyloric  tumor,  the  Oppler-Boas  bacillus  and 
metastases  develop  with  relative  rapidity.  The  spasmodic  form  runs 
an  intermittent  course.  The  prognosis  depends  on  the  etiology  and 
amenability  to  treatment;  spasmodic  types  are  curable;  relative  stenosis 
may  somewhat  improve.  In  infants  with  spastic  obstruction  or  hyper- 
trophied  pylorus  the  onset  within  the  first  month  of  life  is  characteristic, 
with  forcible  vomiting,  though  the  child  be  carefully  fed,  emaciation, 
visible  peristalsis,  constipation,  and  usually  a  palpable  pylorus.  The 
23  cases  of  volvulus  of  the  stomach  (Miihlfelder,  1911),  showed  gastric 
meteorism,  difficulty  in  introducing  the  stomach-tube,  singultus,  symp- 
toms of  ileus,  sinistrocardia,  dysphagia  and  thoracic  pains. 

Treatment. — 1.  Etiological  factors  should  be  treated. 

2.  General  measures,  to  give  tone  to  the  musculature  are  abdominal 
massage,  only  when  ulceration  and  inflammation  are  excluded;  drugs, 
especially  strychnine  and  atropine,  and  an  ice-bag  to  the  epigastrium; 
hydrotherapy;  faradization   of    the  stomach;   external    is    seemingly  as 


508  DISEASES  OF   THE  STOMACH 

efficacious  as  intragastric  application;  and  nhdomincil  hinders  or  supports. 
This  treatment  avails  only  in  atony. 

3.  Gastric  therapy,  (a)  Gastric  lavage  ^em()^•es  the  fermenting  contents, 
relieves  the  pressure  exerted  by  accumulated  food  and  fluid,  cleans  off 
the  mucus,  lessens  vomiting  and  auto-intoxication,  and  may  permanently 
help  atony  and  temporarily  mitigate  stenosis.  Th^  stomach  is  washed 
with  luke-warm  water  until  it  returns  clear;  salicylic  acid  and  sodium 
bicarbonate  may  be  added,  as  in  chronic  gastritis;  the  patient  soon 
welcomes  the  relief  afforded;  washing  two  hours  before  the  evening 
meal  is  preferable,  to  insure  less  stagnation  through  the  night,  (h) 
The  food  should  be  well  divided,  nourishing  not  voluminous,  and  given 
with  moderate  quantities  of  water,  in  small  amounts  and  at  inter\'als 
of  four  hours.  The  diet  consists  of  meat,  eggs^  leguminous  purees, 
thoroughly  cooked  rice,  small  amounts  of  butter  (fats  and  carbohydrates 
are  more  prone  to  fermentation),  and  an  ounce  or  two  of  olive  oil  in 
pylorospasm  and  moderate  benign  stenosis.  A  dry  diet  was  advised  by 
Van  Swieten,  but  moderate  amounts  of  fluid  aid  in  propulsion  of  food 
into  the  gut.  A  fluid  diet  is  indicated  in  great  pyloric  stenosis  and  when 
the  HCl  is  decreased;  meat  may  be  given  if  the  acid  is  not  decreased  and 
the  pylorus  is  not  greatly  stenosed.  Recently  there  has  been  a  reversion 
in  favor  of  two  fair-sized  meals  a  day,  giving  the  stomach  time  to  empty 
itself  and  rest.  Water  is  not  absorbed  by  the  stomach;  indeed,  absorp- 
tion from  the  stomach  of  sugar,  peptone,  dextrin  and  alcohol  is  attended 
by  actual  excretion  of  water  into  the  stomach.  In  pronounced  cases 
peptonized  milk  and  water  are  given  by  rectum  to  supplement  gastric 
feeding.  In  all  cases  careful  individualization  is  indicated;  the  degree 
of  insufficiency,  i.  e.,  the  time  required  for  evacuation,  should  be  tested 
by  Leube's  meal  and  the  patient  fed  accordingly,  (c)  Posture:  The 
patient  should  lie  on  his  right  side  one  or  two  hours  after  eating,  thereby 
relieving  pressure  upon  the  greater  curvature  and  directing  the  food 
toward  the  pylorus,  (d)  Medication:  (See  Chronic  Gastritis,  Ulcer, 
Hyperchloehydria) .     (e)   Thiosinamin:  (see  page  553). 

4.  Surgical  intervention  is  imperative  in  severe  or  malignant  stenosis 
and  when  medical  treatment  fails.  It  embraces  (a)  pylorectomy,  (b) 
pyloroplasty,  (c)  gastro-enterostomy.  In  153  operations  for  benign  stenosis 
]\Ioynihan  had  only  two  deaths.  In  the  pyloric  stenosis  of  infancy  the 
mortality  under  medical  treatment  is  72  per  cent.,  under  surgical  17 
per  cent.  (10  per  cent.,  H.  M.  Richter).  In  24  operations  for  tetany 
with  pyloric  stenosis  21  recovered  (McKendrick). 

CHANGES  IN  FORM,  SIZE  AND  LOCATION  OF  THE  STOMACH. 

Form. — The  antrum  cardiacum  is  a  congenital  bulging  of  the  esophagus 
just  below  the  diaphragm  and  the  fore-stomach  is  a  congenital  dilatation 
above  the  diaphragm.  There  also  exists  a  congenital  narrowness  of  the 
pylorus  as  well  as  hour-glass  stomach. 

The  acquired  hour-glass  deformity  is  more  common  and  may  result 
from  spastic  hypertrophic  muscle,  idcer,  especially  cancer  developing 
upon    ulcer,    adhesions,    abdominal    tumors,    peritoneal    tuberculosis, 


ULCER  OF   THE  STOMACH  AND  DUODENUM  509 

twisting  of  the  stomach  or  hernia  of  it  through  the  mesocolon.  It  may 
coexist  with  pyloric  stenosis.  Randolph  and  Thomas  observed  2  cases 
in  one  famil}'.  The  pyloric  sphincter  normally  contracts  so  vigorously 
as  to  give  an  hour-glass  appearance  in  many  x-ray  plates. 

Symptoms  may  be  lacking  in  the  lesser  degrees  of  deformity;  in  the 
higher  grades  they  are  those  of  stenosis.  (1)  Only  a  part  of  a  given 
amount  of  water  introduced  into  the  stomach  may  be  recovered  (Wolfler's 
first  S}'mptom).  (2)  After  the  stomach  has  been  washed  till  the  water 
returns  clear  the  fluid  may  suddenly  become  clouded  (Wolfler's  second 
symptom) .  (3)  The  stomach  is  apparently  emptied  by  the  stomach-tube 
and  yet  splashing  is  obtained,  from  the  cavity  nearest  the  pylorus 
(Jaboulay's  paradoxical  dilatation).  (4)  Inflation  by  carbon  dioxide 
produces  distention  first  of  the  left  and  later  of  the  right  half  of  the 
epigastrium  (von  Eiselsberg's  first  symptom).  (5)  Normally  when  the 
stomach  is  distended  and  the  gas  passes  through  the  pylorus  into  the 
bowel,  there  is  a  sharp  gurgle  over  the  pylorus;  in  the  hour-glass  stomach 
the  gurgle  is  heard  two  to  four  inches  to  the  left  of  the  median  line  (von 
Eiselsberg's  second  symptom).  (6)  On  distention  by  carbon  dioxide 
Moynihan  found  tympany  only  over  the  upper  part  of  the  stomach  and 
not  over  its  lower  half.  (7)  When  the  stomach  is  distended  a  furrow  may 
appear  (Eichliorst  and  Schmid-Monard) .  (8)  Filling  the  stomach  with 
water  and  illuminating  it  by  a  light  introduced  into  the  stomach,  the 
cardiac  portion  appears  translucent  and  the  pyloric  part  dark  (Ewald). 
(9)  A  rubber  balloon,  introduced  into  the  stomach  and  then  inflated 
through  the  stomach-tube,  fills  or  outlines  a  part  only  of  the  stomach 
(Hemmeter) . . 

Treatment  is  surgical.  Moynihan  successfully  operated  on  23  cases 
by  single  or  double  gastro-enterostomy,  gastroplasty,  gastrogastrostorny, 
partial  gastrectomy  and  dilatation  of  the  stenosis. 

Size. — Megalogastria  and  microgastria  are  usually  accidental  findings 
if  not  associated  with  other  gastric  disease.  Microgastria  may  be  con- 
genital, or  result  from  spasm,  infiltrating  cancer  or  chronic  stenosing 
gastritis  (linitis  plastica).  The  latter  condition  is  a  diffuse  or  circum- 
scribed cirrhosis  of  the  stomach.  Many  cases  of  carcinoma  are  brought 
under  this  caption,  even  after  microscopic  examination.  The  connective- 
tissue  increase  may  be  localized,  as  at  the  pylorus,  or  diffuse,  involving 
the  entire  stomach,  particularly  in  its  submucous  coat.  The  localized 
form  gives  the  usual  symptoms  of  pyloric  stenosis.  The  generalized 
type  is  attended  by  pain,  vomiting  and  the  toleration,  by  the  stomach, 
of  small  amounts  of  food;  a  rounded,  or  sausage-shaped  tumor  is  felt 
in  the  epigastrium.     The  prognosis  is  grave  unless  surgery  is  invoked. 

Location. — The  stomach  at  birth  is  vertical;  in  adult  life  three-quarters 
or  the  whole  stomach  is  to  the  left  of  the  median  line. 

Gastroptosis. — (See  Enteroptosls,  page  555). 

ULCER  OF  THE  STOMACH  AND  DUODENUM. 

Definition. — Ulcer  is  characterized  pathologically  by  a  ''punched  out" 
funnel-like  ulcer,  oftenest  near  the  pylorus,  and  clinically  by  localized  pain 
and  tenderness,  hematemesis  and  hyperacidity. 


510  DISEASES  OF   THE  STOMACH 

Frequency. — It  is  found  in  2.5  to  5  per  cent,  of  all  autopsies. 

Etiology. — The  causation  is  obscure,  (a)  Age. — Most  ulcers  occur 
between  twenty  and  sixty  years  of  age,  with  about  equal  frequency  in 
each  decade.  (6)  Anemia  and  chlorosis  are  predisposing  factors.  Anemia 
and  (c)  hj-peracidity  are  usually  regarded  as  important  factors;  the 
writer  believes  that  hyperacidity  is  only  a  result,  (d)  As  a  normal 
access  to  the  stomach  of  arterial  blood  prevents  its  autodigestion,  it  is 
thought  that  interruption  in  the  local  circulation  is  the  cause  of  ulcera- 
tion (embolism  and  arterial  spasm).  Embolism  and  ulceration  follow 
burns  (13  per  cent.).  However,  ulcer  often  occurs  at  an  age  when  arterial 
changes  are  rare,  though  syphilis,  alcoholism,  arteriosclerosis,  hard 
work,  cardiac,  renal  and  hepatic  diseases  apparently  cause  some  of  the 
cases  in  later  life,  (e)  Occupation.  Many  cases  occur  in  servant  girls 
and  in  cooks ;  (/)  trauma  in  cooks,  shoemakers  and  tailors  is  an  accessory 
factor;  the  tasting  of  hot  foods  and  pressure  against  the  stomach;  the 
pressure  of  corsets,  the  swallowing  in  certain  trades  of  particles  of  iron, 
porcelain  and  glass;  and  imperfectly  masticated  or  improper  food,  may 
be  brought  under  this  caption.  External  trauma  is  a  distinct  factor. 
(g)  Bacterial  necrosis  may  cause  ulcer,  as  in  Dieulafoy's  cases  of  pneu- 
mococcic  hemorrhagic  ulceration  of  the  stomach,  (h)  The  idea  was 
recently  advanced  that  ulcer  results  from  lack  of  anti-enzyme,  which 
normally  resists  necrosis  or  digestion.  Operative  figures  indicate  that 
duodenal  ulcers  are  twice  as  frequent  as  gastric,  but  these  statistics 
represent  a  narrow  group  of  cases;  Mayo's  figures  give  64.5  per  cent, 
duodenal,  32.5  per  cent,  gastric  and  3  per  cent.  both. 

Pathology. — Scars  indicating  healed  ulcers  are  three  times  as  frequent 
at  autopsy  as  open  ulcers.  The  ulcer  is  known  as  ulcus  simplex  to 
distinguish  it  from  malignant  or  s^'philitic  ulceration;  ulcus  rotundum, 
as  the  smaller  ones  especially  are  round;  ulcus  yepticum  and  perforans. 
The  peptic  ulcer  occurs  almost  exclusively  in  the  stomach,  lower  esophagus 
and  upper  duodenum.  Its  general  morphology  was  first  thoroughly 
described  by  Cruveilhier  (1829)  and  Rokitansky  (1839) ;  it  has  a  "punched 
out,"  clean-cut  appearance;  in  contour  it  is  round  or  oval  in  small,  and 
irregular  in  large,  ulcers;  it  is  usually  small,  but  may  even  measure  four 
by  seven  and  a  half  inches;  it  is  funnel-shaped  in  old  cases;  its  apex 
is  eccentric  and  directed  toward  the  serosa,  its  sides  are  terrace-shaped 
and  its  floor  is  clean.  In  90  per  cent,  the  ulcer  is  single;  as  many  as  3-1 
ulcers  have  been  reported.  Extension  is  more  common  in  acute  than 
chronic  types  and  more  toward  the  peritoneum  than  laterally.  ]\Iicro- 
scopically  there  is  no  infiltration  with  round  cells.  Its  localization  in 
90  per  cent,  is  near  the  pylorus  on  the  posterior  wall  or  lesser  cur\-ature; 
its  complications,  as  hemorrhage  and  perforation,  and  its  sequelae,  as 
pyloric  stenosis  and  deformations,  will  be  considered  under  clinical 
symptoms. 

Symptoms. — The  general  clinical  picture  varies,  cases  being  typical, 
doubtful  or  latent. 

In  the  typical  cases  there  is  an  epigastric  pressure,  which  later  becomes 
a  cutting,  localized  pain;  this  is  observed  one  and  a  half  to  two  hours 
after  eating,  and  ceases  only  with  vomiting  or  passage  of  the  food  into 


ULCER  OF  THE  STOMACH  AND  DUODENUM 


511 


the  bowel.  The  appetite  is  usually  good;  hyperacidity  and  hypersecretion 
are  noted  in  the  test  meal  or  the  vomitus;  tenderness  occurs  over  the 
epigastrium,  and  in  half  the  cases  bleeding  from  the  stomach  or  blood 
in  the  stools  is  observed. 

The  typical  triad  of  cardinal  symptoms  includes  pain  with  localized 
tenderness,  hematemesis  and  hyperacidity. 

1.  Pain. — The  most  important,  early,  characteristic  and  constant 
symptom  (in  90  per  cent.)  is  pain,  which  is  paroxysmal  and  is  localized 
and  occurs  during  digestion.  It  is  boring  or  burning,  seldom  lancinating. 
The  diet  affects  the  pain  greatly;  milk  is  well  tolerated,  usually,  but  solid 
food  and  very  hot  or  very  cold  foods  or  beverages  cause  discomfort. 
This  disappears  quickly  with  rectal  feeding.  The  seat  of  the  pain  varies 
in  different  patients,  but  is  the  same 
in  a  given  case.  Generally  it  is  epi- 
gastric and  near  the  ensiform  or  cramp- 
like in  the  right  mammary  line  under 
the  liver.  Sometimes  there  is  wide 
irradiation  toward  the  sternum,  ribs, 
shoulder,  scapula,  lower  abdominal 
quadrants,  and  infrequently  in  the 
brachial  plexus  and  pulmonary 
branches  of  the  vagus,  resembling 
angina  pectoris  or  producing  pain  in 
the  arms  and  legs.  The  pain  may 
vary  with  change  of  position,  depend- 
ing on  the  localization  of  the  ulcer. 

In  relation  to  eating,  sometimes 
the  pain  occurs  two  to  ten  minutes 
after  eating,  the  old  ''wound  pain," 
supposedly  due  to  contact  of  food 
with  the  eroded  nerves  in  the  ulcer. 
Typically,  pain  occurs  at  the  height 
of  digestion,  i.  e.,  one  and  one-half 
or  two  hours  after  ingestion  of  food, 
caused  by  the  hyperacidity.  Patients 
fear  to  eat  because  of  the  inevitable 

pain.  Pain  may  increase  at  the  time  of  the  menses  or  cease  during  preg- 
nancy. Pain  from  the  scars  or  adhesions  of  an  ulcer  is  infrequent  and  is 
usually  drawing  or  vague.  In  old  ulcers  pain  may  be  atypical  or  absent. 
If  pain  comes  on  at  once  it  may  suggest  esophageal  or  cardiac  ulcer;  or, 
if  it  occurs  three  hours  or  more  after  eating  it  is  suggestive  of  ulcer  of  the 
duodenum. 

Moynihan  describes  the  symptoms  of  duodenal  ulcer  as  follows:  "The 
patient  tells  you  that  he  has  certain  definite  attacks,  and  if  you  let  the 
man  tell  his  own  story,  he  will  give  you  the  impression  of  having  read 
something  which  has  been  \\Titten  about  duodenal  ulcer,  which  he  is 
recounting  to  the  best  of  his  recollection  to  please  you.  Pie  sa}'s  that  his 
trouble  comes  on  in  attacks  which  are  nearly  always  worse  in  winter  than 
in  summer  ancj  are  very  apt  to  be  precipitated  by  a  chill.    He  takes  a 


Fig.  37. — Normal  adult  stomacli. 
x-ray  after  bismuth  meal.  Note  that 
the  duodenal  cap  and  pyloric  part  of 
the  stomach  are  to  the  right  of  the 
spine,     (x-ray  by  Dodd.) 


512  DISEASES  OF   THE  STOMACH 

meal  at  eight  in  the  morning  and  from  two  to  two  and  one-half  hours 
after  it  he  is  fairly  comfortable;  it  is  his  best  time.  At  the  end  of  that 
time  he  has  a  feeling  of  discomfort  in  the  epigastrium;  he  feels  full  and 
heavy  and  may  get  some  relief  from  the  belching  of  gas.  Some  of  these 
patients  develop  a  habit  of  belching.  They  may  bring  up  a  very  sour 
fluid,  which  tastes  very  bitter  and  acid  and  makes  the  mouth  dry  and  the 
teeth  chalky.  This  pain  gradually  increases  until  the  next  meal-time 
comes.  To  this  I  applied  the  name  of  'hungry  pain.'  At  the  next  meal 
the  patient  almost  instantly  gets  relief  and  that  relief  persists  for  two  or 
three  hours  again.  He  probably  eats  a  heavy  dinner  and  will  nearly 
always  tell  you  he  has  something  before  he  gets  into  bed,  a  glass  of  milk 
or  a  cup  of  cocoa  and  a  biscuit.  He  sleeps  comfortably,  until  he  wakes 
about  2  A.M.  He  get  relief  from  nibbling  a  biscuit,  which  he  keeps  at 
the  bedside.  The  pain  is  found  to  be  most  relievable  by  something 
stodgy  and  indigestible.  Taking  an  alkali  relieves  the  pain;  so  will 
washing  the  stomach." 

Tenderness  is  most  often  found  under  the  ensiform.  It  is  usually 
circumscribed  and  is  more  often  and  advantageously  found  on  the  lightest 
touch  rather  than  on  deep  palpation;  rigidity  is  a  protective  reflex. 
Tenderness  in  the  back  (Cruveilhier)  suggests  ulcer  on  the  posterior  wall 
of  the  stomach,  often  with  adhesions  to  the  pancreas,  and  is  found  in 
30  per  cent,  of  cases  to  the  left  of  the  tenth  to  twelfth  dorsal  or  upper 
lumbar  vertebrae.  The  abdomen,  back  and  chest  are  often  exquisitely 
hyperesthetic. 

2.  Hematemesis. — The  second  cardinal  symptom  is  hematemesis.  Its 
average  frequency  is  50  per  cent.  Vomiting  of  blood  in  ulcer  is  most 
frequent  in  the  pyloric  ulcer  (posterior  wall  and  lesser  curvature)  or,  less 
frequently,  from  ulceration  reaching  the  liver,  panrceas  or  spleen.  Hemor- 
rhage when  small  may  be  overlooked  (occult  hemorrhage);  melena 
alone  is  found  in  11  per  cent,  of  cases.  The  hemorrhage  must  amount  to 
a  pint  to  turn  the  stools  black.  It  may  be  large  and  lethal;  no  blood 
may  be  vomited  and  the  stomach  and  bowels  are  found  filled  with  one 
massive  clot.  The  usual  signs  of  internal  hemorrhage  exist,  as  collapse, 
pallor,  moderate  fever,  hemic  murmurs,  amaurosis  and  rarely  optic 
atrophy  or  hemiplegia.  If  profuse  it  is  voided  bright  red;  if  slow  and 
moderate  the  acid  turns  it  dark,  "coffee-grounds"  vomitus.  If  red  blood 
cells  cannot  be  found  because  of  complete  disintegration  of  the  cells, 
blood  can  be  detected  by  treating  it  with  acetic  acid,  extracting  with 
ether  and  then  testing  with  the  guaiac  and  turpentine  reaction.  Occult 
hemorrhage  occurs  in  25  to  50  per  cent,  of  cases  but  is  not  as  constantly 
l)resent  as  in  gastric  cancer  (see  Hematemesis  and  Cancer).  The  tests 
for  occult  hemorrhage  are  valuable  to  determine  the  length  of  the  medical 
treatment  of  ulcer  and  to  detect  bleeding  in  apparently  normal  vomitus. 
Profuse  hemorrhage  usually  indicates  deep  vilceration.  Hemorrhage 
complicates  acute  more  than  chronic  cases.  The  hemorrhage  is  usually 
fairly  profuse  in  ulcer;  it  may  be  spontaneous  during  sleep  or  rest  or 
may  result  from  excitement,  exertion  or  improper  diet.  One  or  two 
hemorrhages  are  the  average  but  they  may  recur  many  times.  In  a  case 
of  "chronic  dyspepsia"  with  vague  symptoms  the  writer  inflated  the 


ULCER  OF   THE  STOMACH  AND  DUODENUM  513 

stomach  with  carbon  dioxide;  the  patient  collapsed  in  the  office  and 
vomited  nearly  a  quart  of  blood. 

3.  Hyperacidity. — This  is  the  third  cardinal  finding.  Leube  finds 
it  in  50  per  cent.  In  old  ulcers  hyperchlorhydria  is  present  in  only  10 
per  cent,  and  they  explain  most  of  the  cases  of  decreased  acidity;  in  fresh 
ulcers  hyperacidity  occurs  in  70  per  cent.  Hyperchlorhydria  is  probably 
due  to  irritation  of  the  vagus  (Pawlow),  and  like  hypersecretion,  develops 
notably  in  ulcers  near  the  pylorus  and  especially  with  stenosis.  Compli- 
cating cancer,  hypersecretion  or  catarrh  may  cause  subacidity. 

Test  meals  should  not  be  given  when  there  is  pain,  tenderness  and 
vomiting  of  blood,  although  some  employ  the  stomach- tube  for  diagnosis 
in  atypical  cases,  and  also  to  relieve  the  vomiting  and  to  introduce  silver 
and  bismuth.  Organic  acids,  as  lactic,  are  absent,  the  carbohydrates 
poorly  digested  and  the  albumins  are  rapidly  converted  into  albumoses 
or  peptones.  The  motility  of  the  stomach  is  normal  in  one-quarter  and 
slow  in  three-quarters  of  the  cases. 

4.  Other  Symptoms. — Vomiting,  present  in  75  per  cent.,  is  a  less 
valuable  diagnostic  than  pain.  It  occurs  at  the  height  of  the  pain, 
two  or  three  hours  after  eating,  whereas  in  dilatation  or  hypersecretion 
it  occurs  much  later.  Vomiting  and  pain  depend  directly  on  the  diet 
and  localization,  vomiting  and  hypersecretion  denoting  chiefly  pyloric 
ulceration;  vomiting  usually  relieves  the  pain.  The  vomitus  consists 
of  fine  particles,  is  sour,  grits  the  teeth  and  shows  much  acid  and  no 
fermentation.  The  appetite  is  frequently  good  or  exaggerated.  Acid 
eructations  may  cause  a  burning  sensation  back  of  the  sternum  or  between 
the  shoulder  blades;  much  esophageal  burning  indicates  incontinence 
of  the  cardiac  orifice.  Diarrhea  is  rare.  Constipation  is  due  to  anemia, 
diet,  rest,  vomiting,  possibly  reflex  inhibition  of  intestinal  motility  or  to 
impeded  peristalsis  by  scars  and  adhesions.  Dysmenorrhea  and  amenor- 
rhea are  not  infrequent.  Emaciation  and  anemia  may  become  profound. 
The  urinary  findings  are  not  characteristic;  reduction  of  the  chlorides 
does  not  difterentiate  from  carcinoma;  the  urine  is  slightly  acid  or 
alkaline  when  the  stomach  is  dilated;  the  phosphates  are  increased; 
with  dilatation,  indican  and  ethereal  sulphates  are  increased.  Acetonuria 
and  diaceturia  sometimes  result  from  inanition. 

Clinical  Forms  of  Lebert. — (a)  In  the  hemorrhagic  form  bleeding  may 
be  acute  or  chronic,  the  first  or  the  last  and  fatal  symptom.  (6)  In  the 
perforatim  form  there  may  have  been  no  previous  symptoms,  (c)  In 
the  dysyeytic  type  there  are  atypical  symptoms,  such  as  pain  which  is 
not  sharp,  vomiting  which  is  infrequent  and  excess  of  hydrochloric  acid, 
but  no  increase  in  mucus,  {d)  The  cachectic  form,  in  old  ulcers  with  dilata- 
tion and  hypersecretion,  may  be  confused  with  carcinoma.  Other  types 
are  (e)  gastralgic  or  neuralgic  form;  (/)  vomitive  form;  (g)  latent  ulcer 
(scars  at  autopsy);  (//)  a  form  with  tumor;  (i)  recurrent  type;  (j)  stenotic 
type;  {k)  secondary  carcinomatous  type. 

Clinical  Course. — Ulceration  is  frequently  long  latent  before  diagnosis 

is  possible  and  persists  some  time  after  all  symptoms  have  disappeared. 

The  course  may  be  acute  and  rapid,  especially  under  appropriate  therapy, 

but  averages  three  to  five  years  (even  twenty  to  thirty-five  years,  due  to 

33 


514  DISEASES  OF   THE  STOMACH 

pyloric  obstruction,  dilatation  or  adhesions.)  Yery  large  ulcers  probably 
never  heal.  They  frequently  remit  with  appropriate  therapy,  but  recur, 
especially  in  the  spring  and  fall,  or  with  the  resumption  of  the  old  diet. 
Ulceration  can  be  considered  cured  only  when  all  symptoms  have  been 
absent  for  six  months. 

Localization. — Tenderness  and  tumor  are  indicative  of  ulcer  on  the 
anterior  wall;  hemorrhage  and  dorsal  pain  suggest  posterior  involvement. 
Pain  in  a  lateral  decubitus  suggests  localization  in  the  fundus  or  pylorus; 
dilatation,  in  the  pylorus  or  duodenum;  pain  under  the  ensiform  during 
the  act  of  deglutition  suggests  cardiac  ulcer.  Ulcers  are  palpable  in  only 
0.1  per  cent,  of  cases.  The  percentage  of  involvement  of  the  cardia 
is  6;  of  the  fundus  4;  of  the  lesser  curvature  36;  of  the  posterior  wall 
30;  of  the  pylorus  12;  of  the  anterior  wall  9.  In  over  80  per  cent,  of 
cases  it  occurs  in  a  small  area  about  the  pylorus,  lesser  curvature  and 
posterior  wall. 

Complications  and  Sequels. — (a)  Perforation  (3  per  cent.)  may  occur 
into  the  peritoneum,  usually  with  collapse,  peritonitis  and  vomiting 
(in  33  to  66  per  cent,  of  cases) .  Perforation  may  be  prevented  by  omental, 
peritoneal,  pericardial  and  pleural  adhesions.  The  danger  of  perforation 
in  ulcer  of  the  anterior  wall  is  seven  times  greater  than  of  other  locations. 
Perforation  of  a  latent  ulcer  maybe  confused  with  rupturing  appendicitis 
or  salpingitis.  Perforation  may  occur  into  the  heart,  colon,  gall-bladder, 
portal  vein,  pericardium,  thoracic  or  abdominal  wall;  or  it  may  produce 
pneumothorax  subphrenicus,  which  is  suggested  by  pleurisy,  epigastric 
and  h^TDOchondriac  pain,  stiffness  in  the  back,  painful  eructations  and  swal- 
lowing, singultus  or  local  edema.  In  90  per  cent,  of  all  perforations  there 
is  a  history  of  ulcer  covering  over  three  years  (Brunner).  (b)  Simple 
jjeritonitis  (perigastritis)  may  cause  a  friction  murmur  over  the  stomach. 
Perigastritis  may  invade  all  contiguous  organs  and  cause  the  greatest 
gastric  intolerance,  (c)  Adhesions  develop  in  about  40  per  cent,  of  ulcers; 
they  are  protective  against  perforation,  but  may  impede  cicatrization 
of  the  ulcer  or  lead  to  erosion  of  the  pancreatic  or  hepatic  bloodvessels; 
they  may  impede  motility,  deform  the  stomach  (hour-glass  stomach)  or 
obstruct  either  orifice  or  even  the  bowels;  75  per  cent,  of  adhesions  are 
to  the  liver  and  pancreas.  The  dragging  pain  of  adhesions  is  increased 
by  exercise,  standing  and  eating.  Pain  in  the  shoulder,  back  or  chest, 
suggests  adhesions  to  the  liver,  pancreas  and  diaphragm,  respec- 
tively. Dilatation  of  the  stomach  indicates  pyloric  stenosis,  or  less 
often,  pyloric  sj)asm.  Troublesome  adhesions  may  finally  so  stretch 
as  to  relieve  all  symptoms,  {d)  According  to  Liebert  (9  per  cent.)  or 
Zenger,  the  majority  of  cases  of  cancer  develop  from  ulcer.  The  typical 
s;sTiiptoms  of  ulcer  are  followed  by  loss  of  weight,  occult  bleeding,  gradual 
lessening  of  hydrochloric  acid  and  other  evidences  of  carcinoma.  Poly- 
neuritis is  a  rare  complication. 

Diagnosis. — The  diagnosis  is  determined  by  the  cardinal  symptoms 
and  various  clinical  types  enumerated.  In  general  it  is  more  easy  in 
the  young  than  in  older  individuals  with  chronic  ulcer. 

Pain  is  often  the  only  symptom;  if  it  is  atj^ical,  hyperacidity  may 
indicate  ulcer;  according  to  Riegel  pain  in  simple  hyperacidity  is  less 


ULCER  OF   THE  STOMACH  AND  DUODENUM  515 

regular  than  in  ulcer  and  localized  tenderness  is  absent.  Where  pain 
alone  exists,  one  must  remember  the  gastric  crises  of  tabes,  small  hernias 
in  the  linea  alba,  and  pain  in  the  transverse  colon,  which  usually  ceases 
on  evacuation  of  the  bowels.  Without  careful  examination  movable 
kidney  may  be  confused.  The  pain  in  gall-stones  is  paroxysmal,  but  more 
irregular  and  independent  of  eating.  The  gall-bladder  is  tender  and  may 
be  distended  and  palpable.  The  paroxysm  in  gall-stones  is  longer,  far 
more  violent  and  is  often  attended  by  fever  and  a  chill.  The  pain  more 
often  radiates  to  the  right  side  and  to  the  shoulder  and  the  vomiting 
is  not  that  of  ulcer,  though  hyperacidity  and  gastric  dilatation  may  follow 
cholelithiasis.  As  to  duodenal  ulcer  Graham  states  "There  remains  a 
certain  proportion  of  cases  that  will  mislead.  Those  cases  of  gall-stones 
in  which  the  stomach  symptoms  of  gas,  distress,  sour  belching  and  dilata- 
tion predominate,  and  pain  is  only  of  a  dull  character,  will  usually  be 
diagnosticated  as  ulcer;  but  the  duodenal  case,  of  which  the  chief  symp- 
tom is  the  sudden,  sharp,  intense  pain  of  perforative  peritonitis,  and  in 
which,  with  no  obstruction  or  hyperacidity,  the  other  stomach  symptoms 
are  in  abeyance,  will  be  diagnosticated  cholelithiasis.  Differentiation 
in  many  cases  must  be  made  on  the  operating  table." 

In  differentiating  ulcer,  gall-stones  and  appendicitis,  we  consider  the 
chronicity  and  periodicity  of  the  symptoms,  the  "hunger"  pain,  vomiting 
and  eructations  of  gas,  which  occur  in  all  three;  the  time  of  the  pain,  its 
regularity  and  its  relief  by  vomiting,  eating  or  alkalies  determine  an 
ulcer.  Even  in  "appendix  dyspepsia"  we  may  observe  pain,  vomiting 
and  hematemesis.  In  gastric  arteriosclerosis,  pain  may  follow  a  full  meal 
with  or  without  exercise.  Chronic  poisoning,  as  by  arsenic,  may  be  sus- 
pected, as  in  the  case  of  the  Duchess  of  Orleans  until  Littre  diagnosed 
ulcer. 

Hemorrhagic  erosions  and  fissures  of  the  stomach  present  no  constant 
clinical  picture.  After  eating  there  is  a  sense  of  burning  over  the  entire 
stomach.  The  chemism  and  tender  points  of  ulcer  are  lacking,  though 
Cohnheim  finds  hyperchlorhydria  and  believes  that  solid  food  relieves 
the  pain.  Shreds  of  tissue  are  always  found,  according  to  Pariser,  which 
cease  with  cessation  of  pain. 

Pyloric  spasm  may  also  occur  in  cardiac  disease,  appendicitis,  tenia, 
ascaris,  spastic  constipation  or  nicotinism. 

Differentiation  from  carcinoma  is  not  often  necessary.  In  Kraus's 
clinic  the  author  saw  2  cases;  1  was  an  old  man  with  cachexia,  pyloric 
tumor  and  decreased  hydrochloric  acid,  which  was  diagnosticated  cancer; 
the  other  was  a  young  girl  with  vomiting  of  blood,  in  whom  the 
diagnosis  of  ulcer  was  made.  The  postmortem  examination  showed 
that  the  old  man  had  a  round  ulcer  and  the  girl  had  a  cancer.  The 
author  has  seen  15  cases  of  carcinoma  under  the  age  of  thirty.  (See 
table  on  page  517.) 

'K-ray  Findings. — (a)  In  gastric  ulcer;  the  finding  of  bismuth  in  the 
stomach  after  six  hours  indicates  atony,  tumor  or  spasm  or  stenosis  of 
the  pylorus.  The  pylorus  may  be  displaced  upward  to  the  left,  by  ulcer 
on  the  lesser  curvature,  bringing  the  pylorus  and  cardia  nearer  together. 
The  last  part  of  the  greater  curvature  may  be  drawn  up  vertically,  instead 


516  DISEASES  OF   THE  STOMACH 

of  curving  upward  to  the  right.  Fluoroscopy  may  detect  adliesions  (caus- 
ing displacement),  antiperistalsis  (indicating  organic  disease,  as  cancer 
or  ulcer),  puckerings,  indentations,  filling  defects,  protrusions,  partial 
or  imminent  perforation  or  an  organic  or  spastic  hour-glass  stomach. 
(b)  In  duodenal  idcer,  we  may  observe  gastric  hyperperistalsis ;  residual 
bismuth  in  the  duodenum  or  in  the  stomach  if  stenosis  from  scar  con- 
traction occurs;  hypermotility  with  early  emptying  of  the  stomach; 
tenderness  over  the  ulcer;  irregular  outline  of  the  cap  or  first  portion, 
where  95  per  cent,  of  postpyloric  ulcers  are  found;  and  dilatation  of  the 
duodenum  or  diverticulum  of  a  perforating  ulcer. 

Prognosis. — The  mortality  averages  7  per  cent.,  about  equally  divided 
between  hemorrhage  and  perforation;  in  over  one  thousand  cases, 
death  occurred  in  2  per  cent.  (Leube).  Very  deep,  old  ulcers  rarely  heal. 
The  deeper  the  ulcer  the  greater  the  danger  of  hemorrhage  and  per- 
foration. Ulcers  with  hypersecretion  give  a  relatively  poor  prognosis. 
Carcinomatous  degeneration  must  be  considered  when  treatment  is  not 
successful. 

Treatment. — 1.  Absolute  Rest. — Rest  in  bed  for  a  month  or  more  was 
recommended  by  Cruveilhier,  in  addition  to  which  Leube  advises  hot 
fomentations  to  the  epigastrium,  which  relieve  pain  within  a  few  days. 
\Yomen  should  remain  in  bed  during  menstruation,  even  after  recovery. 

2.  Absolute  Rest  of  the  Stomach. — ^The  ingestion  of  even  small 
quantities  of  food  or  water  excites  peristalsis  and  secretion  and  distends 
the  ulcer.  Rest  permits  the  stomach  to  contract  and  the  edges  of  the 
ulcer  to  come  more  completely  in  apposition.  The  more  absolute  the 
rest  of  the  stomach  the  more  rapidly  the  ulcer  granulates  and  cicatrizes. 
Chronic  ulcers  show  little  tendency  to  cicatrize.  In  rectal  feeding  the 
usual  rules  should  be  followed;  pancreatized  milk,  grape-sugar,  baby 
foods,  meat  juice  and  eggs,  should  be  given,  in  amounts  not  to  exceed 
eight  ounces,  at  eight-hour  intervals;  they  should  be  injected  slowly, 
with  the  patient  on  his  left  side  and  should  be  given  warm,  which  pre- 
cautions obviate  excessive  peristalsis.  A  fountain  syringe  with  a  soft 
tube  is  always  used.  Nutrient  rectal  enemata  can  be  retained  invariably 
if  the  technique  is  carefully  carried  out.  Wine  or  spirits  irritate  the  bowel. 
Rectal  tenesmus  is  obviated  by  administering,  a  short  time  before  the 
enema,  an  opium  suppository  of  one-half  grain  of  the  extract.  A  patient 
in  bed  can  manage  with  1800  calories;  in  rectal  alimentation  by  milk 
only  300  calories  are  absorbed;  enemata  of  10  per  cent,  dextrose,  by 
the  drop  method,  increase  the  nutrition  and  lessen  the  acidosis  of  starva- 
tion. Peptonized  milk  is  far  inferior  to  milk  pancreatized  for  twenty-four 
hours,  in  which  amino-acids  abound.  Among  1000  gastric  ulcers,  parotitis 
developed  in  4.5  per  cent,  on  the  strictest  diet,  but  only  in  0.4  per  cent, 
when  water  was  given  by  mouth  (Rolleston  and  Oliver) .  ^Yater  may  be 
given  by  rectum  or  food  by  the  duodenal  tube. 

3.  Pain. — Rest  of  the  stomach  relieves  pain  in  most  cases;  small 
doses  of  opium  or  atropine  by  rectum,  may  be  given,  but  there  is  danger 
of  the  habit. 

4.  SuPERACiDiTY. — ^Treatment  should  be  initiated  after  one  week  of 
gastric  rest.     Massive  doses  of  sod.  bicarbonate  5ss-j  in  a  starch  wafer. 


PLATE  XIV 


Fig.    1 


Fig.    2 


Fig.  1. — Uleer  of  Lesser  Curvature,  Retraction  of  Lesser  Curvature,  draw- 
ing Pylorus  up  and  to  the  left.  The  so-called  "snail-form,"  described  .by 
Haudek.     (Radiologist,  Dr.  Learning.) 

Fig.  2. — Ulcer  of  Lesser  Curvature  and  Pylorus.  The  typical  bowl- 
shaped  bismuth  residue  is  not  as  niarked  as  is  usual,  although  pyloric 
stenosis  exists.     (Radiologist,  Dr.  Busby.) 


Fig.  8 


Fig.  4 


Fig.  S.  —  Uleer  of  Lesser  Curvature.  Spasmodic  Incisure  of  Greater 
Curvature.       (Radiologist,  Dr.  Busby.) 

Fig.  4. — Ulcer  of  Pylorus  with  Adhesions  and  Distortion,  Closely  Resem- 
bling  Carcinoma.     (Radiologist,  Dr.  Busby.) 


(From  Lockwood's  Diseases  of  the  Stomach.) 


ULCER  OF   THE  STOMACH  AND  DUODENUM 


517 


Cancer. 


Ulcer. 


Chronic 
gastritis. 


Gastralgia. 


Hjrperchlor- 
hydria. 


Collat- 
eral 

Symptoms 
Course 


75  per  cent,  over  40 
years.' 

Heavily  coated. 
Usually  anorexia. 

Often  pyrosis. 

TTSiTa  11  y  fetid 
belching. 

The  pain  is  less  in- 
tense, but  more 
constant;  sel- 
dom free  in- 
termissions,  dur- 
ing  which  no 
distress  is  felt  in 
gastric  region. 
Pain  not  in- 
creased at  the 
height  of  diges- 
tion. Tenderness 
less  frequent  and 
intense. 


Usual.  Hours  after 
eating  or  once  a 
day  or  alternate 
days,  etc.  Copious, 
coarse  mucus, 
fermented. 

Frequent — small, 
dark,  like  coffee 
grounds,  decom- 
posed, usually  late 
in  disease. 

Early  reduction 
HCl  and  later, 
total  absence;  fer- 
ments decreased 
or  absent;  lactic 
acid  present;  im- 
paired motility 
and  absorption; 
abundant  mucus, 
Oppler-Boas  bacil- 
lus— yeast — pos- 
sibly  tumor 
shreds;  coarse,  un- 
digested particles 
of  food. 

In  80  per  cent. 


Cachexia — edema. 


Part  of  a  year. 


75  per  cent,  un- 
der 40  years — 2 
zo  4  times  oft- 
ener  in  women. 

Usually  clean 
and  red. 

Good;  only  fears 
to  eat. 

Water  brash. 

Usually  absent. 

Intense;  appears 
shortly  after 
meals;  grows 
severer  on  pres- 
sure  ;  disap- 
pears at  the  end 
of  digestive 
period ;  per- 
fectly  free 
periods  more 
frequent;  par- 
oxysmal. 


Frequent — -at 
height  of  diges- 
tion— smaller 
amount,  finely 
homogeneous, 
no  mucus,  acid. 

Frequent — co- 
pious, bright; 
may  be  early 
symptom. 

Hyper  chlor- 
hydria  often; 
ferments  nor- 
mal or  in- 
creased; no 
lactic  acid  or 
Oppler-Boas 
bacilli;  food 
well  digested. 
No  mucus. 


In  but  one  pro 
miUe  (from  py- 
loric spasm, 
hypertrophy, 
cicatrix,  etc.). 

Absent. 


Longer;  helped 
by  treatment — 
aggravated    by 


Males. 


Grayish-white 

fur. 
Poor. 

Frequent. 
Copious. 

May  be  present 
but  not  pro- 
nounced and 
rarely  actual 
pain  but  ten- 
derness of 
diffuse  char- 
acter. Lanci- 
nating pains 
in  atrophic 
gastritis  only. 


Women. 


Normal. 


times  perverted. 
None. 
Variable. 

The  pain  appears 
without  regu- 
larity, and  not 
dependent  upon 
meals;  may  be 
relieved  by  pres- 
sure; intervals 
of  several  days 
free  from  pain. 
Tenderness  rare; 
conforms  to  out- 
lines of  the 
stomach.  Elec- 
trical test_(Leube) 
during  digestion; 
if  pain  decreases, 
it  is  gastralgia; 
if  it  does  not, 
may   be   ulcer   or 


Frequent;    mu- 
cus. 


None. 


Decreased  HCl 
(rarely  in- 
creased, gas- 
tritis acida) ; 
later  may  be 
achylia.  Much 
mucus. 


None. 


Absent. 


Chronic;  helped 
by  treatment 
—  aggravated 
by  arsenic. 


Males. 


Clean. 


Variable.        Some-lGood,     often 


Rare;  no  mucus. 


None. 


Normal  or  vari- 
able. If  HCl  is 
decreased,  the  fer- 
ments are  normal. 


increased. 
Present. 
Usual. 

The  pain  ap- 
pears, about 
one  or  two 
hours  after 
meals,  disap- 
pears after 
eating,  espe- 
cially meat, 
milk  or  eggs, 
or  after  the 
administra- 
tion of  bicar- 
bonate of  so- 
dium. Pain  is 
less  regular. 


Much  less  fre- 
quent, then 
acid  and  no 
mucus. 


None. 


Absent.      Nervous 
stigmata  often. 

Arsenic  helps. 


None. 


As  in  ulcer. 


None  (very 
rarely  from 
pyloric  spasm) . 


Absent. 


Like  ulcer. 


followed  by  a  swallow  of  water,  give  the  best  results.  Then  Carlsbad 
water  should  be  given,  in  small  quantities  and  in  sips ;  it  consists  of  sodium 
sulphate  50,  sodium  bicarbonate  6  and  sodium  chloride  3  parts ;  it  neutral- 
izes the  acid,  aids  intestinal  digestion  and  cleanses  the  stomach  (half- 
an  ounce  of  the  salts  in  a  pint  of  water,  taken  in  quarters  every  ten 
minutes,  the  last  dose  one-half  hour  before  meals).  Alkalies  operate 
also  on  the  duodenum  relaxing  the  pylorus.   Roberts  prescribed  a  lozenge 


518  DISEASES  OF  THE  STOMACH 

composed  of  magnesium  carbonate  grains  3|,  chalk  grains  2|,  sodium 
chloride  grain  1,  which  dissolved  slowly  in  the  mouth,  increased  the  sali- 
vary flow  and  neutralized  the  excess  of  acid  {v.  i.  5  and  6) . 

5.  Diet. — ^After  a  week  of  rectal  feeding,  eight  to  ten  meals  daily  of 
predigested  milk  with  soda  should  be  given  in  small  quantities.  Cooked 
milk  is  more  easily  digested  and  curds  less.  The  casein  engages  and 
neutralizes  the  acid.  If  peptonized  milk  is  distasteful  or  the  stomach  is 
irritable  it  may  be  administered  as  a  thin  gruel.  Potato  puree,  arrow- 
root, wheat-meal,  baby  foods,  buttermilk,  soups  with  meal  and  alkalies 
which  precipitate  the  casein  in  finer  form  and  ice-cream  may  also  be  given ; 
but  the  milk  diet,  recommended  by  Cruveilhier  is  most  efficacious.  After 
the  patient  has  been  on  the  above-mentioned  diet  for  ten  days,  soups, 
rice,  sago,  soft-boiled  eggs,  calves'  brains  and  chicken  may  be  adminis- 
tered. Slightly  boiled  or  poached  eggs  are  digested  better  than  raw 
eggs  and  may  be  given  with  bread-crumbs  from  the  inside  of  the  loaf. 
Custards  may  be  given.  Tea  and  coffee  should  be  forbidden.  Strauss 
has  found  that  sugar  lessens  the  amount  of  acid.  Cohnheim  gives  olive  oil 
freely  at  all  times  to  relieve  spasm  and  inhibit  hyperchlorhydria;  it 
also  protects  the  surface  of  the  ulcer,  promotes  regurgitation  of  the  alka- 
line duodenal  contents  into  the  stomach,  increases  nutrition  and  lessens 
constipation.  After  fifteen  days  Leube  permits  grated  beef,  and  after 
about  another  week  tender  roast  beef,  chicken  and  pigeon,  to  which  others 
would  add  lamb,  macaroni,  thymus  gland  and  bread.  After  the  fifth 
week  roasts  and  souffles  may  be  given.  The  Lefihartz  diet,  which  allows 
ice-cold  milk  and  eggs,  sugar  and  egg,  raw  minced  beef  and  ham,  rice, 
etc.,  is  of  higher  caloric  value;  it  is  given  even  at  once  after  hematemesis 
on  the  ground  that  increased  nutrition  promotes  cicatrization.  The 
practitioner  will  find  the  first  method  superior,  but  the  writer  with- 
holds meat,  meat  extractives  (in  soup)  and  salt  for  months  after  the 
ulcer  course. 

6.  Drugs. — Bismuth  relieves  pain  and  is  taken  most  advantageously 
in  olive  oil,  but  it  has  no  curative  value.  Fleiner,  Kussmaul  and  others 
administer  bismuth  by  means  of  the  stomach-tube.  Large  doses  may 
accumulate  in  the  ulcer,  the  drug  is  expensive  and  the  subnitrate  may 
cause  nitrite  poisoning,  methemoglobinemia,  cyanosis,  fever,  salivation, 
vomiting,  cramps,  dyspnea,  collapse  and  the  black  line  on  the  gums, 
whence  the  subcarbonate  is  preferable.  Belladonna  relieves  pain,  relaxes 
the  pylorus  and  lessens  hyperacidity  by  its  vagal  action.  Silver  is  used 
to  wash  the  stomach  before  meals  (Reichmann) ;  it  is  readily  precipitated 
and  may  produce  nausea,  diarrhea  and  even  argyria. 

7.  Symptomatic  Treatment. — Pain  is  best  relieved  by  rectal  alimen- 
tation, as  is  vomiting,  which  sometimes  may  necessitate  the  adminis- 
tration of  bismuth,  belladonna  or  minute  doses  of  phenol.  Hemorrhage 
is  treated  by  absolute  rest  of  the  stomach,  intestine,  mind  and  body; 
morphine  quiets  peristalsis  and  mental  excitement.  Styptics,  astringents, 
fomentations  and  ergot  are  contra-indicated.  Syncope  promotes  spon- 
taneous coagulation  and  stimulation  should  be  avoided  as  long  as  possible. 
In  severe  hemorrhages  adrenalin  (gtt.  x,  1  to  1000  solution)  and  horse 
serum  are  indicated;  saline  transfusion  should  be  considered,  but  more 


CANCER  OF   THE  STOMACH  519 

than  one  pint  seldom  should  be  given,  for  death  has  occurred  from 
reaction  and  renewal  of  hemorrhage. 

8.  Surgical  Treatment. — Most  cases  heal  absolutely  or  improve 
greatly  under  proper  medical  treatment;  this  is  especially  true  of  fresh 
ulcers.  Leube's  last  series  (v.  s.)  of  627  ulcers,  gave  2.5  per  cent,  mortality 
in  the  cases  of  hemorrhage;  in  the  cases  without  hemorrhage,  the  mor- 
tality was  0.3  per  cent.,  the  complete  cures  90  per  cent.,  the  improved 
cases  8.5  per  cent,  and  the  failures  1  per  cent.  Clairmont,  with  gastro- 
enterostomy, obtairied  complete  cures  in  but  52  per  cent,  and  improve- 
ment in  15  per  cent.;  a  comparison  with  Leube's  figures  is  suggested;  the 
average  surgical  mortality  is  6  per  cent.,  though  the  figures  of  Robson, 
Mayo  and  Moynihan  are  close  to  1  per  cent. ;  156  cases  of  sequential  jejunal 
ulcer  are  recorded,  and  the  gastric  ulcer  returned  in  20  per  cent,  of 
gastro-enterostomy  cases.  Excision  of  callous  ulcers  entails  a  5  per 
cent,  death-rate,  not  a  high  figure  in  consideration  of  the  frequency  of 
carcinomatous  degeneration.  Perigastric  adhesions  or  abscess  and  col- 
lections of  pus  beneath  the  diaphragm,  necessitate  operation.  In  cases 
of  perforation  if  operation  is  undertaken  within  twelve  hours,  71  per  cent, 
recover. 

Surgical  interference  is  necessary  in  a  limited  number  of  cases.  The 
writer's  conclusions  are  that  (i)  fresh  ulcers  always  and  (ii)  chronic  ulcers 
in  far  over  half  the  instances  belong  to  internal  medicine;  (iii)  half  the 
"inveterate"  cases  respond  to  medical  treatment;  (iv)  some  of  the  cases 
with  "chronic  dyspepsia"  and  almost  none  of  the  cases  with  hemorrhage 
call  for  surgical  interference;  (v)  the  results  of  operation  are  disappoint- 
ing; and  (vi)  no  proof  exists  that  ulcers  heal  better  with  gastro-enteros- 
tomy than  with  medical  treatment. 


CANCER  OF  THE  STOMACH. 

Cancer  of  the  stomach  constitutes  33  to  50  per  cent,  of  all  cancers 
and  is  found  in  1  per  cent,  of  autopsies. 

Etiology. — This  is  as  obscure  as  in  other  carcinomata.  (a)  Age: 
According  to  Lebert  1  per  cent,  occurs  in  persons  under  thirty  years; 
18  per  cent,  between  thirty  and  forty;  61  per  cent,  between  forty  and 
sixty  and  20  per  cent,  in  those  over  sixty  years  of  age.  Rare  congenital 
cases  are  recorded.  Of  late  years  cancer  is  becoming  more  frequent  in 
relatively  young  persons,  (h)  Heredity  is  noted  as  an  etiological  factor 
in  6  to  17  per  cent,  and  in  Broca's  series  there  were  15  instances  among 
a  family  of  26.  (c)  Ulcer  of  the  stomach  is  a  frequent  antecedent; 
C.  Graham  found  ulcer  in  60  per  cent,  of  his  cases — a  higher  figure  than 
is  found  in  general  practice  (4  per  cent.).  Trauma,  external  pressure, 
as  in  shoemakers,  or  internal  ulceration,  pulmonary  tuberculosis  and 
alcoholism  are  slightly  predisposing  factors. 

Pathology. — (a)  In  origin  it  is  an  abnormal  growth  of  the  glandular 
epithelium  (Waldeyer),  which  unlike  mere  adenomatous  or  papillomatous 
proliferations,  extends  beyond  the  mucosa  into  the  other  coats  of  the 
stomach  and  very  often  into  other  organs  and  tissues.     Cancer  may 


520  DISEASES  OF  THE  STOMACH 

develop  in  the  normal  or  atrophied  mucosa  or  in  open  or  cicatrized  ulcers. 
(b)  It  is  almost  always  primary  and  is  very  rarely  metastatic  or  extends 
to  the  stomach  by  contiguity;  secondary  growths  are  usually  from 
mammary  or  pancreatic  cancer;  Welch  collected  37  cases.  It  is  almost 
invariably  single. 

Histology  and  Morphology. — A  tumor,  in  the  clinical  sense,  usually 
develops,  although  in  some  cases  the  cancer  is  infiltrative  and  flat  {car- 
cinoma ylanum).  There  are  three  main  types:  (a)  Carcinoma  fibrosum 
(scirrhus),  the  most  frequent  type,  contains  much  poorly  vascularized 
stroma  and  relatively  little  carcinomatous  tissue ;  it  is  hard  and,  leading 
to  much  induration,  is  prone  to  stenose  the  pylorus,  where  it  is  especially 
frequent,  or  the  cardia;  if  it  is  diffuse,  it  causes  the  stomach  to  shrink 
(carcinoma  atrophicans);  its  onset  is  insidious;  it  grows  slowly  and 
ulcerates  less  than  other  types.  (6)  Carcinoma  mechiUare  is  next  in  fre- 
quency; the  cell  elements  preponderate;  there  is  much  soft,  vascular 
tissue  and  the  knife  scrapes  out  much  "cancer  juice";  it  may  form 
cauliflower-like  exuberances;  early  extensive  degeneration,  ulceration 
and  metastases  are  common;  this  type  includes  the  cylindrical-celled 
adenocarcinoma,  epithelioma  and  the  very  vascular  fungus  forms,  (e) 
Carcinoma  gelaiinosum  (coUoides)  is  least  frequent;  it  produces  nodular 
tumors  or  diftuse  infiltrations,  which  contain  colloid  material ;  it  inclines 
rather  to  extension  by  contiguity  than  to  metastatic  deposits. 

The  gastric  mucosa  shows  focal  wasting  of  the  peptic-  and  acid-secreting 
epithelium  and  substitution  by  cylindrical  epithelium,  round  cells  and 
connective  tissue.  This  secondary  atrophic  gastritis  explains  the  chemism 
of  gastric  cancer,  viz.,  diminution  in  the  secretion  of  acid,  rennet  and 
pepsin;  in  some  cases  after  surgical  extirpation  of  the  tumor,  the  secretion 
of  acid  and  pepsin  has  returned. 

Localization.- — Cancer  occurs  (a)  in  the  pylorus  in  about  60  per  cent., 
(6)  in  the  lesser  curvature  in  20  and  (c)  in  the  cardia  in  10  per  cent,  of 
cases;  i.  e.,  about  90  per  cent,  of  cancers  occur  in  these  sites;  this  is 
explained  by  their  greater  exposure  to  mechanical  insult,  their  relative 
fixation  and  the  greater  muscular  activity  of  the  pylorus  and  cardia. 
Many  tumors,  apparently  pyloric  in  origin,  begin  in  the  lesser  curvature, 
whence  a  palpable  pyloric  tumor  often  means  one  of  considerable  exten- 
sion; this  is  an  important  surgical  point. 

Complications. — (a)  Ulceration  results  from  inadequate  vascularization; 
it  is  usually  central  and  does  not  depend  on  the  size  of  the  tumor.  The 
tumor  may  ulcerate  almost  completely  and  Ziegler  observed  total  disap- 
pearance, though  metastases  declared  the  nature  of  the  scar,  (b)  Hemor- 
rhage or  slow  seeping  of  blood  is  caused  by  ulceration,  as  is  also  (c)  j^er- 
foration  (3  per  cent.)  into  the  peritoneum  or  by  adhesions  into  adjacent 
abdominal  organs  or  vessels,  into  the  lung,  pleura,  pericardium  or  the 
abdominal  wall,  of  which  latter  25  cases  are  recorded  (Taussig);  per- 
foration is  often  prevented  by  adhesions,  (d)  Stenosis  of  the  cardia 
or  pylorus  is  common,  sometimes  causing  hypertrophy  of  the  muscle 
fibers,  which  on  section  of  the  stomach  appear  as  red  lines,  (e)  Dila- 
tation of  the  stomach  follows  pyloric  obstruction;  atrophy  is  observed 
in  cardiac  localization  or  in  carcinoma  atrophicans  (diffuse  cancer)  and 


CANCER  OF   THE  STOMACH  521 

hour-glass  deformation  may  result  when  an  annular  scirrhus  develops 
in  the  mid-stomach.  (/)  Local  extension  by  contiguity  occurs  by  the 
submucous  lymphatics  with  early  involvement  along  the  lesser  curva- 
ture ;  the  peritoneum  is  often  involved  and  less  often  there  is  extension 
to  the  portal  vein,  spleen,  esophagus  or  colon,  (g)  Metastases  occur 
in  50  per  cent.,  in  the  liver,  peritoneum,  lymphatics,  pancreas  and 
lungs. 

Symptoms. — General  Clinical  Picture. — Anorexia,  distaste  for 
meats,  gastric  oppression  and  eructations  after  eating,  mark  the  usually 
insidious  onset,  and  generally  the  dyspepsia  develops  in  a  patient  pre- 
viously free  of  gastric  symptoms.  Less  frequently  the  disease  begins 
acutely  or  follows  closely  on  symptoms  of  gastric  ulcer.  Vomiting  occufs, 
and  then  distress  after  eating  solid  food  and  mechanical  or  secretory 
insufficiency.  There  is  gradual  loss  of  weight,  strength  and  endurance. 
Examination  reveals  anemia,  cachexia,  emaciation,  lax  skin,  flabby 
muscles  and  often  a  tumor  near  the  pylorus.  A  test  meal  shows  imper- 
fectly digested  food  and  absence  of  free  hydrochloric  acid.  The  symp- 
toms progress  steadily  or  remissions  occur,  especially  early  in  the  disease. 
The  ankles  become  puffy  and  the  prostration  is  profound.  Ulceration 
may  relieve  pyloric  or  cardiac  stenosis,  but  gradually  within  a  year  after 
the  first  marked  symptoms  death  results  from  the  exhaustion  due  to  pain 
or  vomiting,  local  complications  or  intercurrent  disease. 

1.  General  Digestive  Symptoms. — (a)  The  tongue  is  heavily  coated, 
not  being  cleaned  by  mastication,  and  there  is  a  bad  taste  in  the  mouth. 
The  appetite  is  decreased  or  absent  in  85  per  cent.,  specially  for  meat 
and  fats;  the  appetite  may  be  normal  when  the  motor  power  is  good  and 
cancer  develops  on  an  ulcer,  (b)  Pain,  present  in  90  per  cent.,  is  usually 
diffuse,  dull,  oppressive  and  less  severe  than  in  ulcer.  Boas  describes  a 
grating  sensation.  It  is  increased  several  hours  after  eating  or  in  the 
night,  but  is  not  wholly  relieved  by  vomiting  or  dieting.  Localized 
pain  and  tenderness  are  suggestive  of  circumscribed  peritonitis.  Pain 
may  be  reflected  to  the  sternum,  shoulders  and  acromion,  (c)  Vomiting 
(in  85  per  cent.)  is  an  obstinate  and  rather  late  symptom,  resulting 
chiefly  from  pyloric  stenosis.  It  appears  late  in  the  day  or  in  the  night, 
and  may  occur  only  on  alternate  days.  There  may  be  no  vomiting  in 
cancer  of  the  curvatures,  in  diffuse  cancerous  infiltration  involving  the 
muscularis  or  in  pyloric  cancer  when  ulceration  is  marked.  The  fre- 
quently fetid  vomitus  contains  much  mucus,  poorly  digested  food, 
little  or  no  free  hydrochloric  acid,  much  lactic  acid  and  often  blood, 
which  may  be  obvious  or  occult.  Sudden  vomiting  may  be  the  first 
symptom.  Fecal  vomiting  usually  indicates  gastrocolic  fistula  (of 
which  Voorhoeve  in  1912  collected  104  cases) ;  the  stools  in  these  cases 
may  contain  undigested  meat  (lientery) — "the  patient  vomiting  into 
his  own  bowel."  (d)  Hematemesis,  present  in  over  50  per  cent,  of 
cases,  is  due  to  parenchymatous  oozing  and  is  therefore  moderate  in 
amount;  it  is  dark  in  color,  as  the  blood  stagnates  in  the  stomach  and  is 
converted  from  oxyhemoglobin  to  hematin.  Profuse  bleeding  occurs  in 
1  per  cent.  The  author  has  seen  4  cases  with  fatal,  profuse,  bright 
hematemesis.     (e)  Constipation  is  present  in  75  and  diarrhea  in  25  per  cent. 


522  DISEASES  OF   THE  STOMACH 

of  the  cases;  the  writer  has  seen  ichorous  stools  resulting  from  necrosis 
of  the  ileum. 

2.  Special  Gastric  Symptoms. — (a)  Tumor  is  felt  in  80  and  seen  in 
40  per  cent,  of  the  cases,  but  is  not  an  early  symptom.  It  is  most  often 
missed  in  persons  with  wide  thoraces  and  rigid  abdominal  muscles.  It 
occupies  the  right  epigastric  area,  as  an  ovoid,  irregular  mass,  best  de- 
termined when  the  knees  are  drawn  up  and  the  mouth  is  open,  after  the 
bowels  have  been  flushed  out  and  with  the  patient  in  several  postures, 
as  on  the  side,  face,  genupectoral  position,  etc. ;  in  some  cases  the  tumor 
may  be  felt  lower  or  even  on  the  left  side.  The  tumor  may  be  palpable 
one  day  and  not  the  next.  Distention  of  the  stomach  hy  gas  brings  for- 
ward tumors  of  the  anterior  wall  and  greater  curvature,  obliterates  tumors 
of  the  posterior  wall  and  lesser  curvature  and  pushes  downward  and  to 
the  right  tumors  of  the  pylorus;  motility  on  distention  excludes  adhesions. 
Distention  must  be  moderate  lest  the  stomach  rupture.  If  the  pylorus 
is  incontinent  from  ulceration  or  infiltration,  the  gas  escapes  rapidly  into 
the  gut.  A  visible  peristaltic  wave  or  gastric  rigidity  (Cruveilhier,  1852) 
suggests  pyloric  obstruction.  Percussion  is  subordinate  to  palpation 
and  inspection,  and  auscultation  occasionally  elicits  friction  or  a  stenotic 
murmur  over  the  abdominal  aorta.  Respiratory  excursion  is  often 
present,  though  less  than  the  excursion  of  the  liver  or  spleen;  if  adherent 
to  the  omentum  there  is  no  excursion.  If  non-adherent  tumors  of  the 
stomach,  intestine  and  omentum  are  grasped  at  the  height  of  inspi- 
ration their  ascent  during  expiration  can  be  prevented  (Minkowski's 
expiratory  fixation);  on  the  other  hand,  tumors  of  the  liver,  spleen 
or  stomach  (if  adherent  to  the  liver)  must  ascend  during  expiration. 
(h)  Chemisvi:  (i)  Bird  (1842)  and  Van  der  Velden  (1879)  noted  the 
achlorhydria  of  gastric  cancer.  Absence  or  decrease  of  hydrochloric  acid 
is  not  pathognomonic,  as  it  is  also  absent  in  nervous  dyspepsia,  fevers, 
cardiac,  renal  or  hepatic  disease,  pernicious  anemia,  cachectic  states, 
gastric  atrophy,  amyloid  degeneration  and  toxic  gastritis;  hydrochloric 
acid  is  absent  in  66  per  cent,  and  decreased  in  33  per  cent,  of  carcinoma 
involving  other  organs  than  the  stomach;  the  writer  has  seen  many  cases 
of  rectal  cancer  in  which  digestive  symptoms  and  achlorhydria  led  to  an 
erroneous  diagnosis  of  gastric  cancer.  In  cancer  it  is  due  to  the  secondary 
atrophic  gastritis.  An  Ewald  test  breakfast  is  withdrawn  in  an  hour 
and  tested  as  described  under  Chronic  Gastritis.  If  there  is  no  stagnation 
the  total  acidity  ranges  from  6  to  8 ;  in  stagnation  it  is  higher  from  lactic 
and  other  organic  acids.  The  absence  of  free  acid  is  observed  early, 
while  the  total  acidity  remains  normal;  later  the  total  acidity  is  decreased. 
Free  acid  may  persist,  both  in  those  cases  which  develop  from  peptic 
ulcer  and  in  those  without  this  antecedent.  The  gastric  contents  are 
often  fetid,  (ii)  The  pepsin  and  rennet  are  decreased  in  66  per  cent,  of 
cases,  (iii)  Lactic  acid  is  present  in  75  per  cent,  of  cases  (Croner  and 
Riitimeyer),  and  though  also  present  in  atony,  gastritis  and  pyloric 
obstruction,  85  per  cent,  of  cases  in  which  it  is  found  are  gastric  cancer 
(Schift") ;  it  does  not  develop  early.  The  factors  involved  in  its  formation 
depend  on  the  reduced  hydrochloric  acid,  motor  insufficiency,  stagnation, 
pyloric  obstruction,   slow  absorption  and  probably  poor  digestion  of 


PLATE  XV 


Oppler-Boas  Bacillus  in  Vomitus.     (Musser.) 


CANCER  OF   THE  STOMACH  523 

proteids;  in  the  normal  stomach  it  is  absorbed  as  fast  as  formed  (Sticker) } 
(c)  Micruscopicalh/  the  thread-hke,  Gram-positive  (Plate  XY)  Oppler- 
Boas  bacilli  appear  in  the  test  meal,  feces,  or  in  clumps,  in  the  fenestrse 
of  the  stomach-tube.  They  produce  lactic  acid  in  the  presence  of  proteids 
which  act  like  ferments  and  originate  from  the  tissues  or  the  cancer; 
the  bacilli  pomt  strongly  to  the  existence  of  cancer,  but  may  occur  in 
ulcer  and  atrophic  gastritis  (with  hypertrophy  of  the  pyloric  musculature). 
Small  particles  of  tumor  tissue  or  sarcinae  are  rarely  observed.  Occult 
hemorrhage,  i.  e.,  blood  seen  only  with  the  microscope  or  detected  chemic- 
ally or  spectroscopically,  has  the  same  significance  as  in  gastric  ulcer, 
but  is  more  frequent  (95  per  cent.) ;  pus  in  the  fastmg  and  washed  stomach 
is  very  important,  {d)  Motility:  Aspiration  of  the  fasting  stomach 
demonstrates  stagnation  in  over  tliree-fourths  of  the  cases;  disturbed 
motility  may  appear  very  early  in  the  disease.  The  stomach  is  usually 
much  dilated  in  patients  whose  appetites  persist  and  little  dilated  in  those 
with  anorexia.  If  the  stomach  is  empty  after  seven  hours,  good  motility 
alone  is  proved,  not  good  digestion.  Every  case  of  stagnation  should 
arouse  suspicion  of  carcmoma.  The  recent  tr}T)tophan  reaction  has  no 
great  or  early  clinical  value;  it  depends  upon  the  fact  that,  in  gastric 
carcinoma,  the  ingested  proteins  are  split  into  more  elaborate  products, 
amino-acids,  than  in  normal  digestion. 

3.  Other  SriiPTOMS  .\xd  Complications. — (a)  Cachexia  is  more 
than  malnutrition;  it  is  probably  the  result  of  toxins  which  break  dov;*!! 
the  proteids.  The  body  weight  is  usually  greatly  reduced;  in  exceptional 
cases  it  may  temporarily  increase,  as  in  pyloric  stenosis  or  from  hope, 
as  in  a  patient  who  gained  70  pounds  after  operation.  The  skin  itches 
and  is  anemic  or  clay-colored,  somewhat  resembling  the  tint  of  pernicious 
anemia,  though  distinguished  (i)  by  its  later  appearance,  (ii)  by  its 
association  with  loss  of  weight,  (iii)  by  the  red  cells  being  seldom  lower 
than  2,000,000  (60  per  cent,  being  between  2,000,000  and  4,000,000) 
and  the  hemoglobin  seldom  below  40  per  cent.;  and  (iv)  by  the  leuko- 
cytosis (see  Pernicious  Ant:mia).  Schneyer  described  the  absence  of 
the  digestite  leuJiOcytosis;  it  occurs  in  only  half  the  cases.  As  in  nephritis 
or  chlorosis,  the  face  may  not  show  the  real  anemia;  the  ■v\Tinkling  and 
wastmg  of  the  hands  and  face  and  the  melasticity  of  the  skin  may  be  far 
more  significant.  (6)  The  urine  is  decreased  from  poor  absorption  and 
vomiting,  the  physiological  change  in  the  acidity-cm-ve  after  eating  is 
absent,  the  urea  is  increased  from  increased  toxemic  catabolism,  albu- 
minuria is  present  in  35  per  cent,  of  cases  and  indicanuria  is  common,  (c) 
Toxemic  symptoms.  Fever  of  a  low,  irregular  or  mtermittent  type  results 
in  half  the  cases,  from  the  cancer  products,  from  septic  absorption  through 
the  ulcer  or  from  complications.  Coma  closely  resembling  coma  diabeti- 
cum  may  result  from  the  cancer  toxins  or  the  breaking  doTMi  of  the 

1  As  a  test  meal  Boas  emploj^s  1.5  per  cent,  oatmeal  to  100  parts  of  water,  given  at  night 
after  lavage;  the  gastric  contents  are  tested  the  next  morning;  the  Uffelmann  method  is 
employed  as  modified  bj-  Strauss,  for  phosphates,  alcohol  and  sugar  also  give  the  reaction; 
5  c.c.  of  the  gastric  filtrate  are  added  to  25  c.c.  of  ether  and  shaken  in  a  burette;  the  lower 
25  c.c.  are  drained  away  and  25  c.c.  of  distilled  water  are  added  to  what  remains  in  the 
burette  (the  ctheral  extract).  Two  drops  of  a  10  per  cent,  solution  of  ferric  chloride  and 
20  c.c.  of  water  are  added;    the  hhw  solution  turns  to  green  if  lactic  acid  is  present. 


524  DISEASES  OF   THE  ."^TOMACH 

proteids:  acetonuria  ]ia5  been  noted.  Phlebitis  and  the  less  common 
multiple  neuritis,  tetany  and  amaurosis  are  toxemic,  id)  Metastases 
or  extension  hy  contiguity:  Enlargement  of  Virchow's  supraclavicular 
gland  may  result  from  any  abdominal  carcinoma,  but  50  per  cent,  are  due 

to  cancer  of  the  stomach  fTroisierj ;  enlargements  of  the  para-  and  peri- 
umbilical glands  or  of  the  umbilicus  itself  TQuenu  and  Longuetj  are 
late  SATnptoms.  Tansini  remarks  that  the  abdomen,  sunken  in  pyloric 
stenosis,  becomes  distended  in  peritoneal  diff'iision.  Liver  deposits  may 
appear  before  any  stomach  SATuptoms.  Icterus  occurs  in  5  per  cent. 
Schnitzler  remarked  metastasis  in  Douglas's  cul-de-sac,  stenosing  the 
rectum  but  T\dthout  ulceration  in  it;  Boas  rates  its  frequency  at  25  per 
cent,  (e)  Ascites  results  from  the  cachexia  and,  like  the  swelling  of  the 
ankles,  appears  late  in  the  malady.  Some  cases  are  due  to  carcinomatous 
peritonitis,  the  fluid  often  shoeing  blood  and  cancer  cells,  with  mitoses 
(Dockj,  and  others  result  from  glands  or  tumor  compressing  the  porta' 
heyatis.     (f)  Perjoration  may  occur  ix.  Pathology,. 

Cancer  of  the  cardia  presents  sjinptoms  Hke  those  of  esophageal  cancer 
{q.  v.).  SATuptoms  may  be  absent.  The  stomach  is  never  distended. 
There  may  be  tenderness  under  the  xiphoid.  The  tumor  when  advanced 
may  be  palpated,  as  well  as  the  perigastric  lymph  nodes. 

Diagnosis. — Diagnosis  is  easy  in  the  tA'pical  case.  No  single  fuiding, 
as  achlorhydria  or  even  tumor,  is  pathognomonic;  only  the  grouping 
of  syrnptorns  and  signs  is  final.  Single  analyses  of  the  stomach  contents 
are  often  deceptive;  they  should  be  repeated  frequently  and  considered 
in  comiection  with  other  findings,  ^'omiting  m  middle  or  ad\'anced 
life  is  suspicious  when  accompanied  by  emaciation,  anemia,  pruritus 
and  insomnia.  AVith  absence  of  hydrochloric  acid  and  the  ferments, 
the  findings  of  tumor,  blood,  lactic  acid,  Oppler-Boas  bacilli  and  dilated 
stomach  are  positive.  The  diagnosis  may  be  doubtful,  even  in  the  presence' 
of  pyloric  tumor,  emaciation  and  gastric  dilatation,  when  hydrochloric 
acid  is  present;  the  tumor  may  then  be  due  to  peptic  idcer,  hypertrophy 
of  the  pyloric  musculature  or  pyloric  spasm  due  to  hyperchlorhydria ; 
in  the  last  instance  the  tumor  is  alternately  hard  and  then  soft.  The 
diagnosis  between  beginning  cancer,  nervous  dyspepsia  and  atrophic 
gastritis  must  be  reserved  for  a  time.  Atrophic  gastritis  is  more  chronic, 
often  lasting  years  -udthout  emaciation.  Youth  and  adolescence  do  not 
exclude  cancer;  m  the  young,  gastric  cancer  is  more  rapid  in  evolution, 
and  hydrops  and  peritonitis  are  more  common.  Abdominal  atheroma 
may  closely  simulate  cancer.  Ulcer  iq.  v.).  Early  diagnosis  may  be 
possible  when,  in  an  ulcer  cure,  the  patient  still  A'omits  and  occult  blood 
persists.  Achylia  and  stagnation,  in  the  fasting  stomach,  are  particularly 
suggestive.  The  meiostagmin,  isohemolytic  and  complement-deviation 
reactions  may  prove  helpful. 

'K-ray  plates  and  fluoroscopy  develop  many  decisive  results — more 
often  late  than  early  in  the  disease.  Holzknecht  holds  that  residual 
bismuth  after  six  hours  with  an  achylia  indicates  cancer  if  the  second 
bismuth  meal  shows  a  normaUy  shaped  stomach  ^thereby  excluding 
atony)  and  if  the  first  bismuth  meal  has  reached  the  splenic  flexure. 
Ragged  edges  may  appear  or  indentations,  like  finger  prints.    Bismuth 


PLATE  XVI 

Fig.   1  Fig.   2 


Fig.  1. — Carcinoma  of  Body  of  Stomach.  Rigid  Patency  of  Pylorus.  In- 
creased Motility  of  the  Colon,  Head  of  Bismuth  CoKmin  in  Six  Hours 
being  in  the  Descending  Colon.  Fluoroscopic  examination  of  this  ease 
sho-ws  duodenum  filled  with  bismuth  as  far  as  the  duodenojejunal  angle 
-within  ten  n-iinutes  after  the  ingestion  of  the  bismuth  meal.  (Radiologist, 
Dr.   Learning.) 

Fig.  2. — Carcinonia  of  the  Lesser  Curvature,  not  Involving  the  Pylorus. 
(Radiologist,  Dr    Le  Wald.J 


Carcinoma     of    Pyloric     Half    of    the 
Stomach.     (Radiologist,  Dr.  Leaming.) 


Carcinoma  of  liie   Pars  Media. 


(From  Lockwood's  Diseases  of  the  Stomach.) 


CANCER  OF   THE  STOMACH  525 

flowing  early  into  the  duodenum  denotes  pyloric  insufficiency.  The 
narrowing  in  ulcer  is  short,  linear  and  sharply  contoured,  whereas  in 
cancer  it  is  longer,  and  its  outlines  more  vague.  The  hook-shaped  picture 
means  an  operable  carcinoma,  and  the  horn-shaped  picture  indicates 
inoperability.  Gastrocolic  fistula,  adhesions,  hour-glass  deformity, 
perforation  or  metastases  may  be  apparent. 

The  so-called  latent,  dyspeptic,  gastralgic,  anasarcous  and  ascitic 
forms  of  cancer,  and  those  causing  early  metastases  (for  example,  in 
the  liver,  lungs  or  bones)  and  intestinal  obstruction,  show  in  what  direc- 
tion error  may  occur.  In  some  cases  the  general  symptoms  overshadow 
the  local,  as  anemia,  fever  or  inexplicable  emaciation;  in  other  instances, 
the  local  symptoms  may  mislead,  as  finding  hypersecretion,  or  when  the 
trouble  begins  acutely,  as  in  one-quarter  of  cancer  cases  (Boas). 

Differentiation. — (a)  Pancreatic  tumors  {q.  v.)  are  deep,  fixed, 
immobile  and  disappear  on  gaseous  inflation  of  the  stomach;  the  normal 
pancreas  is  sometimes  palpable  in  meagre  subjects.  (6)  Cancer  of  the 
gall-bladder  has  respiratory  excursion  but  neither  expiratory  fixation  nor 
lateral  movement;  the  digestive  symptoms,  chemism  and  ectasia  of 
gastric  cancer  are  lacking,  (c)  In  duodenal  carcinoma  the  gastric  chemism 
is  lacking;  occult  blood  and  icterus  are  suggestive,  {d)  Cancer  of  the 
colon  is  usually  distinguished  by  the  intestinal  signs  and  absence  of 
stomach  symptoms,  (e)  Enlarged  aortic  glands  are  distinguished  by  lack 
of  altered  chemism,  and  abdominal  aneurysm  by  presence  of  expansile 
pulsation.  (/)  Omental  and  peritoneal  tumors  are  more  diffuse,  (g) 
Foreign  bodies  (hair  tumors),  subserous  lipoma,  fibromyoma  (62  cases 
reported),  myxoma  and  other  benign  gastric  tumors,  and  palpable  round 
ulcers,  are  much  rarer  sources  of  error.  Of  sarcoma  171  cases  are  reported 
(Grosset,  1912);  perforation  occurs  in  10  per  cent.;  52  were  successfully 
operated  on. 

Prognosis. — The  average  duration  is  one  year  (three  months  to  three 
years).  Death  results  from  exhaustion  by  pain  or  vomiting,  hemorrhage, 
gangrene,  perforation,  portal  pressure,  intercurrent  pneumonia,  nephritis 
and  tuberculosis. 

Treatment. — 1.  Medical  or  Palliative. — (a)  Condurango  bark  seems 
to  increase  the  appetite.  (6)  Vomiting  is  treated  as  in  gastritis,  dilatation 
and  ulcer,  but  witluless  success;  lavage  is  indicated  in  pyloric  stenosis; 
boric,  or  salicylic  acid  may  be  added  for  fermentation;  narcotics  by 
rectum,  rectal  feeding,  champagne  and  carbolic  acid,  as  outlined  before, 
are  also  useful,  (c)  Hemorrhage  is  rarely  profuse  and  usually  subsides 
on  rectal  feeding;  iron,  ergot  and  lead  should  be  avoided,  (d)  Achylia 
is  seldom  helped  by  hydrochloric  acid  or  pepsin,  (e)  Pain  necessitates 
fomentations,  lavage,  chloroform  (3  to  5  drops)  with  ice,  and  atropine 
or  opium  by  rectum.  (/)  For  constvpation ,  cathartics  are  inferior  to  warm 
colonic  flushings  or  salts,  glycerin  or  olive  oil  by  rectum,  (g)  Diarrhea 
is  lessened  by  lavage;  when  due  to  pyloric  insufficiency,  salol,  beta- 
naphtol  (aa  gr.  x)  and  opiates  are  indicated.  (//)  Stenosis  of  the  cardia^ 
may  yield  to  dilatation,  (t)  Motor  insufficiency  necessitates  lavage, 
w^hich  should  be  practised  before  supper,  (j)  The  diet  should  be  soft 
and  small  in  bulk.    Meats  and  fats  are  digested  with  difficulty.    Vege- 


526  DISEASES  OF   THE  STOMACH 

tables,  cereals,  small  quantities  of  milk,  koumyss,  honey,  pastries,  tea, 
coffee,  diluted  wine,  peptones  and  baby  foods  may  be  tolerated. 

2.  Surgical  Treatment. — Cases  having  good  surgical  prospects  are 
few,  but  operation  only  can  cure.  When  a  tumor  is  found  it  usually 
has  reached  the  pylorus  from  the  lesser  curvature,  yet  tumor  does  not 
contra-indicate  operation  {v.  X-rays).  For  resection  cases  should  reach 
the  surgeon  before  the  tumor  is  palpable,  a  condition  possible  only  in 
private  practice,  for  hospital  cases  are  always  advanced.  Metastases, 
peritonitis,  extreme  anemia,  nephritis  and  other  visceral  lesions  and 
glandular  invasion  are  contra-indications  to  operation.  Pylorectomy 
results  in  an  immediate  mortality  of  under  30  per  cent.,  half  the  death- 
rate  in  the  time  of  Billroth,  who  did  the  first  operation  (1878).  Recur- 
rence has  been  noted  after  five  years.  Leriche  reports  one  case  well  after 
16,  and  Kocher,  after  19  years.  The  Mayos  report  resections  with  a 
mortality  of  10  per  cent.;  in  one  group  of  25  cases  only  one  case  died; 
38  per  cent,  of  their  cases  were  living  three  years  and  25  per  cent,  were 
well  five  years  after  resection.  Gastrostomy  in  cardiac  cancer  and  gastro- 
enterostomy in  pyloric  obstruction  seldom  prolong  life. 


HEMATEMESIS. 

Definition. — Hematemesis  is  not  synonymous  with  gastric  hemor- 
rhage; it  is  the  vomiting  of  blood,  which  may  issue  from  the  stomach 
or  may  reach  it  from  the  gums,  nose,  larynx,  lungs,  esophagus,  or  even 
the  intestine.  Gastrorrhagia  designates  profuse  hemorrhage  from  the 
stomach.    It  may  be  arterial,  venous  or  capillary. 

Etiology. — (a)  Various  forms  of  ulceration,  as  simple  ulcer,  carci- 
nomatous, tuberculous,  diphtheritic,  typhoid,  syphilitic,  uremic  or 
phlegmonous  ulcers,  hemorrhagic  erosions,  and  perforations  into  the 
stomach  from  without,  as  gall-stones,  or  aneurysm  dissecting  down 
from  the  arch  of  the  aorta  are  etiological  factors.  Parrot  described 
superficial  ulcers  in  the  newborn.  Dieulafoy  describes  a  pneumococcic 
hemorrhagic  gastritis.  Chiari,  Murchison  and  Dieulafoy  described 
small  smple  ulcers  causing  profuse,  often  repeated  and  fatal  hemorrhage; 
they  dievelop  in  perfect  health,  with  no  previous  stomach  symptoms; 
they  are  easily  overlooked  at  operation  or  autopsy  because  they  involve 
only  the  mucosa  or  perhaps  some  of  the  muscularis.  (6)  Trauma,  such 
as  external  violence,  or  internal  trauma,  as  from  foreign  bodies,  thermal 
or  chemical  injury,  and  violent  vomiting,  as  sea-sickness  and  hyper- 
emesis,  may  be  causal,  (c)  The  cause  may  be  vascular,  such  as  amyloid 
degeneration  which  sometimes  involves  the  stomach  and  bowels  alone, 
aneurysm,  embolism,  vicarious  congestion  from  suppressed  menstruation, 
passive  congestion  of  cardiac  or  hepatic  origin;  and  esophageal  varix 
(when  due  to  cirrhosis  of  the  liver,  there  is  in  33  per  cent,  of  cases  no 
other  evidence  of  cirrhosis) ;  Welch  and  Powell  found  varices  in  the  floor 
of  peptic  ulcers;  malarial  deposits  in  the  liver;  acute  pylethrombosis, 
causing  profuse  hemorrhage;  and  parenchymatous  oozing,  where  no 
postmortem  changes  are  found  (Hale  White  reports  36  cases  of  what  he 


NEUROSES  OF  THE  STOMACH  527 

terms  gastrotaxis) .  (d)  Nervous  causes  are  injuries  to  the  central  nervous 
system,  vasomotor  influences,  hysteria  in  which  the  blood  is  small  in 
amount  and  occurs  usually  in  the  morning  vomit,  tabetic  crises,  etc. 
(e)  Acnie  injections  may  be  etiological  factors,  as  malaria,  hemorrhagic 
exanthemata,  yellow  fever,  sepsis,  appendicitis  and  genito-urinary  sepsis; 
Busse  (1905)  collected  96  cases  following  operations;  they  result  from 
direct  embolism  (of  which  35  per  cent,  were  in  the  mesentery  or  omentum) 
or  retrograde  embolism;  the  hemorrhage  occurred  in  the  stomach  or 
bowels;  55  per  cent.  died.  (/)  Blood  diseases,  as  pernicious  anemia, 
leukemia,  hemophilia,  purpura,  scurvy  and  splenic  anemia,  may  be 
causal,  {g)  Poisons,  which  early  erode  and  later  ulcerate,  as  acids  and 
caustics,  those  causing  fatty  degeneration  of  the  vessels,  as  arsenic  and 
phosphorus,  and  uremia  or  cholemia,  may  cause  hematemesis. 

Of  all  causes,  round  ulcer  and  liver  cirrhosis  are  the  first  suggested. 

Symptoms. — ^The  symptoms  are  (a)  those  of  the  antecedent  disease, 
(b)  In  some  cases  no  blood  may  be  vomited,  and  the  incident  remains 
undiscovered,  unless  the  stools  are  examined.  In  wmitus  cruentus 
gastric  uneasiness  Is  common.  The  amount  vomited  varies  from  micro- 
scopic quantities  to  those  sufficiently  large  to  cause  death.  "Occult 
hemorrhage"  has  been  particularly  emphasized  by  Boas;  the  diet  for  days 
previously  should  contain  no  meat,  blood,  iron  or  chlorophyl,  but  solely 
eggs,  fruit,  starch  or  fat.  In  profuse  gastrorrhagia  the  blood  is  bright 
red,  if  it  remains  in  the  stomach  only  a  short  while,  as  in  most  cases 
of  peptic  ulcer.  In  smaller  hemorrhages  it  is  black  or  rust-colored,  as 
in  cancer,  uremia,  cholemia  and  various  poisonings;  rust-colored  blood 
may  become  bright  on  the  edges  or  surface  when  it  has  stood  for  some 
time.  Blood  may  issue  in  the  fluid  form,  or  as  clots,  in  which  case  it  is 
suggestive  of  valvular  disease,  vascular  disease  or  the  dangerous  hema- 
temesis of  cirrhosis ;  the  author  has  seen  large  clots  in  typhoid  and  gastric 
carcinoma,  (c)  Helena  may  render  the  stools  black,  tarry  and  offensive. 
{d)  Systemic  signs.  A  gradual  or  sudden  intense  ariemia  may  be  noted, 
with  the  usual  signs  of  secondary  anemia  (q.  v.),  vertigo,  syncope,  rapid 
pulse  and  some  dyspnea,  and  later,  amaurosis,  slight  fever,  dicrotic 
pulse,  hemic  murmurs,  moderate  edema,  albuminuria  and  ^metimes 
hemiplegia  or  convulsions.  ^ 

Diagnosis. — Differentiation  from  hemoptysis  (q.  v.),  from  the  swallow- 
ing of  blood  from  the  nipples  in  nurslings  or  from  the  vagina  in  the 
newborn,  fracture  of  the  skull,  esophageal  or  throat  disease  and  from 
simulation  of  blood  in  the  stools  from  ingestion  o^|pismuth,  coft'ee,  tea, 
claret,  iron  or  blueberries,  does  not  need  particwK"  elaboration,  as  the 
microscopic,  chemical  and  spectroscopic  examinijpon  determines  doubt- 
ful cases.      Treatment  {v.  Ulcer). 


NEUROSES  OF  THE  STOMACH. 

Neuroses  of  the  stomach  occur  as  a  part  of  a  neurosis,  as  isolated 
nervous  symptoms,  to  be  considered  under  neurasthenia  or  as  reflex 
affections. 


528  DISEASES  OF   THE  STOMACH 


I.  Secretory  Neuroses. 

These  affections  have  been  described  especially  by  Reichmann,  Ross- 
bach,  Sahli  and  Riegel. 

1.  Hyperchlorhydria. — A  qualitative  anomaly  of  gastric  secretion  in 
which  there  is  an  excessive  secretion  of  hydrochloric  acid  during  digestion; 
it  is  not  solely  a  neurosis,  though  conveniently  classified  as  such. 

Etiology, — (a)  General  etiological  factors:  (i)  It  is  most  frequent 
in  youth  and  middle  age,  the  better  situated  classes,  Polish  Jews  and 
brain-workers;  (ii)  a  neurotic  or  psychopathic  tendency  is  a  predisposing 
factor,  as  is  also  (iii)  chlorosis.  (6)  Local  causes  are  (i)  rapid  eating, 
cold  drinks  and  condiments;  (ii)  tobacco,  alcohol  and  coffee;  (iii)  gall- 
stones, constipation  and  appendicitis. 

Symptoms. — (a)  Pain,  the  chief  symptom,  varies  from  a  sense  of  dis- 
comfort in  mild  cases  to  extreme  gastralgia  in  severe  cases;  it  is  most 
marked  in  ulcer,  pyloric  stenosis  and  dietetic  vices.  It  develops  at  the 
height  of  gastric  digestion — i.  e.,  one  or  two  hours  after  eating — and  is 
due  to  the  excess  of  free  hydrochloric  acid;  the  more  food,  especially 
meat,  ingested  the  later  is  the  pain,  for  the  food  engages  the  free  acid 
longer.  Carbohydrates  cause  increased  pain  as  they  do  not  engage  the 
acid  and  amylolysis  is  decreased.  The  patient  often  feels  a  cramping 
or  spasm  of  the  pylorus.  Pain  lasts  one-half  to  several  hours.  It  is  re- 
lieved hy  vomiting  and  usually  also  by  ingestion  of  more  food  or  of  alkalies. 
(b)  Belching  and  pyrosis  are  frequent  and  the  eructated  hyperacid  fluid 
causes  a  burning  in  the  esophagus,  (c)  Vomiting  of  a  burning  sour  fluid 
is  not  frequent,  save  in  severe  cases,  {d)  The  appetite  is  usually  good, 
and  occasionally  ravenous,  (e)  Tenderness  over  the  stomach  and  gastric 
hyperesthesia  are  usually  diffuse,  moderate  in  degree,  coincident  with 
the  pain  and  associated  with  some  epigastric  distention.  (/)  Stomach 
tests  show  a  total  acidity  of  100,  even  160;  the  proteids  are  well  subdivided, 
amylolysis  delayed,  motility  and  absorption  normal  or  increased  in  un- 
complicated cases  and  no  lactic  acid,  no  fermentation  and  no  gas  are 
present,  {g)  Constipation  and  headache  are  common;  the  gums  may 
retract;  the  urine  chlorides  are  decreased,  the  acidity  lessened  during 
digestion  and  an  alkaline  reaction  and  phosphaturia  are  present. 

Diagnosis.— The  diagnosis  is  determined  by  hyperchlorhydria  in  the 
vomitus  and  test  meal,  by  the  relief  of  pain  by  vomiting  or  ingestion  of 
more  food  or  alkalies  and  by  negative  physical  findings. 

Differentiation. — (a)  Ulcer  is  marked  by  localized  tenderness,  hema- 
temesis  or  occult  bleeding  and  more  symptomatic  regularity,  ih)  Gastritis 
is  characterized  by  mucous  formation  and  decreased  secretion,  (c)  Gastro- 
succorrhea  or  continuous  secretion  {v.  i.).  (d)  Gastrectasia  and  gastroptosis 
are  excluded  by  the  .r-rays.  (e)  In  gall-stones  pain  has  no  relation  to  eating, 
occurs  at  longer,  irregular  intervals  and  is  associated  with  tenderness 
of  the  gall-bladder. 

Course  and  Prognosis. — The  disease  begins  slowly  and  may  disappear, 
to  recur  after  days  to  months,  from  irregular  living,  nervous  strain, 
excesses,   diet  or  without  obvious  cause.     The  nutrition  is  fairly  well 


NEUROSES  OF  THE  STOMACH  529 

maintained.    The  outlook  is  good  if  early  treatment  is  instituted;  com- 
plications modify  the  prognosis. 

Treatment. — 1.  Prophylaxis. — Nervous  factors,  smoking,  haste  in 
eating,  chlorosis,  etc.,  should  receive  appropriate  treatment. 

2.  Diet. — (a)  Proteids  are  most  beneficial,  for  they  take  up  the  largest 
amount  of  hydrochloric  acid,  without  increasing  the  HCl ;  veal,  beefsteak, 
mutton  and  ham  absorb  twice  as  much  hydrochloric  acid  as  other  pro- 
teids; fish  fat  and  salt  are  avoided;  milk  and  some  kinds  of  cheese  may 
be  given,  (b)  Carbohydrates  are  restricted,  because  the  early  amylolytic 
digestion  by  the  ptyalin  is  arrested;  a  slice  of  stale  bread,  biscuits, 
toast,  zwieback  or  purees  of  aleuronat  meal  may  be  tried;  Strauss 
allows  six  ounces  of  2  per  cent,  grape-sugar  solution,  unless  there  is  motor 
insufficiency.  Potatoes,  salads  and  most  uncooked  vegetables  should 
be  interdicted,  (c)  Fats  may  be  given  in  limited  quantities,  including 
small  amounts  of  cream  or  unsalted  butter  (one  ounce) ;  two  drams  of 
olive  oil  before  meals  inhibit  the  secretion  of  acid,  (d)  Condiments, 
mustard,  pepper,  vinegar,  spices,  lemon,  horseradish,  coffee,  alcohol, 
cold  foods  and  drinks  should  be  forbidden.  Cocoa  or  milk  may  be  given. 
ie)  Thorough  mastication  and  small  meals,  at  frequent  intervals,  are  most 
efficacious. 

3.  Medication. — (a)  Sodium  bicarbonate  5i,  in  a  starch  wafer  with 
but  little  water,  at  the  height  of  digestion  neutralizes  the  hyperchlor- 
hydria;  alkalies  not  only  act  chemically  but  inhibit  secretion  by  action 
on  the  glandular  cells,  (h)  Extract  of  belladonna,  i  to  ^  grain,  given  at 
meal-time,  lessens  secretion  and  mitigates  pain;  opiates  should  be 
avoided.  Nux  vomica  is  valuable,  (c)  Lavage  with  silver  nitrate  (1  to 
1000)  solution  is  useful  in  obstinate  types. 

2.  Gastrosuccorrhea  (Hypersecretion,  Continuous  Secretion). — This 
is  a  quantitative  perversion  of  gastric  secretion,  in  which  secretion  exceeds 
the  needs  of  digestion ;  the  lightest  forms  occur  only  when  food  is  ingested 
(alimentary  form);  the  severest  occur  without  ingestion  of  food.  Some 
gastric  juice  may  be  found  in  the  normal  stomach,  due  to  secretion 
initiated  by  swallowed  saliva  or  mucus,  but  over  one  ounce  is  rarely 
physiological,  (a)  The  intermittent  form  occurs  in  attacks  which  last  a 
day  or  two,  is  often  called  acute  or  nervous  dyspepsia  and  has  about 
the  same  etiology  as  hyperchlorhydria;  it  has  been  observed  during 
tabetic  crises.  Colic-like  pain  develops,  usually  at  night,  followed  by 
sour  eructations  and  repeated  vomiting,  first  of  food,  then  of  three  ounces 
or  more, of  yellowish-green  fluid  which  contains  hydrochloric  acid  and 
ferments';  there  is  seldom  blood.  During  the  attack  the  pulse  is  small  and 
rapid,  the  skin  clammy,  the  urine  scanty  and  alkaline,  and  headache 
is  frequent.  Thirst  is  great  and  drinking  may  give  temporary  relief, 
but  is  followed  by  increased  vomiting.  Between  attacks  the  acidity 
is  normal  and  the  general  health  good;  occasionally  there  is  a  constant 
sense  of  gastric  discomfort,  (b)  The  second  form  is  continuous  gastro- 
succorrhea. Its  etiology  in  most  instances  is  pyloric  obstruction  or 
pyloric  spasm  from  ulcer,  gall-bladder  disease  or  appendicitis. 

Symptoms. — (a)  Pain  is  more  marked  than  in  hyperchlorhydria, 
develops  later  after  eating  and  very  often  from  11  p.m.  to  2  a.m.; 
34 


530  DISEASES  OF   THE  STOMACH 

it  may  occur  before  meals,  for  the  gastric  secretion  is  constant,  or  in 
severe  cases,  day  and  night;  it  is  relieved  by  eating  and  vomiting,  (b) 
Vomiting  closely  follows  the  pain  and  may  occur  at  its  height  or  during 
the  night;  the  quantity  of  vomitus  is  large  when  there  is  dilatation  (a 
frequent  complication  or  a  common  cause  of  this  type).  It  contains 
hydrochloric  acid,  ferments  and  little  mucus;  vomiting  may  be  absent 
in  light  cases,  (c)  Other  digestive  symptoms.  The  tongue  is  often  red 
and  clean,  sometimes  coated.  The  teeth  are  often  carious.  The  appetite 
is  usually  good,  sometimes  ravenous  or  in  advanced  cases  poor.  The 
marked  thirst  sometimes  suggests  diabetes.  The  bowels  are  sluggish. 
{d)  The  test  meal  and  lavage  show  a  total  acidity  up  to  100  and  free  acid 
to  60.  After  a  test  dinner  the  fluid  separates  into  three  layers — ^the 
upper  foamy,  the  middle  consisting  of  yellowish  fluid  and  the  lower  one 
of  sediment  of  undigested  carbohydrates;  the  proteids  are  found  con- 
verted into  peptones.  When  the  stomach  is  washed  out  thoroughly  at 
night,  examination  on  the  next  morning  of  the  fasting  stomach  reveals 
up  to  ten  ounces  (or  even  a  pint)  of  hydrochloric  acid  and  ferments, 
i.  e.,  secretion  without  the  stimulus  of  food;  if  the  fasting  stomach  is  washed 
out  two  or  three  hours  later,  gastric  juice  is  again  found,  (e)  The  urine 
is  the  same  as  in  hyperchlorhydria.  Old  cases  show  marked  emaciation, 
even  cachexia,  lax  muscles  and  dry,  inelastic  skin. 

Course  and  Prognosis. — The  onset  is  slow  and  the  course  protracted. 
Death  from  exhaustion  may  result  in  untreated  cases.  Complications  are 
frequent,  especially  (a)  dilatation,  for  the  stomach  is  never  empty;  the 
hydrochloric  acid  does  not  inhibit  the  growth  of  sarcinse  or  yeast  and 
gases  may  generate.  The  dilatation  is  most  often  secondary.  Dilatation 
may  also  result  from  (fe)  pyloric  spasm;  in  health  the  pylorus  relaxes 
intermittently  and  allows  the  acid  chyme  to  reach  the  duodenum;  the 
pylorus  is  reflexly  contracted  by  the  acid  fluid  in  the  duodenum  until 
this  is  neutralized,  when  it  again  relaxes.  When  the  secretion  is  con- 
tinuous, the  passage  of  acid  into  the  duodenum  constantly  contracts 
the  pylorus,  which  may  be  felt  as  a  tumor.  In  this  case  cancer  may  be 
simulated,  especially  when  there  is  emaciation  or  blood  in  the  stomach. 
(c)  Tetany  is  a  rare  complication. 

Diagnosis. — The  diagnostic  features  are  pain  at  night,  vomiting,  and 
thirst,  which  are  more  common  than  in  hyperchlorhydria;  and  continuous 
secretion  after  lavage  and  during  fasting. 

Treatment. — Treatment  is  (a)  that  of  hyperchlorhydria  as  to  prophyl- 
axis, diet,  mastication  and  stimulants.  (6)  Rectal  feeding  is  a  valuable 
accessory;  water  by  rectum  quenches  the  raging  thirst,  (c)  Oral  feeding 
is  allowed  at  long  intervals;  overloading  the  stomach  with  fluids  is 
carefully  avoided,  {d)  Lavage  with  silver  nitrate  (1  to  1000)  relieves 
pain  and  hypersecretion,  (e)  Olive  oil,  alkalies  and  belladonna  are  indi- 
cated as  in  hyperchlorhydria.  (/)  Gastro-enterostomy  may  be  indicated 
by  pyloric  obstruction,  never  by  hypersecretion  per  se. 

3.  Hyposecretion. — Hypacidity  (hypochlorhydria)  and  anacidity 
(achlorhydria)  refer  respectively  to  reduction  or  absence  of  hydrochloric 
acid,  which  may  occur  from  nervous  or  organic  causes.     When  the 


NEUROSES  OF   THE  STOMACH  531 

ferments  and  acid  are  absent,  achylia  gastrica  nervosa  is  a  more  ap- 
propriate term;  the  condition  may  be  transient  or  enduring.  Suppressed 
secretion  may  occur  in  hysteria  or  tabetic  crises. 

II.  Motor  Neuroses  of  the  Stomach. 

1.  Irritative  Type. — (a)  Hyperkinesis  or  hypermotility  hurries  the  food 
into  the  intestine  in  three  to  five  hours  or  less.  It  exists  as  a  separate 
neurosis,  or  in  the  hasty  digestion  of  hyperchlorhydria  and  in  achy  ha, 
that  the  intestines  may  earher  digest  the  unaltered  food.  (6)  Peri- 
staltic unrest  or  tormina  ventricnli  nervosa  occurs  particularly  in  neuras- 
thenia and  organic  pyloric  stenosis.  In  some  cases  the  unrest  may  be 
wholly  subjective;  in  others,  both  neurotic  and  organic,  the  peristaltic 
movements  from  left  to  right  may  be  seen,  as  well  as  antiperistalsis  in 
the  opposite  direction.  Treatment  is  that  of  the  underlying  neurosis, 
(c)  Pyloric  spasm  occurs  very  seldom  as  an  independent  neurosis;  it 
occurs  usually  in  connection  with  ulcer,  hyperacidity,  hypersecretion, 
erosions,  chronic  stenosing  gastritis,  gall-stones,  cancer  of  the  stomach, 
poor  mastication  of  food  and  drinking  of  cold  fluids,  (d)  Spasm  of  the 
cardia  occurs  in  organic  disease  or  neuroses  of  the  esophagus  and  stomach; 
it  is  the  cause  of  idiopathic  dilatation  of  the  esophagus  and  the  spasm  in 
tetanus  and  hydrophobia;  it  makes  vomiting  difficult.  The  treatment  is 
causal,  (e)  Nervous  eructation  was  first  described  by  Dejardin  (1814).  It 
occurs  especially  in  sexual  neuroses.  The  odorless  nictus  results  from  swal- 
lowing of  air  (aerophagia),  which  constitutes  a  most  intractable  habit. 
Bouveret  thinks  air  is  forced  down  by  pharyngeal  contractions,  either  un- 
consciously or  during  false  eructations,  in  which  the  patient,  in  attempting 
to  raise  gas,  swallows  air;  such  large  quantities  could  never  generate  in  the 
stomach;  Bardet  estimated  that  one  patient  raised  twenty  quarts  in 
an  afternoon.  Coincident  cardiac  and  pyloric  spasm  causes  distention 
(pneumatosis) .  Treatment  lies  in  the  use  of  the  sound,  suggestive  therapy, 
the  difficult  task  of  breaking  the  habit  and  asafetida  w^hich  renders  the 
ructus  offensive.  (/)  Nervous  vomiting  occurs  (i)  only  in  the  neuroses, 
as  neurasthenia,  migraine  and  exophthalmic  goitre ;  but  under  this  caption 
we  may  bring  for  difterential  purposes  (ii)  cerebrospinal  conditions,  as 
compression  of  the  brain,  meningitis,  tumor,  tabes,  etc.,  or  toxic  con- 
ditions, as  uremia  or  cholemia.  (iii)  Most  cases  are  reflex  from  the  nose, 
as  from  disagreeable  odors;  the  respiratory  tract;  pelvic  or  abdominal 
conditions,  as  pregnancy,  menstruation,  calculi,  etc.  The  symptoms 
may  present  many  incompatible  elements;  thus  the  patient  may  vomit 
without  nausea,  almost  without  effort  like  an  eructation;  it  often  occurs 
without  pain  or  reference  to  the  fulness  or  emptiness  of  the  stomach ; 
even  though  it  is  frequent,  the  nutrition  may  be  remarkably  good,  the 
tongue  clean  and  the  appetite  good.  Periodic  or  cyclic  vomiting,  described 
by  Gruere  (1838),  has  some  resemblance  to  tabetic  crises;  Edsall  con- 
siders it  an  acidosis,  for  which  3ss-ii  of  sodium  bicarbonate  is  indicated. 
In  the  10  fatal  cases  on  record  there  was  fatty  degeneration  of  the  liver 
and  sometimes  appendicitis. 


532  DISEASES  OF   THE  STOMACH 

Robert's  conclusions  are  as  follows: 

1.  Vomiting  of  a  chronic  type,  following  a  gradual  epigastralgia,  from 
one-half  to  three  hours  after  eating,  is  attributable  to  ulcer. 

2.  Chronic  vomiting,  soon  after  food  ingestion  is  stenosis  of  the  cardia, 
nervous  abnormality,  cerebral  lesion  or  acute  gastritis. 

3.  Copious  vomiting  ten  or  more  hours  after  eating  indicates  mus- 
cular insufficiency;  frequent  repetition  indicates  stenosis. 

4.  Vomiting  in  the  night  occurs  in  cholelithiasis,  hypersecretion, 
muscular  insufficiency  and  nervous  abnormality. 

5.  Vomiting  attempts  when  the  stomach  is  empty  indicate  a  cause 
other  than  gastric,  e.  g.,  reflex  cause,  toxemic,  cerebral  or  nervous. 

6.  Morning  nausea  and  retching  indicate  pregnancy,  alcoholism, 
pharyngitis,  nephritis  or  a  nervous  abnormality. 

7.  Periodic  vomiting  of  clear  gastric  juice  in  considerable  amounts 
indicates  a  secretory  neurosis  or  ulcer. 

8.  Vomiting  as  a  sequel  of  headache,  accompanied  by  severe  nausea, 
but  no  gastric  symptoms,  characterizes  migraine. 

9.  Sudden  vomiting  with  tinnitus,  deafness  and  vertigo  is  attributable 
to  disturbances  of  pressure  in  the  internal  or  middle  ear. 

10.  Periodic  sudden  vomiting,  with  gastric  pain  and  nausea,  retraction 
of  the  abdomen,  obstinate  constipation  during,  but  not  preceding,  the 
attack  and  freedom  from  abdominal  tenderness  are  suggestive  of  the 
spinal  crises,   nervous  vomiting  and  lead  colic. 

11.  Periodic  attacks  of  vomiting  with  colic,  constipation  and  tympany 
suggest  chronic  intestinal  stenosis. 

2.  Depressive  Motor  Neuroses  (Lessened  Motility). — There  are 
three  types:  (a)  Atony,  which  has  been  considered  under  dilatation; 
(fe)  pyloric  insufficiency,  which  is  seldom  a  neurotic  condition,  as  compared 
with  its  frequency  in  cancer,  ulcer  and  duodenal  obstruction;  inflating 
the  stomach  with  carbon  dioxide,  it  rapidly  passes  into  the  intestine  with 
a  gurgling  gush,  (c)  Insufficiency  of  the  cardia  causes  regurgitation  of 
food  and  fluid;  rumination  (merycismus)  is  regurgitation  in  which  the 
food  is  again  chewed  and  reswallowed.  These  are  generally  involuntary 
processes,  but  some  neurotic  males,  psychopaths  or  idiots  can  regurgitate 
at  will.  The  affection  is  hereditary  or  imitative.  Its  mechanism  is 
congenital  weakness  of  the  cardia,  stimulation  of  the  vagus  or  aspira- 
tion into  the  esophagus  by  the  inspiratory  act.  It  should  be  treated 
by  giving  small  meals  at  frequent  intervals;  suggestive  measures  are 
indicated. 

III.  Sensory  Neuroses  of  the  Stomach. 

1.  Hyperesthesia. — A  sensation  of  burning  or  weight  usually  occurs 
when  the  stomach  is  full,  but  at  times  also  when  it  is  empty.  Carbo- 
hydrates, fats  or  spices  may  induce  the  condition.  Silver  nitrate,  gr. 
^  to  I,  or  phenol,  gr.  i  to  j,  given  on  the  empty  stomach,  often  affords 
relief. 

2.  Gastralgia. — Gastralgia  (or  cardialgia,  a  poor  but  widely  used 
term)  does  not  strictly  include  the  pain  of  ulcer,  hyperacidity  or  hyper- 
secretion.    An  etiological  classification  is  as  follows:  (i)  Cerebrospinal 


NEUROSES  OF   THE  STOMACH  533 

causes,  including  various  brain,  cord  (tabes),  peripheral  and  functional 
nervous  affections,  (ii)  Constitutional  causes,  including  chlorosis  and 
debility,  (iii)  Toxic  causes  (gout,  nicotine  and  constipation),  (iv) 
Reflex  causes,  from  the  genito-urinary  and  alimentary  tracts,  splanch- 
noptosis, uterine  or  ovarian  disease  or  masturbation.  Fliess  holds  that 
dysmenorrhea  and  gastralgia  may  arise  from  disease  of  the  lower  nasal 
turbinates.  Most  cases  occur  in  women  between  fifteen  and  forty-fivg 
years  of  age. 

Symptoms. — Severe  gastric  pain  begins  suddenly,  often  at  night,  lasts 
for  a  few  minutes  to  an  hour  or  so  and  subsides,  usually  to  recur  after 
a  variable  interval.  The  pain  may  radiate  widely.  It  bears  no  relation 
to  eating.  Diffuse  superficial  hyperesthesia  over  the  stomach  is  not 
infrequent,  but  deeper  pressure  usually  affords  some  relief.  Vomiting, 
hiccough,  hunger,  headache,  depression,  polyuria,  clammy  sweats,  rapid 
pulse  or  even  collapse  may  attend  the  seizure. 

Diagnosis. — A  diagnosis  is  made  only  by  exclusion  and  usually  after 
the  seizure.  Rheumatic  myalgia  is  more  constant.  A  tabetic  crisis  is 
at  once  recognized  by  the  Argyll-Robertson  pupil  and  the  absent  knee- 
jerks.  Intercostal  neuralgia  gives  Valleix's  three  tender  points.  In 
ulcer  or  circumscribed  peritonitis  the  pain  is  associated  with  localized 
tenderness.  Hyperacidity  and  hypersecretion  should  be  excluded.  A 
sharp  thrust  over  the  gall-bladder  during  deep  inspiration  nearly  always 
elicits  well-localized  tenderness  in  biliary  colic. 

Treatment. — Treatment  is  (a)  etiological — neurasthenia,  anemia  or 
constipation.  Fowler's  solution  ITlij  before  meals  is  excellent.  (6)  The 
attack.  Morphine  hypodermically  affords  the  only  certain  immediate 
relief,  but  in  these  very  cases  may  establish  the  habit.  If  given,  it  should 
be  exhibited  by  mouth  without  the  patient's  knowledge.  Heat  aud  ^  ' 
sinapisms  may  relieve  or  aggravate  the  attack.  Silver,  phenol,  gelsemiiij^,  r 
belladonna  and  Hoffmann's  anodyne  often  give  relief.  ^r      yr 

3.  Disturbances  in  the  Sense  of  Hunger  and  Appetite. — Loss  oT 
appetite  (anorexia)  may  be  nervous,  though  more  commonly  gastric, 
tuberculous  or  toxic.  Anorexia  nervosa  may  be  absolute  and"*  cause 
profound  emaciation.  Parorexia  is  a  perversion,  in  which  the  patient 
craves  for  unusual  foods.  In  polyphagia  the  appetite  is  enormous, 
but  is  capable  of  satiation;  in  boulimia  {Jiyperorexia)  the  polyphagia 
is  paroxysmal,  sometimes  with  vertigo,  palpitation,  etc.;  they  are 
most  frequent  in  hyperchlorhydria,  hypersecretion  and  hypermotility, 
but  also  occur  in  diabetes,  brain  disease,  intestinal  parasites  or 
from  quinine,  orexin  or  even  opium.  Acoria  is  loss  of  the  sense  of 
satiation.  These  anomalies  probably  result  from  changes  in  the  bulbar 
hunger  centre. 

IV.  Mixed  Neuroses  of  the  Stomach. 

Dyspepsia  nervosa  or  pseudodyspepsia  may  occur  as  a  species  of 
local  neurosis,  as  a  reflex  from  other  organs,  but  much  oftener  a  part  of. 
the  neurasthenic  symptom-complex.  Leube's  contention  that  digestion 
itself  is  normal  must  be  modified,  as  the  hydrochloric  acid  may  be  in- 
creased, normal  or  decreased,  but  perhaps  in  the  majority  of  cases  the 


534  DISEASES  OF   THE  INTESTINES 

gastric  functions  are  nearly  normal.  Two  main  groups  of  symptoms 
prevail:  (a)  the  centric,  neurasthenic  or  hysteric  apathy,  irritability  and 
vertigo;  (b)  the  gastric  eructations,  variations  in  appetite,  oppression 
and  diffuse  tenderness,  which  are  probably  also  cerebral  in  origin.  The 
symptoms  vary  greatly  in  degree,  often  change  their  form  with  rapidity 
and  the  general  nutrition  is  good.  Organic  disease  must  be  carefully 
excluded  by  repeated  examinations  of  the  secretions  and  motility  of  the 
stomach.  The  treatment  is  rest,  correction  of  worry  and  strain,  self- 
control  and  suggestion. 


DISEASES  OF  THE  INTESTINES. 

ACUTE  ENTERITIS. 

It  is  difficult  to  draw  a  close  distinction  between  acute  catarrhal 
enteritis,  intestinal  dyspepsia  and  simple  diarrhea.  Catarrhal  enteritis 
is  the  most  common  intestinal  disease. 

Etiology. — 1.  Primary  Forms. — (a)  Errors  in  diet  and  ingestion  of 
spoiled  food  containing  ptomaines,  unripe  fruit  and  impure  water  are 
common  causes.  (6)  Disturbance  in  intestinal  secretion  possibly  occasions 
acute  enteritis,  (c)  Cold,  trauma,  foreign  bodies,  fecal  retention  and 
toxins  eliminated  from  the  blood  may  initiate  inflammation,  (d)  Some 
cases  are  infectious.  Bacteria  are  an  important  factor;  one-third  of  the 
weight  of  the  normal  stool  is  caused  by  bacteria,  of  which  48  species  are 
normally  present;  inflammation  may  arise  from  pathogenic  organisms  or 
virulence  attained  by  some  inhabitant  of  the  intestine,  e.  g.,  the  Bac.  coli 
and  Gartner's  Bacillus  enteritidis.  In  a  milk  diet  the  Bacterium  lactis 
aerogenes  and  in  a  meat  diet  the  Proteus  vulgaris  may  be  possible  factors. 

2.  Symptomatic  Forms. — (a)  Enteritis  is  constant  in  some  infections, 
as  in  typhoid;  it  is  frequent  in  others,  as  in  sepsis  or  influenza;  and  rare 
in  others,  as  in  measles,  scarlatina,  etc.  (6)  General  diseases,  as  nephritis; 
burns-  intestinal  parasites,  ulcers  or  tumors;  and  metallic  or  other  poisons 
are  etiological  factors;  (/)  stasis  is  rarely  by  itself  a  potent  cause. 

Pathology. — Redness,  swelling,  increased  mucus  secretion,  parenchy- 
matous degeneration  and  interstitial  infiltration,  in  the  few  cases  coming 
to  autopsy,  may  not  be  conspicuous,  as  they  regress  after  death.  Folli- 
cular swelling  or  eyen  ulceration,  ecchymoses,  erosions  or  swelling  of  the 
mesenteric  glands  may  be  observed. 

Symptoms. — The  chief  symptom  is  diarrhea,  due  to  increased  peri- 
stalsis, secretion  or  exudation.  The  stools  number  two  to  fifteen  daily 
and  contain  mucus;  they  are  brownish-yellow  and  moderately  frequent, 
or  colorless,  odorless  and  alkaline  or  neutral,  and  very  frequent;  they 
contain  triple  phosphates,  calcium  phosphate  and  oxalate  crystals, 
sometimes  cholesterin,  Charcot-Leyden  crystals,  and  few  leuko- 
cytes. Thirst,  colic  pains,  borborygmus,  visible  peristalsis,  tympany 
and  gurgling  are  frequent.  Febrile  forms  with  acute  splenic  tumor  are 
recorded,  which  may  at  first  resemble  typhoid.    Albuminuria,  cylindruria 


ACUTE  ENTERITIS  535 

or  even  acute  nephritis  may  develop  exceptionally;  the  urine  is  scanty 
in  proportion  to  the  amount  of  fluid  lost  by  the  bowel;  indican,  ethereal 
sulphates  and  acetone  may  be  present.  In  some  few  cases,  gastritis, 
herpes  or  muscle  and  joint  pains  occur.  Collapse  is  rare  in  adults,  though 
there  may  be  a  close  resemblance  to  cholera.  In  the  vast  majority  of 
cases  convalescence  is  established  in  a  few  days. 

Diagnosis. — (a)  Duodenitis  can  seldom  be  diagnosticated,  though  sug- 
gested by  pain,  tenderness  over  the  duodenum  and  catarrhal  icterus. 
(b)  Jejunoileitis  seldom  exists  alone;  diarrhea  is  absent  if  the  colon  is 
not  affected ;  the  stools  contain  intimately  mixed  mucus,  as  small  hyaline 
globules  under  the  microscope,  (c)  In  enterocolitis  the  bile  is  decomposed 
below  the  small  intestine;  when  it  is  present  in  the  stools  it  signifies 
increased  peristalsis  which  moves  the  bile  along  before  it  can  be  disin- 
tegrated and  indicates  acute  enterocolitis;  bile  may  be  found  only  in  the 
globules  of  mucus^  Many  undigested  food  particles  (lientery)  are  rather 
significant  if  fever,  biliary  or  pancreatic  obstruction  and  gastric  atrophy 
are  excluded;  they  consist  of  undigested  meat,  starch  granules  (which 
are  more  significant  than  muscle  fibers)  and  fat  particles,  (d)  Colitis 
is  characterized  by  the  absence  of  bile  and  lientery,  by  thin  stools  and 
by  more  or  less  mucus,  obtained  especially  on  washing  out  the  bowel 
immediately  after  a  movement,  (e)  Proctitis  is  marked  by  tenesmus, 
dysuria,  evacuation  of  mucus  alone  and  bloody  mucus  covering  but  not 
mixed  with  the  solid  stools;  it  is  also  diagnosticated  by  digital  or  procto- 
scopic examination. 

Treatment. — (a)  In  the  early  stage  evacuation  of  the  causal  irritant 
indicates  fractional  doses  of  calomel,  followed  by  castor  oil;  stronger 
evacuants  irritate  or  inflame  the  intestine.  Colonic  flushings  with  pure 
water  or  injections  of  olive  oil  may  be  added.  (6)  Absolute  rest  in  bed  is 
always  indicated,  (c)  The  diet  should  be  restricted  to  barley-water,  or 
no  food  should  be  given  for  a  day  or  two.  (d)  Heat  is  applied  to  the 
abdomen,  (e)  A  dram  each  of  paregoric  and  bismuth  should  be  given 
after  each  bowel  movement  until  the  number  is  controlled. 

If  bismuth  is  given  in  large  amounts,  the  subcarbonate  is  preferable 
{v.  page  518). 

I^ — Phenylis  salicylatis  (salol) gr.  xx         5i 

Sodii  bicarbonatis 5ss  5J 

Cretse  preparatse 3ss  3iss 

Bismuthi  subnitratis 5J  Sj 

M.  et  divide  in  pulveres  x.  For  child;     adult. 

S. — One  powder  in  milk  or  thin  arrow-root  solution  every  three  hours. 

Lack  of  tone  is  relieved  by  gambir  (catechu),  colic  by  belladonna 
and  flatulency  by  ammonia  and  ginger: 


I^ — Tincturse  gambir  compositse 

Fluidextracti  belladonnse 

Spiritus  ammonise  aromatici 

Syrupi  zingiberis     . 

Misturge  cretse  .... 
M.  et  S. — A  tablespoonful  every  two  or  three  hours 


q.  s 


gtt.  xij 
3i.i 
Sss 
§iv 


Betanaphtol  gr.  x  p.  c.  in  capsules,  or  tannigen  gr.  xv  every  three  hours, 
are  seldom  indicated.     (/)  No  laxatives  are  given  for  the  resulting  con- 


536  DISEASES  OF   THE  INTESTINES 

stipation.  (g)  Opium  suppositories  relieve  tenesmus  (see  Dysentery). 
(/^)  The  diet  may  be  increased  in  a  few  days  to  bouillon  with  raw  egg, 
hashed  beef  or  chicken,  toast,  zwieback,  roast  beef  and  milk;  fruits 
and  vegetables  even  when  cooked  should  be  given  with  caution,  because 
recurrence  predisposes  to  chronic  enteritis,  (i)  Cramps,  collapse,  etc., 
are  treated  as  in  cholera  (q.  v.). 

CHRONIC  ENTERITIS. 

Etiology  and  Pathology. — The  etiology  is  that  of  acute  enteritis,  from 
repeated  attacks  of  which  the  chronic  type  may  develop. 

Chronic  enteritis  suggests  a  causative  chronic  gastritis,  achylia  gastrica 
and  other  gastric  conditions;  or  intestinal  catarrh  may  cause  anorexia, 
eructations  or  abdominal  distention.  Hyperchlorhydria  may  disturb 
the  intestines  by  the  escape  into  them  of  more  acid  than  they  can  neutral- 
ize, and  hypo-  or  achlorhydria  initiates  bowel  trouble  because  hydro- 
chloric acid  bears  an  important  relation  to  the  intestinal  and  pancreatic 
secretions. 

The  pylorus  remains  closed  until  the  food  in  the  stomach  is  ready 
for  the  intestinal  juices  and  then  it  relaxes;  the  hydrochloric  acid, 
reaching  the  duodenum,  provokes  a  flow  of  bile  (which  arrests  the  action 
of  the  pepsin),  and  of  the  pancreatic  secretion  (which  neutralizes  the 
hydrochloric  acid)  by  acting  upon  the  duodenal  mucosa,  which  gives 
off  into  the  blood  "secretin";  secretin  acting  upon  the  pancreas  causes 
it  to  secrete;  then  the  pylorus  again  relaxes.  When  the  pancreatic  juice 
is  poured  out  it  contains  no  active  proteolytic  ferment,  but  in  the  succus 
entericus  there  is  an  activating  ferment  (enterokinase)  which  converts 
trypsinogen  into  trypsin.  The  bile  activates  the  fat-splitting  pancreatic 
ferment. 

In  chronic  enteritis  the  mucous  membrane  is  brownish-red  or  slate-gray 
and  often  thickened  and  the  muscularis  is  sometimes  hypertrophied. 
Polypoid  hyperplasia,  cystic  degeneration,  atrophic  changes,  catarrhal 
erosions  and  follicular  ulcers  may  occur. 

Symptoms. — Constipation  is  more  frequent  than  diarrhea ;  in  some 
cases  a  single,  soft,  morning  evacuation  is  noted,  or  perhaps  several;  in 
others  constipation  is  broken  occasionally  by  short  attacks  of  colic  and 
diarrhea;  continuous  diarrhea  indicates  inflammation  of  both  the  large 
and  small  gut.  Constipation  is  due  to  alteration  of  the  nerve  fibers 
or  inflammation  in  the  muscular  coat.  Abdominal  tension  or  colic  is 
distinguished  from  gastric  discomfort  and  pyloric  spasm  in  that  it  occurs 
independently  of  eating.  Diarrhea  results  from  decomposition  and  fecal 
irritation.  There  may  be  pain,  flatulency,  borborygmus  or  occasionally 
tenderness  over  the  bowels,  but  the  sole  diagnostic  criterion  is  the  presence 
of  mucus;  its  intimate  mixture  with  the  stool  indicates  inflammation  in 
the  small  gut;  coating  of  the  passages  with  mucus  indicates  colitis, 
and  evacuations  of  mucopus  alone,  proctitis.  Mucus  globules  when 
bile-stained  indicate  inflammation  of  the  small  gut,  as  do  shreds  of 
bile-stained  mucus.  Pus  cells  are  rare  except  in  proctitis.  Mucus  is 
alivays  indicative  of  enteritis  and  never  occurs  from  ulceration  or  carcinoma 


CHRONIC  ENTERITIS  537 

alone  (a  slight  coating  of  mucus  over  hard  feces  is  not  significant.)  Blood 
always  indicates  a  complication,  such  as  piles,  ulceration  or  cancer.  The 
stools  may  contain  much  undigested  meat,  starch  or  fat. 

The  functional  examination  of  the  feces  does  not  give  us  as  exact 
information  as  does  the  examination  of  the  stomach  contents.  Schmidt's 
test  diet  includes  3  pints  of  milk,  3  ounces  of  zwieback,  two  eggs,  1.6 
ounces  of  butter,  one-quarter  pound  of  rare,  tender  steak,  6  ounces  of 
boiled  potatoes,  2  ounces  of  oatmeal  and  two-thirds  ounce  of  sugar, 
distributed  among  the  three  meals.  With  the  first  meal  a  capsule  of 
five  grains  of  charcoal  or  carmine  is  given  and  the  first  examination  is 
not  made  until  the  stools  become  colored  black  or  red.  In  this  way  (i) 
the  "  period  of  passage"  is  established,  the  normal  time  being  ten  to  twenty 
hours.  (ii)  Mucus,  microscopically,  appears  as  translucent,  sago-like 
and  often  bile-stained  flakes,  which  must  not  be  confused  with  starch 
particles,  (iii)  Much  connective  tissue,  recognized  by  its  yellowish- white 
color  and  its  toughness,  indicates  reduction  of  the  hydrochloric  acid. 
(iv)  Muscle  fibers,  appearing  as  reddish  threads  or  lumps,  may  indicate 
achylia  gastrica,  lack  of  trypsin,  lack  of  the  activating  enterokinase  or 
very  active  peristalsis,  (v)  Free  starch  granules  indicate  intestinal  catarrh ; 
normally  only  starch  enveloped  in  cellulose  is  present,  (vi)  The  normal 
stools  shows  hydrobilirubin,  detected  by  mixing  fluid  feces  with  an 
equal  amount  of  a  5  per  cent,  solution  of  bichloride  of  mercury,  which 
mixture  turns  yellowish-red  after  twenty-four  hours;  bilirubin,  recognized 
by  a  green  color  in  the  above  test,  indicates  catarrh  of  the  small  bowel 
(except  in  young  children),  (vii)  The  fermentation  test  is  made  by  mixing 
a  dram  of  the  feces  with  sterile  water  in  a  bottle  which  is  connected 
above  with  a  tube  containing  water;  almost  no  gas  results  in  normal 
cases;  an  acid  reaction  with  fermentation  is  due  to  carbohydrate  fer- 
mentation; if  it  becomes  alkaline  and  foul  in  odor  it  is  due  to  proteid 
fermentation,  (viii)  With  experience,  it  can  be  readily  determined 
whether  the  fat  is  increased. 

Nutrition  is  maintained  in  some  cases;  in  others  pallor,  emaciation, 
slow  pulse  and  cold  extremities  may  be  noted.  x\ttacks  of  diarrhea  and 
lientery  suggest  achylia  gastrica. 

Prognosis. — Save  in  either  extreme  of  age  it  is  good  as  to  life,  but  is 
doubtful  at  any  age  as  to  complete  recovery.  Improvement  is  tardy 
and  often  transient.  Intestinal  atrophy  may  develop,  though  less  fre- 
quently than  in  puerile  forms. 

Treatment. — (a)  An  hygienic  conduct  of  life  is  most  essential.  A 
flannel  band  should  be  worn  over  the  abdomen.  (6)  The  diet  must  be 
carefully  supervised;  salads,  alcohol,  fruits  and  vegetables  of  every 
description,  either  raw^,  or  cooked,  sweets,  pickles  and  acids  are  among 
the  forbidden  foods;  eggs,  fresh  butter,  lean  meats,  stale  bread,  rusks, 
thoroughly  cooked  rice  or  sago  and  potato  puree  are  permissible;  i.  e., 
simyle  foods,  in  small  amounts  and  at  frequent  intervals,  controlled  by 
frequent  examination  of  the  feces,  (c)  For  constipation,  often  due  to 
the  careful  diet,  purgatives  are  avoided  and  the  bowels  moved  by  enemata 
of  olive  oil.  For  diarrhea,  bismuth  in  dram  doses  and  tannigen  are  most 
efficacious  (see  Acute  Enteritis).     Calcium  carbonate  and  salicylate 


538  DISEASES  OF  THE  INTESTINES 

are  recommended  (aa  3ss  to  a  quart  of  charged  water;  one-half  glass 
q.  i.  d.).  Schmidt  employs  10  per  cent,  hydrogen  peroxide  in  agar,  (d) 
Flatulency.  As  flatus  results  from  stagnation  plus  catarrh,  the  indications 
are  restriction  of  foods  which  ferment  (v.  s.)  and  the  administration  of 
aromatic  remedies  (see  page  535). 

li — Mentholis    ....  gss 

Phenylis  salicylatis 5iij 

Extracti  belladonnae gr.  iv 

M.  et  fac  capsulas  xx. 

S. — One  after  meals. 

• 

(e)  Colitis  (see  Treatment  of  Dysentery). 

ENTERITIS  (COLITIS)  MUCOSA  OR  MEMBRANACEA. 

This  disease  was  described  by  Mason  Good  (1825)  and  Da  Costa 
(1871).  The  name  implies  inflammation,  but  most  cases  are  neither 
enteritis  nor  colitis.  Nothnagel  named  the  non-inflammatory  variety 
colica  mucosa,  which  is  a  secretory  neurosis. 

Etiology. — (a)  Eighty  to  90  per  cent,  occur  in  young,  nervous  women, 
40  per  cent,  of  whom  have  uterine  troubles ;  few  cases  are  seen  in  nervous 
men  or  children.  (6)  Nearly  all  patients  suffer  from  chronic  constipation. 
Its  pathology  is  unknown;  in  some  autopsies  no  anatomical  alteration  is 
noted,  in  others  that  of  enteritis. 

Symptoms. — (a)  Mucous  casts  of  the  bowel,  shreds  or  lumps  are  voided 
periodically ;  the  mucus  may  resemble  a  huge  diphtheritic  cast,  is  usually 
evacuated  in  large  amounts,  which  often  constitutes  the  entire  bowel 
move/ment  and  contains  very  few  leukocytes  or  other  signs  of  inflamma- 
tion. (6)  There  is  usually  in  the  attack  colic  or  pain  and  tenderness 
over  the  splenic  flexure  of  the  colon,  sometimes  diffuse  and  occasionally 
radiating  into  the  leg.  If  the  mucus  firmly  adheres  to  the  bowel  wall 
the  pain  is  particularly  severe  and  obstruction  of  the  bowels  may  be 
simulated.  Tenesmus  in  voiding  the  mucus  is  usual,  as  are  formation 
of  gas  and  increase  of  the  original  nervous  symptoms,  as  palpitation, 
tremor  or  vertigo.  There  may  also  be  coincident  diarrhea,  achylia 
gastrica  and  a  periodic  sand  formation,  (c)  Constipation,  distention 
and  anorexia  exist  between  the  paroxysms,  which  last  a  day  or  even  a 
week  and  are  separated  by  weeks  or  months.  It  is  said  that  death  may 
occur  during  an  attack. 

Treatment.^ — (a)  The  less  the  fundamental  neurotic  symptoms  are  in 
evidence  the  better  are  the  results  of  therapy;  education,  the  rest  cure 
and  other  measures  outlined  under  hysteria  and  neurasthenia  are  indi- 
cated, (h)  Constipation  iv.  i.)  is  treated  dietetically — Graham  bread, 
leguminous  vegetables,  including  the  husks,  vegetables  with  much 
cellulose  (which  seems  to  be  the  most  important  element) — fruits  with 
small  seeds  and  thick  skins,  as  gooseberries,  currants  or  grapes,  large 
amounts  of  cream,  butter  and  bacon,  and  olive  oil.  Von  Noorden's 
results  with  this  diet  are:  79  per  cent,  partially  or  permanently  cured, 
16  per  cent,  unknown  result  and  5  per  cent,  failure,  (c)  Local  measures 
include  colonic  flushings  with  normal  salt  solution,  or  half  a  pint  of 


INTESTINAL   ULCERATION  539 

olive  oil  left  in  the  rectum  over  night  (Kussmaul) .  {d)  Narcotics,  'purga- 
tives, irrigation  with  alum,  tannin  and  silver  solutions,  and  operations 
are  distinctly  contra-indicated.  The  morphine  habit  may  be  readily  con- 
tracted. Belladonna  suppositories  are  very  efficient  for  the  pain.  The 
patient  in  an  attack  is  kept  in  bed  and  heat  is  applied  to  the  abdomen, 

DIPHTHERITIC,    CROUPOUS    AND   PHLEGMONOUS   ENTERITIS. 

Klebs-Loeffler  diphtheria  is  very  rarely  encountered,  and  practically 
all  membranous  enteritis  is  diphtheroid  {v.  page  78). 

Phlegmonous  or  purulent  enteritis  is  extremely  rare  and  chiefly  of 
anatomical  interest.  Most  cases  develop  in  the  duodenum.  It  may  be 
primary,  but  more  often  is  secondary  to  intestinal  ulceration,  carcinoma 
or  intussusception.  In  a  form  due  to  the  colon  bacillus,  multiple  purulent 
foci  are  found  in  the  intestinal  wall,  which  frequently  cause  perforation. 

INTESTINAL  ULCERATION. 

Ulceration  in  acute  infections,  as  typhoid,  dysentery,  sepsis,  diph- 
theria, etc.,  and  chronic  ulcers,  as  syphilitic,  tuberculous  and  actinomy- 
cotic, are  considered  under  General  Infections.  Rarely  ulceration  has 
been  observed  from  favus  and  mucor  corymbifer.  Inflammatory  idcers 
as  the  catarrhal  and  follicular,  usually  occur  in  the  colon;  they  may  be 
simple  or  so-called  dysenteric  (g.  v.) ;  they  are  seen  in  enteritis,  infantile 
diarrheas,  etc.  Stercoral  (decubital)  ulcers  develop  from  the  pressure  of 
hard  feces  or  foreign  bodies,  in  the  dilated  pouches  of  the  colon  or  above 
an  intestinal  stenosis.  Constitutional  affections,  as  leukemia,  scurvy 
and  amyloidosis,  uremia  and  mercurial  and  arsenical  poisoning  are 
occasionally  causes. 

Symptoms. — The  symptoms  are  rarely  distinctive  without  suggestive 
etiological  factors;  most  ulcerations  occur  without  symptoms  or  with 
ambiguous  symptoms,  (a)  Diarrhea  is  frequent,  particularly  in  ulcera- 
tion of  the  large  gut;  it  is  often  absent  with  lesions  of  the  small  gut  or 
upper  colon;  it  results  from  decreased  absorption  and  increased  peris- 
talsis, due  to  exposure  of  the  intestinal  nerves,  (b)  Blood  in  the  stools 
is  mixed  with  them  in  lesions  of  the  small  gut,  sometimes  covers  them 
in  lesions  of  the  large  gut  and  is  voided  independently  of  the  feces  in 
rectal  lesions.  It  is  more  often  dark  and  tarry,  especially  in  tuberculosis, 
than  bright,  except  in  low-situated  lesions  and  in  some  profuse  typhoid, 
dysenteric  or  duodenal  hemorrhages.  Blood  is  common  in  other  diseases 
than  ulceration,  as  in  cancer,  piles,  stasis  and  blood  diseases,  (c)  Pus 
is  seen  more  frequently  in  colonic  than  in  ileac  ulceration;  it  is  common 
in  cancer,  proctitis  and  croupous  enteritis.  Pure  pus  is  rather  indicative 
of  rupture  of  extra-intestinal  pockets  into  the  intestine,  as  appendicitic 
and  saipingitic  abscesses,  (d)  Mucus  indicates  enteritis  only,  which  may 
complicate  ulceration,  (e)  Shreds  of  tissue  are  very  rare,  save  in  dysentery. 
(/)  Local  symptoms  are  ambiguous,  as  tenderness,  pain  and  tympanites. 
(g)  General  symptoms  depend  on  the  basic  disease ;  fever  is  most  frequent 
in  cancerous,   dysenteric   or  tuberculous   ulcers,      {h)    Rupture   causes 


540  DISEASES  OF  THE  INTESTINES 

peritonitic  adhesions,  diffuse  peritonitis,  retroperitoneal  cellulitis  or 
subphrenic  pyopneumothorax.-  (i)  The  x-Tay  may  show  total  absence  of 
a  shadow  where  the  ulcers  lie  or  else  a  fine  marbled  appearance. 

Treatment. — ^Treatment  is   that   of   enteritis  or   colitis.     In   chronic 
ulcerative  colitis  colostomy  may  result  favorably. 


INTESTINAL   DISORDERS    IN   INFANTS. 

Etiology. — Classification  of  the  etiological  factors  is  difficult  because 
of  the  numerous  species  of  bacteria  in  the  intestine  and  the  impossibility 
of  drawing  any  absolute  line  between  chemical  and  bacterial  factors 
and  between  functional  and  organic  changes.  Most  cases  occur  in 
children  between  six  and  eighteen  months  old,  in  the  summer  months, 
July  especially,  in  the  poorer  classes  and  in  infants  not  fed  at  the 
breast,  for  two  main  reasons:  cow's  milk  is  prone  to  disturb  digestion 
and  there  is  a  greater  chance  for  bacterial  infection.  Toxins  may  form 
in  milk,  when  it  is  long  in  transit,  particularly  in  hot  weather.  The 
Bacterium  lactis  aerogenes  causes  inflammation  in  the  small  and  the 
Bacterium  coli  in  the  large  intestine;  the  proteus,  pyocyaneus,  gas  bacil- 
lus, various  saprophytes,  and  Bacillus  dysenterise  are  also  factors,  but 
their  relative  importance  is  not  clearly  defined ;  the  Streptococcus  enter- 
itis can  hardly  be  considered  as  a  distinct  type.  The  distinction  between 
intoxication  and  infection  is  maintained  with  difficulty;  intoxication 
causes  symptoms  as  erythema,  hemorrhagic  diathesis,  anemia,  nervous 
disturbances  and  dyspnea;  and  infection  produces  complications,  as 
lobular  pneumonia,  nephritis,  phlegmon,  arthritis,  'purulent  pleurisy 
and  necroses  in  the  liver.  In  institutional  epidemics  infection  may  be 
carried  from  one  individual  to  another  by  fecal  contaminations.  Insects 
may  convey  infection. 

Symptoms. — 1.  The  acute  dyspeytic  or  fermental  form  cannot  be  sharply 
distinguished  from  other  severer  forms,  though  possibly  caused  by  the 
same  microorganisms.  The  pathological  findings  are  often  remarkably 
insignificant.  The  temperature  usually  rises  suddenly  to  103°  or  104°, 
remains  high  for  a  few  days  and  falls  suddenly.  The  tongue  is  dry,  the 
face  red,  the  pulse  rapid  and  the  breathing  sometimes  dyspneic.  There 
is  restlessness — sometimes  initial  convulsions — anorexia  and  vomiting. 
The  stools  in  infants  are  normally  yellow  from  bilirubin,  thick  and  slightly 
acid  in  reaction;  they  become  green  from  bacterial -action  or  reduction 
of  the  bilirubin  into  biliverdin,  react  alkaline  from  albuminous  decom- 
position or  acid  from  acid  fermentation  and  become  thin  and  offensive; 
the  evacuations  number  six  to  ten  daily.  The  microscopic  findings  are 
those  of  acute  enteritis  in  adults,  as  mucus,  leukocytes,  triple  phosphates 
in  the  alkaline  stools  or  cholesterin  in  the  acid  stools;  blood  in  any  quan- 
tity is  uncommon.  Involvement  of  the  small  intestine  is  attended  by 
gas,  cramping,  large  movements,  and  tenderness.  Marked  nervous 
symptoms,  extensive  edema  and  emaciation  may  result.  Albuminuria 
and  cylindruria  occur  in  20  per  cent.  Recovery  is  usual  and  prompt 
after  thorough  intestinal  evacuation. 


INTESTINAL   DISORDERS  IN  INFANTS 


541 


2.  Cholera  infantum  occurs  in  severe  infections,  usually  in  children 
already  suffering  from  some  intestinal  disorder;  it  constitutes  2  per  cent, 
of  summer  diarrheas.  The  hoioel  movements  are  coyious,  alkaline  and 
flocculous;  though  at  first  they  contain  food  and  are  perhaps  offensive, 
they  become  watery  and  odorless.  Both  the  stools  and  the  general 
clinical  aspect  resemble  the  picture  of  cholera  Asiatica  and  cholera  nostras 
{q.  v.).  Though  there  is  fever,  the  extremities  are  algid  and  cyanotic,  the 
'pulse  small,  the  heart  tones  weak  and  all  symptoms  of  collayse  are  present; 
there  are  the  pinched  pallid  fades  cholerica,  the  thirst  and  the  incoercible 
vomiting.  The  skin  is  rigid,  as  though  the  fatty  tissue  had  hardened 
(scleredema  or  sclerema  adiyosum),  and  nephritis  is  almost  invariable. 
These  symptoms  result  from  loss  of  great  quantities  of  fluid  by  purging 
and  vomiting,  and  from  intoxication  which  produces  the  convulsions, 
irregular  and  Cheyne-Stokes's  breathing,  retraction  of  the  neck,  stupor 
and  other  symptoms,  termed  the  " hydrencephalic  state."  Oestreich 
holds  that  hypostasis,  resulting  from  compression  of  the  lungs  by  the 
tympany,  causes  more  deaths  than  does  the  toxemia. 

3.  Acute  enterocolitis  (ileocolitis)  may  follow  the  dyspeptic  form  or 
the  various  specific  infections  in  children,  or  may  begin  as  an  indepen- 
dent form.  Pathologicalh^  it  includes  types  which  cannot  be  separated 
clinically,  as  simple  enterocolitis,  follicular  ulceration  and  diphtheroid 
enteritis.  In  Rotch's  cases  of  infantile  diarrhea  the  Bacillus  dysenterise 
was  found  in  16  per  cent.,  sometimes  in  the  dyspeptic  type,  but  most 
often  in  the  ileocolitic  type  (78  per  cent.).  In  one  collection  of  412  cases 
Shiga's  bacillus  was  found  in  63  per  cent.;  Geo.  Weaver  never  found  it, 
though  the  Flexner-Harris  type  occurred  in  25  per  cent.  (r.  Bacillary 

DYvSENTERY)  . 

The  symptoms  resemble  those  of  dysentery  in  the  adult.  The  stools 
are  small,  yellow,  green  or  brown  and  very  frequent.  Rotch  tabulates 
the  differential  features  as  follows: 


Acute  fermental  diarrhea. 

Acute  ileocolitis. 

(a) 

Small  intestine,  mostly. 

Large  intestine,  mostly. 

ib) 

10  to  12  discharges;  often  large. 

10,  15  to  50  discharges,  usually  small. 

(c) 

No  or  little  blood. 

Blood  and  sometimes  shreds  of  tissue  or 
membrane. 

id) 

Mucus. 

Mucus. 

(c) 

No  tenesmus. 

Tenesmus. 

(/) 

Not    much    abdominal    tenderness 
pain. 

and 

Abdominal  tenderness  and  pain. 

ia) 

No  or  slight  lesions. 

Lesions  marked. 

ih) 

Temperature   high — 104°   F.   for  one  or 

Temperature  may  be  high  at  first  (103°  F. 

two  days,  and  then  falling  sharply  by 

to    104°    F.)    but   usually   soon    moderates 

crisis. 

(99°  to  101°  F.)  and  falls  gradually  by 
lysis  to  normal  after  some  weeks. 

The  severity  of  the  symptoms  varies  greatly;  the  catarrhal  form  may 
cause  mild  symptoms  or  result  in  death,  with  or  without  gastric  symp- 
toms. The  ulcerative  and  diphtheroid  types  are  less  often  attended  by 
vomiting,  but  run  a  fatal  course  of  days  or  weeks. 


542  DISEASES  OF   THE  INTESTINES 

4.  Chronic  dyspejptic  disturbances  often  occur  with  gastric  dilatation. 
The  onset  is  gradual  or  it  may  directly  follow  the  acute  forms.  The 
stools  are  green  or  gray,  contain  mucus,  gas,  sometimes  pus  and  tissue 
shreds.  Food  and  fluid  are  poorly  absorbed;  undigested  food  particles 
and  fatty  stools  are  observed;  mucus  is  not  common  in  marked  cases 
of  intestinal  atrophy.  Vomiting  is  rather  frequent.  There  is  usually 
little  general  disturbance,  no  fever  and  little  or  no  colic.  In  some  cases 
the  emaciation  may  become  extreme  (pediatrophy,  athrepsia),  the 
muscles  becoming  weak,  the  voice  faint,  the  eyes  lustreless,  the  face  of 
the  "Voltaire  type,"  and  the  abdomen  distended.  Death  results  from 
marasmus  or  intercurrent  infections. 

Preventive  Treatment. — Children  should,  if  possible,  be  taken  to  the 
country  in  the  hot  months.    Excessive  swaddling  is  to  be  avoided. 

Diet. — (a)  If  the  mother  cannot  nurse  her  child,  a  wet-nurse  should 
be  procured,  as  few  stomach  and  bowel  diseases  occur  in  breast-fed 
infants.  The  wet-nm-se  must  be  carefully  examined  for  syphilis  and 
tuberculosis.  The  milk  from  the  breast  should  spurt  freely  in  several 
streams.  A  weak  child  may  become  dyspeptic  even  at  the  breast; 
calomel  irritates  but  magnesiimi  carbonate  gives  the  most  rapid  relief; 
other  children  thrive,  even  when  the  stools  are  green.  Sometimes  colic 
and  dyspepsia  in  the  child  are  due  to  menstruation,  beginning  preg- 
nancy, excitement,  lack  of  exercise  or  alcoholic  indulgence  in  the  nurse 
or  mother.  If  a  wet-nurse  cannot  be  obtained,  (b)  cow's  milk  or  some 
prepared  food  must  be  used,  but  most  of  the  latter  are  objectionable 
because  their  carbohydrates  are  not  dextrinized.  Cow's  milk  differs 
from  human  milk  in  many  details;  its  contamination  is  far  more  likely, 
whence  the  importance  of  pure  milk  and  sterilized  nipples  and  bottles. 
Human  milk  contains  about  1  per  cent,  of  proteids,  4  per  cent,  fats  and 
7  per  cent,  of  milk-sugar,  but  in  cow's  milk  the  percentages  are  respec- 
tively about  3.5,  3.5  and  5  per  cent.;  in  cow's  milk  the  casein  constitutes 
80  per  cent,  of  the  proteids,  which  are  physically  and  chemically  different 
and  contain  more  whey  proteid  and  more  of  certain  relatively  uninves- 
tigated substances.  In  cow's  milk  the  ferments  and  fats  are  different 
and  the  mineral  salts,  especially  phosphates,  are  increased,  which  impede 
digestion.  The  first  objection  is  the  high  percentage  of  proteid  (casein), 
which  must  be  predigested  or  the  milk  diluted.  Simple  dilution,  however, 
necessitates  giving  too  much  water  or  reducing  the  fat  and  milk-sugar. 
In  substitute  feeding,  the  proteid  of  coics  milk  must  be  reduced,  fat  added 
in  the  form  of  cream,  and  milk-sugar  added  to  attain  the  normal  percen- 
tage. The  milk  may  be  diluted  vdih  thin  oatmeal-water,  as  a  diastase 
ferment  is  present  earlier  and  in  larger  amounts  than  previously  admitted, 
though  nature  doubtless  has  her  designs  in  withholding  starches  from 
mother's  milk.  Low  dilutions  should  be  given  at  first  and  gradually 
increased,  regarding  digestion  and  nutrition,  as  determined  by  regular 
weighing.  Sterilization  of  milk  destroys  ferments  and  protective  sub- 
stances. 

Treatment  of  Acute  Dyspepsia.^(a)  The  stomach  is  washed  out,  if 
toxic  symptoms  are  marked,  ^-ith  plain  water  or  a  1  to  3000  resorcinol 
solution,     (b)  Calomel  gr.  |  and  magnesium  carbonate  gr.  j  every  three 


INTESTINAL  DISORDERS  IN  INFANTS  543 

hours  for  three  doses,  or  one  dose  of  castor  oil  (5ss-j)  are  usually 
administered,  but  cathartics  congest  or  even  erode  the  mucosa,  (c) 
The  bowel  should  be  flushed  with  one  pint  of  warm  water,  (d)  Food 
should  be  withheld  for  two  days,  and  plenty  of  boiled  water  should  be 
given.  Albumen-water  (the  whites  of  two  eggs  beaten  in  a  pint  of  water) 
may  then  be  given,  and  thin  arrow-root-water,  beef-juice  and  peptonized 
milk,  may  gradually  be  administered  until  the  green  color  of  the  stools 
changes  to  a  normal  yellowish-brown.  In  one  type,  fat  is  not  assimilated; 
the  fatty  acids,  uniting  wuth  alkali,  form  soapy  stools  and  withdrawing 
alkali,  lead  to  alkali-penia  and  acidosis.  In  another  type,  starch  is  the 
injurious  factor  and  in  another,  there  is  sugar-injury,  as  in  gas-bacillus 
infections.  The  dysentery  bacillus  works  least  injury  with  lactose 
administration,  which  minimizes  the  nitrogenous  waste  (Kendall). 
Milk  proteid  seems  the  least  injurious,  particularly  if  the  whey  is  removed 
from  skimmed  milk,  (e)  Other  medication  is  usually  superfluous.  Lesage 
recommends  lactic  acid  for  alkaline  green  stools,  5j  of  a  2  per  cent, 
solution  (p.  c).  Resorcinol  \  grain  and  dilute  hydrochloric  acid  Tllv 
may  be  given  after  meals. 

Treatment  of  Enteritis. — If  the  case  is  seen  early  the  stomach  is  loashed 
out  and  feeding  suspended  as  outlined  above.  The  child  should  have 
plenty  of  boiled  water  and  cool  applications  to  the  skin  are  indicated 
unless  the  extremities  are  blue  and  cool.  Tannigen  may  be  given,  10 
grains,  several  times  daily,  even  in  the  very  young.  As  in  enteritis  of 
adults,  bismuth  subnitrate,  5ss,  bismuth  salicylate,  ^  to  1  grain  and  if 
these  are  ineffective,  opium  may  be  administered.  (See  page  269  for 
dosage.) 

Treatment  of  Cholera  Infantum. — Lavage  is  ineffective,  unless  it  is  done 
in  the  earliest  stages.  There  are  three  main  indications:  (a)  fluid  must 
be  restored  to  the  tissues,  by  subcutaneous  saline  transfusions  which 
support  the  heart,  fill  the  vessels,  stimulate  the  kidneys  and  eliminate 
the  toxins;  2.5  per  cent,  dextrose  infusions  are  valuable;  (b)  cardiac 
stimulation,  by  hypodermics  of  strychnine  and  camphor  and  local  heat; 
champagne  quiets  vomiting  and  supports  the  heart;  brandy  and  whisky 
are  given  as  in  bronchopneumonia  {q.  v.),  though  perhaps  alcohol  further 
injures  the  intestinal  epithelium;  and  (c)  secretion  must  be  checked  by 
paregoric  every  four  hours,  small  enemas  of  starch  and  laudanum  or, 
which  is  more  effectual,  morphine.  (See  page  269.)  In  the  fortunate 
cases  which  rally,  nourishment  is  resumed  only  with  the  greatest 
caution. 

The  Treatment  of  Colitis. — This  is  like  that  of  dysentery  and  includes 
the  measures  above  indicated,  flushings  with  salt  solution,  1  per  cent, 
tannin  or  1  to  1000  salicylic  acid. 

The  Treatment  of  Chronic  Dyspepsia. — Treatment  in  institutional  cases 
begins  with  nursing;  one  wet-nurse  can  nurse  several  children.  Gastric 
lavage  with  two  ounces  of  plain  water,  normal  salt  or  1  per  cent.  Carlsbad 
salts  solution,  increases  functional  activity.  The  extract  of  nux  vomica 
stimulates  secretion.  Food  is  given  in  the  smallest  amounts  compatible 
with  maintenance  of  weight  and  energy. 


544  DISEASES  OF   THE  IXTESTIXES 


APPENDICITIS. 


Definition. — Appendicitis,  the  chief  abdominal  malady,  is  an  inflam- 
mation of  the  vermiform  appendix. 

History. — Fitz  in  1886  drew  attention  to  the  subject  and  coined  the 
name,  and  AYillard  Parker  first  (1867)  advocated  operation.  Appen- 
dicitis was  previously  confused  with  typhlitis,  inflammation  of  the 
cecum;  the  term  "perityphlitis"'  should  be  discarded.  Our  knowledge 
is  largely  due  to  the  work  of  American  surgeons. 

Etiology. — 1.  Pkedi.sposixg  Factors.— (a)  The  appendix,  a  function- 
less  vestige  of  the  cecum,  is  inherently  less  resistant.  (b)  Its  lumen 
is  smallest  at  its  cecal  end,  which  favors  retention  of  foreign  bodies,  pro- 
motes microbic  growth  and  decreases  or  suspends  drainage  into  the 
bowel,  (c)  The  meso-appendix,  which  conveys  the  blood  to  the  appendix, 
is  shorter  than  the  appendix,  which  therefore  curls;  the  blood  supply  is 
easily  altered  by  appendiceal  edema  and  infiltration.  (d)  Foreign 
bodies  and  fecal  concretions  may  produce  erosions  which  apparently 
promote  microbic  access  and  therefore  inflammation;  Aschoff  combats 
this  view.  .J.  F.  Mitchell  found  foreign  bodies  in  7  per  cent,  of  1400 
cases  of  appendicitis  and  Louis  J.  Mitchell  in  1600  autopsies,  1  per  cent.; 
they  include  seeds,  capsules,  gall-stones,  pins,  nails,  shot,  fish-bones, 
etc.  (e)  Age. — Over  50  per  cent,  occur  under  twenty  years  of  age  and 
30  per  cent,  between  twenty  and  thirty.  It  is  rare  in  infancy  and  with 
advancing  years  obliteration  and  atrophy  lessen  its  frequency.  (J) 
Sex.    There  is  a  slight  preponderance  in  males. 

2.  Bacteriology. — The  colon  bacillus  is  found  in  SO  per  cent,  of  cases, 
though  probably  in  some  of  them  it  has  overgrown  another  causal 
organism.  Xext  is  the  staphylococcus,  the  ^^^ulent  streptococcus,  then 
the  pneumococcus,  proteus  and  pyocyaneus.  In  s^Tubiosis  with  these 
organisms,  or  possibly  operating  without  them  as  in  gangrene,  the 
anaerobes  (gas  bacillus,  fusiform  bacilli  and  anaerobe  streptococcus) 
are  factors  in  the  necrosis,  peritonitis  and  toxemia.  Less  frequently 
the  typhoid,  tubercle,  influenza  or  actinomycosis  organism  is  found;  of 
the  last  150  cases  exist;  Fenwick,  in  1120  tuberculous  ulcerations  in  the 
bowel,  found  but  0.8  per  cent,  in  the  appendix. 

Sjrmptomatology  and  Pathology. — 1.  The  Early  Clinical  Course. — 
The  onset  is  precipitate  and  characterized  by  four  main  sympAoms.  (a) 
Sudden,  severe  abdominal  pain,  the  intensity  of  which  ranges  between 
colic  and  agony,  is  due  to  acute  retention  within  the  appendix  caused 
by  the  occlusion  of  the  cecal  end.  It  is  felt  over  the  right  Icnver  abdomi- 
nal quadrant  or  over  the  pit  of  the  stomach,  and  may  even  radiate  along 
the  genitocrural  nerve  to  the  testis,  which  is  sometimes  retracted.  Reach- 
ing its  greatest  severity  in  a  few  hours,  the  pain  persists  until  the  pressure 
of  the  pus  is  relieved  by  drainage  into  the  bowel,  perforation  or  gangrene. 
Sudden  relief  from  pain  often  indicates  gangrene,  (h)  Nausea  and 
vomiting  result  reflexly  from  occlusion  and  follow  within  a  few  hours 
after  the  pain,  (c)  Abdominal  tenderness  is  general  at  first  and  is  often 
associated  with  a  cutaneous  hyperesthesia,  which  covers  like  half  a 
girdle  the  right  lower  abdomen  from  the  spine  to  the  mid-line.     The 


APPENDICITIS 


545 


right  rectus  muscle  resists  palpation,  which  explains  most  cases  of  early 
apparent  tumor.  K  little  later  the  general  tenderness  disappears,  leavmg 
wen-localized  tenderness  over  the  appendix;  McBurneys  point  is  m  the 
right  lower  quadrant  of  the  abdomen  (about  two  inches  from  the  anterior 
superior  iliac  spine  in  a  line  drawn  bfetween  it  and  the  navel)  or  a  little 


Fig.  38 


Fig.  42 


Fig.  45 


Figs.  38  and  39.— Obliterating  appendicitis.  Fig.  40.— Obliterating  appendicitis,  with 
distal  enlargement.  Fig.  41.— Obliterating  appendicitis  (at  R),  with  calculi  (C).  Fig.  42. 
— Appendicitis  with  bending,  obliteration  and  distal  distention.  Fig.  43. — Appendicitis 
with  curUng  around  its  mesentery.  Fig.  44. — Strangulation  by  a  band.  Fig.  45. — Calcu- 
lous obstruction.    (Dieulafoy.) 

below  it  in  adults  or  above  it  in  children;  less  frequently  the  tender  point 
may  be  found  near  the  loin,  pelvis  (5  per  cent.),  bladder,  rectum  or 
uterus  on  rectal  or  vaginal  examination,  gall-bladder  or  very  exceptionally 
on  the  left  side  of  the  abdomen  or  in  hernial  sacs,  all  of  which  correspond 
to  possible  variations  in  appendicular  location.  Pressure  with  the  hand 
on  the  left  half  of  the  abdomen  causes  pain  in  the  right  side  when  the 
35 


54G  DISEASES  OF  THE  INTESTINES 

pressure  is  relieved.  Palpation  must  be  made  gently,  lest  rupture  occur. 
(d)  Fever  generally  develops  in  a  few  hours  to  a  day,  according  to  the 
severity  of  the  infection,  rarely  with  a  chill,  reaching  101°-102°,  or  higher 
in  some  virulent  types  or  in  children.  It  signifies  septic  absorption  and 
may  cease  suddenly  in  gangrene  or  gradually  in  rupture  and  may  slowly 
recur  from  extension;  abscess  or  peritonitis  may  coexist  with  low  tem- 
perature. The  pulse  usually  follows  the  temperature  curve,  though  the 
author  has  seen  it  remain  normal  in  cases  of  early  gangrene.  The  leuko- 
cytosis parallels  the  fever,  and  often  measures  the  sepsis;  no  reliance 
can  be  placed  on  its  absence  as  an  assuring  sign  nor  on  its  presence  as 
an  indication  for  operation;  extremely  high  counts  (over  100,000)  are 
ominous;  counts  of  900  or  600  are  reported.  The  urine  is  often  febrile, 
scanty  and  usually  contains  indican  and  sometimes  albumin  or  even 
blood;  dysuria  may  result  from  appendicitis  in  the  pelvis;  renal  colic 
may  be  closely  simulated.  Profuse  bowel  hemorrhage  is  recorded. 
Constipation  is  usual.  In  Dieulafoy's  toxemic  type  toxemia  may  obscure 
the  local  symptoms. 

2.  The  Later  Clinical  Course. — (a)  The  inflammation  subsides 
gradually  by  drainage  into  the  cecum.  Though  the  inflammation  may 
be  circumscribed,  the  appendix  rarely  returns  to  normal;  it  suffers 
necrosis  and  ulceration  which  leave  the  appendix  infiltrated,  thickened, 
and  more  or  less  constricted  at  some  point  or  the  lumen  is  obliterated. 
The  mucous  membrane  may  be  wholly  substituted  by  granulation  tissue. 
Occlusion  at  its  intestinal  end  causes  a  cyst-like  swelling  as  large  as  the 
thumb  or  even  as  a  sausage.  Adhesions  to  the  abdominal  wall  and  gut 
are  common,  (b)  After  a  few  days  a  localized  peritonitic  abscess  fre- 
quently forms,  usually  over  the  psoas  muscle  at  the  angle  between  the 
ileum  and  cecum,  but  occasionally  in  some  unusual  localization  of  the 
appendix  (v.  s.),  from  perforation,  generally  near  its  mesenteric  attach- 
ment, from  necrosis  or  gangrene;  when  the  abscess  is  well  demarked, 
the  pain,  fever  and  pulse-rate  decrease.  A  well-defined  tumor  may  develop, 
over  which  no  peristalsis  occurs;  dulness  or  tympany  is  elicited  according 
to  the  depth  of  the  tumor  or  its  fluid  or  gaseous  contents;  fluctuation 
is  present  only  in  large  abscesses;  in  infections  due  to  the  colon  bacillus 
the  tumor  is  more  largely  infiltration  than  pus.  In  the  incised  abscess 
the  green  or  black  and  totally  gangrenous  appendix  usually  may  be 
seen.  The  abscess  may  form  without  any  symptoms  other  than  those 
of  the  onset.  The  result  of  the  abscess  varies  greatly :  (i)  it  may  rupture 
into  the  intestine  which  forms  its  wall  (2  per  cent.),  and  possibly  carry 
the  appendix  with  it;  (ii)  it  may  rupture  into  the  urinary  tract,  of  which 
cases  nearly  one-half  are  fatal;  (iii)  it  may  cause  purulent  thrombophlebitis, 
and  any  manifestations  of  septicopyemia,  as  secondary  fever,  suppurative 
pylephlebitis,  pulmonary  embolism,  liver  abscess,  or  subphrenic  abscess; 
(iv)  it  may  rupture  into  the  retroperitoneal  tissue,  followed  by  high 
temperature;  and  all  possible  extensions  may  occur,  as  into  the  groin, 
scrotum,  pelvis,  pararenal  tissue,  pleura  (84  per  cent,  are  right-sided), 
lung,  gluteal  region,  back,  hip-joint,  etc.;  and  (v)  it  may  rupture  into 
the  free  peritoneal  cavity,  (c)  The  third  cardinal  issue  is  diffuse  septic 
peritonitis;  its  unfortunate  and  unmistakable  symptoms  are  a  sudden 


APPENDICITIS  547 

fall  of  temperature  followed  by  a  secondary  fever,  diffuse  replacing 
localized  tenderness  and  rigidity,  leukocytosis,  persistent  projectile 
vomiting,  rapid  pulse,  Hippocratic  facies  and  collapse  from  profound 
intoxication.  It  most  often  follows  the  localized  abscess,  but  may  occur 
directly  after  a  gangrene  which  is  so  sudden  as  to  allow  of  no  protective 
adhesions,  or  after  perforation  from  a  foreign  body  in  the  appendix. 
Variations,  due  to  the  type  of  infecting  organism  are  as  follows:  (i) 
The  staphylococcic  peritonitis  generally  produces  but  little  pus,  or,  if 
any,  a  seropurulent  fluid;  plastic  lymph  prevents  absorption  for  a  short 
time,  but,  as  the  peritoneum  becomes  abraded,  leads  to  intoxication, 
collapse  and  diarrhea,  (ii)  The  streptococcic  form  produces  no  pus, 
but  causes  a  granular,  blistered,  dry  peritonitis,  rapid  pulse,  delirium 
and  tympany,  (iii)  Colon  infection  produces  an  abundant,  creamy, 
thick,  offensive  pus  and  slowly  causes  death  after  great  depression, 
delirium  and  low  arterial  pressure. 

3.  Remote  Sequences. — Intestinal  strangulation  by  adhesions  and 
from  chronic  changes  in  the  appendix  reflex  disturbances  may  result. 

In  children  the  onset  is  very  abrupt,  the  vomitilig  repeated,  pain  greater, 
the  appendix  more  palpable  and  diarrhea  and  difi^use  peritonitis  more 
common  than  in  adults,  because  the  omentum  is  less  able  to  envelop 
the  appendix.    In  aged  persons  gangrene  is  more  frequent. 

Diagnosis. — The  diagnosis  depends  on  the  four  cardinal  symptoms  of 
onset,  followed  by  leukocytosis  and  other  secondary  developments. 
If  all  these  symptoms  are  considered  separately  an  analysis  is  necessary 
of  every  abdominal  lesion  causing  pain  alone,  vomiting  alone,  tempera- 
ture, sensitiveness,  abscess,  tumor,  disease  in  the  right  lower  abdominal 
quadrant,  perforation  or  peritonitis. 

Pain  occurs  in  gall-stones,  renal  calculi,  tabetic  crises,  internal  incar- 
cerated hernias,  epigastric  hernia,  intussusception,  gastric  or  duodenal 
ulcer,  tuberculous  peritonitis,  stone  or  torsion  of  the  ureter,  Dietl's 
crisis  in  floating  kidney,  uremia,  colica  mucosa,  acute  pancreatitis,  the 
crises  of  angioneurotic  edema,  herpes  zoster,  pelvic  peritonitis,  ruptured 
extra-uterine  pregnancy,  twisted  pedicles,  pyosalpinx,  dysmenorrhea 
and  the  reflected  pain  of  vertebral  disease,  pleurisy  and  pneumonia. 
Femr  in  typhoid  precedes  the  local  symptoms.  These  affections,  as  well 
as  gravitating  abscesses,  infected  urachus,  lesions  of  the  abdominal  wall, 
cancer,  hysteria  and  hypochondriacal  fear  of  appendicitis,  are  almost 
invariably  excluded  by  the  sequence  of  symptoms  and  careful  general 
examination.  Ajjpendicitis,  chronic  ah  initio,  causes  flatulency,  constipa- 
tion alternating  with  diarrhea  and  a  dragging  discomfort  in  the  right 
lower  abdomen;  appendicitis  may  cause  hypersecretion,  hyperchlor- 
hydria,  gastralgia,  epigastric  tenderness  or  pain  (also  experienced  there 
when  pressure  is  made  upon  the  appendix)  and  pylorospasm  {v.  page 
515).    Confusion  is  possible  with  a  mobile  cecum. 

Prognosis. — The  prognosis  is  most  uncertain,  because  (a)  there  is  no 
safe  criterion  for  early  diagnosis  of  the  type;  (6)  the  symptoms  and 
signs  are  not  proportionate  to  the  actual  lesions,  e.  g.,  light  cases  clini- 
cally may  prove  to  be  the  most  severe  anatomically;  (c)  apparent 
improvement  is  often  to  the  experienced  observer  the  onset  of  alarming 


548  DISEASES  OF   THE  INTESTINES 

complications;  Dieulafoy  well  calls  them  "treacherous  hdls"  (arcal- 
mies  traitresses);  (d)  recovery  is  seldom  complete  anatomically,  whence 
chronic,  relapsing  or  residual  appendicitis  occurs  in  a  more  severe  form 
in  a  full  third  of  the  cases. 

Treatment. — Cases  may  recover,  temporarily  (70  to  80  per  cent.), 
but  it  is  impossible  to  predict  which  ones  will  do  so.  After  testing  and 
seeing  tested  the  so-called  medical  treatment,  consisting  of  rest,  starva- 
tion, laxatives  and  other  placebos,  and  seeing  gangrene,  peritonitis  with 
low  temperature  and  death  occur  in  "mild"  cases,  the  conviction  was 
inevitable  that  appendicitis  is  always  surgical,  regardless  of  type,  time  or 
tendencies.  A  surgeon  at  once  should  be  associated  with  the  practitioner. 
Recovery  under  medical  treatment  is  due  to  good  fortune  alone.  The 
so-called  indications  for  operation  are  too  often  signs  of  irreparable 
damage.  Early  operation  within  one  or  two  days  of  onset  is  attended 
by  the  least  danger.  ]\Iany  operators  dislike  to  operate  between  the 
second  and  eighth  days  or  other  arbitrary  limits,  but  this  position  implies 
that  the  clinician  can  diagnosticate  the  anatomical  changes  which  are 
present;  gangrene,  thrombophlebitis,  imminent  rupture,  etc.,  cannot 
be  excluded;  in  this  period  simple  drainage  is  indicated — possibly,  too, 
appendicectom\',  if  the  appendix  obtrudes  in  the  field  of  incision;  lavage, 
exploration  and  protracted  operation  are  dangerous.  In  later  cases,  when 
there  is  apparent  regression,  treatment  may  be  more  conservative;  com- 
plete demarkation  may  be  waited  for,  but  even  in  such  cases  thrombo- 
phlebitis or  rupture  into  the  general  peritoneum  may  intervene.  In 
diffuse  peritonitis  incision  and  simple  drainage  are  indicated.  The  patient 
is  placed  in  the  semisitting  posture  (Fowler)  and  given  constant  normal 
salt  enemas  (Murphy).  Many  cases  recover  (see  Peritonitis),  (e) 
After  the  attack.  After  one  attack  of  appendicitis  the  patient  is  prone 
to  recurrence.  In  cases  in  which  there  was  only  incision  and  drainage 
of  the  abscess  the  attacks  recur.  Adhesions,  flexions  and  stenoses  favor 
a  recurrence  and  digestive  disturbances. 

INTESTINAL    OBSTRUCTION. 

Etiology. — Obstruction  arises  from: 

I.  Intussusception  (Invagination). — In  this  most  frequent  form  of 
acute  obstruction  (40  per  cent.j,  the  external  part  (the  intussuscipiens 
or  vagina)  receives  into  it  the  intestine  just  above  (the  intussusceptum 
or  invaginatum) .  It  develops  in  perfect  health,  in  various  acute  and 
chronic  affections,  tumors,  strictures  of  the  gut,  diarrhea  and  contusion. 
Two  theories  are  advanced:  ia)  that  the  gut  is  spastically  contracted 
and  enters  the  gut  below,  and  (h)  that  the  gut  below  is  paretic.  The 
author  saw,  with  Dr.  Walls,  a  case  in  lead  colic.  In  acute  intussusception 
\Yiggin  found  50  per  cent,  in  the  fourth,  fifth  and  sixth  months  of  life, 
when  the  long  mesentery  of  fetal  life  persists.  In  chronic  intussuscep- 
tion 50  per  cent,  occur  between  twenty  and  forty  years  of  age  and  66 
per  cent,  in  males.  Pathologically  only  the  vital  form  is  of  clinical  impor- 
tance, in  which  the  mesentery  and  its  vessels  are  also  invaginated ;  the 
"agonal"  form  occurs  during  the  death  agony,  chiefly  in  children,  in 


INTESTINAL  OBSTRUCTION  549 

the  small  gut,  is  often  multiple  and  does  not  involve  the  mesentery. 
The  vital  form  is  usually  single,  descending  (in  99  per  cent.)  and  com- 
plete; incomplete  forms  may  result  from  polyps  or  other  tmnors,  usually 
benign,  which  drag  down  the  gut.  There  are  three  main  forms:  (a) 
the  enteric,  the  small  gut  invaginating  into  the  small  gut,  30  per  cent.; 

(b)  the  ileocecal,  the  small  gut  entering  the  large  gut,  52  per  cent.;  and 

(c)  the  colonic,  the  large  gut  invaginating  into  the  large  gut  (18  per 
cent.)  or  rectum;  in  rare  cases  ^Meckel's  diverticulum  may  invaginate 
into  the  small  gut. 

Symptoms. — (a)  There  is  sudden,  severe,  reflex  pain,  which  is  usually 
umbilical  in  children  but  sometimes  occurs  elsewhere  in  adults,  is  con- 
tinuous or  in  chronic  forms  of  intussusception,  paroxysmal,  (b)  Early 
reflex  vomiting  may  occiu"  in  children,  though  in  adults  it  is  less  frequent 
than  in  other  forms  of  obstruction;  the  later  vomiting  is  fecal  in  13  per 
cent.;  vomiting  is  more  marked  in  high  than  in  low  invagination  and 
depends  considerably  on  the  degree  of  mesenteric  invagination  (vascular 
disturbance),  (c)  The  stools  are  characteristic,  showing  blood  and  mucus 
in  97  per  cent,  of  acute  and  in  50  per  cent,  of  chronic  cases;  the  move- 
ments may  not  stop  at  once  but  only  after  several  evacuations,  and 
severe  tenesmus  (50  per  cent.),  (d)  A  sausage-  or  egg-like  movable  firm 
tumor  (55  per  cent.)  may  be  palpated,  most  often  over  the  ascending  or 
transverse  colon,  sometimes  by  the  rectum  or  vagina,  and  is  occasionally 
visible  at  the  anus,  where  it  has  been  mistaken  for  prolapse  or  polyp,  and 
extirpated.  It  is  most  common  in  children,  in  the  ileocecal  form,  and 
nearly  always  to  be  felt  during  paroxysms  of  pain,  (e)  INIeteorism  and 
a  depression  in  the  right  flank  are  infrequent. 

Clubbe's  description  is  excellent:  "The  very  sudden  onset  in  a  pre- 
viously healthy  baby  is  a  peculiarity  of  intussusception.  The  child  is 
seized  suddenly,  screams,  turns  pale,  vomits  and  in  a  short  time  seems  to 
recover  itself,  only  to  cry  again  at  intervals  as  if  in  pain.  Soon  after  the 
first  scream  it  may  pass  a  normal  motion.  In  from  two  to  ten  hours,  in 
97  per  cent,  of  cases,  blood  will  be  passed  by  rectum.  The  mass,  which 
varies  much  in  size  and  position,  can  nearly  always  be  made  out  by  careful 
palpation  when  the  child  is  under  an  anesthetic.  The  child  may  not 
look  ill,  its  pulse-rate  may  be  hardly  raised  and  its  temperature  may 
be  normal." 

Issues. — Peritonitis  residts  in  50  per  cent,  of  acute  and  in  nearly  100 
per  cent,  of  chronic  cases;  perforation  occurs  in  chronic  (15  per  cent.) 
more  often  than  in  acute  cases;  sloughing  off  of  the  gangrenous  bowel 
occurs  in  42  per  cent,  of  adult  cases,  but  seldom  in  children;  in  Cruveil- 
hier's  case  three  yards  of  dead  gut  were  discharged.  Spontaneous  reposi- 
tion and  fistula  are  very  uncommon. 

n.  Strangulation. — ^This  causes  35  per  cent,  of  intestinal  obstructions. 
Its  mechanisms  are  innimierable;  it  is  generally  due  to  bands  or  isolated 
peritonitic  adhesions;  ]Meckers  diverticulum,  the  remains  of  the  omphalo- 
mesenteric duct,  which  lies  within  a  yard  of  the  ileocecal  valve  and  is 
sometimes  continuous  as  a  cord  to  the  navel,  caused  strangulation  in 
183  cases  (Hilgenreiner,  1902);  omental  strands  under  which  the  gut 
is  caught;  holding  of  the  gut  in  abnormal  positions;  and  binding  of  coils 


550  DISEASES  OF   THE  INTESTINES 

to  each  other.  Incarceration  may  occur  in  congenital  or  acquired  orifices 
and  clefts  in  the  omentum  or  mesentery  or  under  the  suspensory  hgament 
of  the  hver,  Kg.  teres  or  Kg.  latum  uteri.  Hernias  include  strangulations 
in  the  femoral,  inguinal,  umbilical  locations  or  in  the  less  frequent  types, 
as  the  obturator,  sciatic,  lumbar,  intersigmoid,  retrocecal,  foramen  of 
Winslow,  duodenojejunal  (Treitz's  retroperitoneal  form)  or  diaphrag- 
matic. Seventy  per  cent,  of  cases  occur  in  males,  40  per  cent,  between 
fifteen  and  thirty  years  of  age,  90  per  cent,  in  the  small  intestine,  67  per 
cent,  in  the  right  iliac  fossa  and  83  per  cent,  in  the  lower  abdomen  (Fitz). 

Symptoms." — The  symptoms  are  urgent,  (a)  Early  reflex  vomiting, 
from  shock,  voiding  in  succession  gastric  contents,  bile  and  fecal  matter 
which  usually  consists  of  yellow,  brown  or  black  fluid,  or  very  rarely  solid 
feces,  is  strongly  indicative  of  organic  strangulation  and  lasts  from  the 
beginning  to  the  end  of  the  disease,  (h)  There  is  early  severe  reflex 
pain,  which  is  greatest  at  the  navel  and  lasts  until  collapse,  peritonitis 
or  paralysis  of  the  gut  develops,  (c)  Collapse,  with  Hippocratic  expres- 
sion, weak  pulse  and  hurried  breathing,  results  reflexly  and  may  occur 
early  from  the  disturbed  local  circulation  in  the  gut  or  later  from  peri- 
tonitis, (d)  Complete,  sudden  stoppage  of  the  hotvels  may  result,  in  which 
no  feces  or  flatus  can  pass;  some  feces  from  the  lower  gut  may  pass 
with  enemata,  but  no  gas.  Meteorism  of  two  kinds  occurs:  (i)  the 
static  variety  in  which  gas  accumulates  above  the  obstruction  and  (ii) 
the  local  variety,  in  which  the  strangulated  loop  becomes  distended, 
because  its  circulation  is  impaired;  it  may  be  seen  or  felt  as  an  immovable, 
tense  mass,  showing  no  peristalsis  and  corresponding  to  the  thick,  edema- 
tous, hemorrhagically  infiltrated  and  finally  gangrenous  gut.  (e)  The 
urine  is  decreased  because  of  the  vomiting  and  collapse;  it  contains 
indican  if  the  obstruction  lies  in  the  small  gut.  Sometimes  casts,  albumin 
or  nephritis  are  observed.  (/)  Strangulation  sometimes  may  be  found  in 
the  usual  hernia  locations. 

Diaphragmatic  hernia  is  left-sided  in  88  per  cent.,  is  congenital  or 
acquired  (from  trauma  especially)  and  is  recognized  in  but  3  per  cent,  of 
the  reported  cases;  it  closely  resembles  pneumothorax  {q.  v.).  The 
a;-ray  differentiates. 

In  obstruction  the  mucosa  in.  the  occluded  area  may  become  ulcerated, 
easily  penetrated  by  bacteria  and  hemorrhagically  infarcted,  leading  to 
necrosis,  perforation  and  peritonitis. 

III.  Volvulus  and  Knots. — ^Volvulus  is  a  twisting  of  the  intestine 
around  its  mesenteric  axis;  twisting  of  the  gut  on  itself  is  rare;  volvulus 
occurs  in  14  per  cent,  of  obstructions  (Fitz);  68  per  cent,  of  the  cases 
are  males,  usually  between  forty  and  sixty  years  old;  it  occurs  in  the 
sigmoid  flexure  in  66  per  cent.,  less  frequently  in  the  cecum,  colon  ascen- 
dens,  small  gut  and  stomach.  Predisposing  causes  are  a  vegetable  diet, 
constipation,  a  long  sigmoid  flexure  with  a  long,  narrow  mesentery,  and 
mesenteritis.    The  twist  may  occur  through  180  to  360  degrees  or  more. 

Symptoms. — The  symptoms  closely  resemble  those  of  the  forms 
described,  especially  when  knots  form  between  coils  of  the  smafl  intestine. 
In  volvulus  of  the  sigmoid  there  is  pain  and  vomiting,  which  are  less  marked 
than  in  stranffulation  or  invagination  and  emesis  is  seldom  fecal;  the  local 


INTESTINAL  OBSTRUCTION  551 

meteorism  is  more  pronounced  than  in  any  other  type  of  obstruction,  for 
the  huge  coil  of  obstructed  gut  passes  upward,  in  extreme  cases  pushes 
up  the  diaphragm  to  the  third  or  fourth  rib  and  seldom  exhibits  peris- 
talsis, since  its  circulation  is  disturbed.  But  little  water  can  be  injected 
into  the  rectum.    Hemorrhagic  peritoneal  exudate  is  common. 

IV.  Strictures. — Enterostenosis  more  often  causes  chronic  than  acute 
obstruction.  (a)  Congenital  stricture  is  even  rarer  than  congenital 
atresia,  of  which  Helmholz  collected  199  cases  in  the  small  bowel.  (6) 
Cicatricial  stricture  results  from  healing  of  tuberculous,  syphilitic,  dysen- 
teric, duodenal  and  very  rarely  typhoid  ulcers.  Arbuson.  collated  129 
cases  of  tuberculous  stricture,  (c)  Annular  cancer,  (d)  compression  by 
tumors  (80  per  cent,  of  which  are  pelvic)  and  {e)  traction  are  other 
causes.  (/)  Inflammatory  hypertrophy  of  the  mucosa  and  muscularis  is 
exceedingly  uncommon. 

Symptoms. — The  symptoms  of  chronic  obstruction  vary  with  the 
location  of  the  stenosis.  (1)  Stenosis  of  the  small  intestirie  may  occur 
(a)  above  the  duodenal  papilla,  as  a  result  of  gall-stones  or  duodenal 
ulcer  and  closely  resembles  pyloric  stenosis;  (b)  stenosis  in  the  duodenum 
below  the  papilla  results  from  gall-bladder  adhesions,  ulcer,  tumors  or 
pancreatic  disease;  icterus  is  frequent,  as  well  as  vomiting  of  bile  and 
pancreatic  juice  which  digests  starch  and  fibrin  in  an  alkaline  medium; 
other  symptoms  are  dilatation  of  the  stomach,  pale  stools,  very  slight 
abdominal  meteorism,  except  over  the  epigastrium,  and  the  absence  of 
indicanuria.  (c)  Jejuno-ileac  stricture  may  result  from  healed  ulcers, 
inflammation  in  replaced  hernias  and  adhesions  to  the  internal  genitalia; 
the  ulcer  stricture  may  be  multiple,  twelve  being  recorded  in  one  case; 
extreme  stenosis  may  cause  no  symptoms.  There  is  constipation,  which 
sometimes  alternates  with  diarrhea,  colic,  meteorism  and  visible  pal- 
pable peristalsis,  causing  "intestinal  stiffness"  until  the  obstruction  is 
finally  overcome  by  the  hypertrophied  muscle  above  the  stricture,  when 
a  gurgling  sound  is  sometimes  heard.  The  colon  is  collapsed.  (2) 
Stricture  of  the  large  gut  is  marked  by  constipation,  which  is  significant 
in  a  person  not  previously  constipated  or  when  cathartics  have  no  effect 
in  chronic  constipation;  by  colicky  pain,  even  more  than  in  stricture  of 
the  small  gut,  because  the  stools  are  harder;  eventually  by  nausea  and 
vomiting,  which  are  successively  gastric,  bilious  and  stercoraceous;  by 
meteorism  along  the  colon  and  in  the  lumbar  region  behind,  which  is 
normally  dull;  by  increased,  even  tetanic,  peristalsis  above  the  stricture, 
which  possesses  a  localizing  value;  and  by  the  ribbon-like  or  sheep-stools, 
which  also  occur  in  tumors,  coHca  mucosa  and  constipation.  Fluoroscopic 
results  are  often  invaluable. 

V.  Tumors. — (See  page  553.) 

VI.  Foreign  Bodies. — Foreign  bodies  caused  obstruction  in  12  per 
cent,  of  Fitz's  series,  (a)  Gall-stones — of  which  250  obstruction  cases 
are  on  record — lodge  in  the  duodenum  or  lower  ileum,  ulcerating  through 
the  gall-bladder  into  the  duodenum  or  less  often  the  colon,  or  compres- 
sing the  duodenum  through  a  dilated  pouch  of  the  cystic  duct.  In  but  50 
per  cent,  is  there  a  history  of  colic  or  of  icterus.  Collapse  is  usually  not 
marked,  a  tumor  is  seldom  felt  and  the  constipation  is  often  onlyrela- 


552  DISEASES  OF  THE  INTESTINES 

tive  or  alternates  with  diarrhea,  (b)  Fecal  masses  constitute  the  chief 
obstruction  of  the  large  gut,  especialh'  in  the  sigmoid.  The  Avriter  saw 
absolute  obstruction  develop  after  a  Thanksgiving  dinner;  there  was 
fecal  vomiting,  collapse  and  a  mass  of  hard  food,  measuring  two  inches 
in  diameter,  (c)  Enteroliths  form  slowlj'  of  phosphates,  sometimes  of 
bismuth,  chalk,  iron  or  magnesia,  usually  with  an  organic  nucleus. 
They  measure  one  to  nine  inches  in  diameter  and  one  enterolith  weighed 
four  pounds.  ]\Iost  common  in  the  large  intestine,  they  may  develop 
in  diverticula  of  the  small  intestine,  (d)  Hair  tumors,  twisted  masses 
of  ascarides,  fruit  seeds,  oatmeal  husks,  stones  and  foreign  bodies  (in 
insane  subjects)  are  possible  causes. 

VII.  Dynamic  Heus. — Under  dynamic  ileus  (paralytic  or  spastic  ob- 
structionj  may  be  included  obstruction  following  mesenteric  embolism, 
trauma,  abdominal  operations  or  inflammation  in  an  undescended  tes- 
ticle; it  is  largely  associated  with  acute  peritonitis.  Spasmodic  obstruc- 
tion may  develop  in  gall-stone  occlusion,  ulceration,  hysteria  and  intes- 
tinal crises  of  tabes;  it  rarely  produces  fecal  vomiting. 

Diagnosis  of  Intestinal  Obstruction. — 1.  Of  the  Fact  of  Obstructiox. 
— The  symptoms  are  generally  unmistakable  and  consist  of  constipation, 
cessation  of  flatus,  local  distention,  compensatory  peristalsis  and  fre- 
quently collapse.  The  hernial  sites,  rectum  and  ^'agina  must  be  carefully 
examined. 

2.  Of  the  Locatiox. — The  uncertainties  are  manifold: 

Obstruction  of  the  Shall. vs. Of  the  Large  Intestine. 

General   Condition. — Earlier   and   more   pro-  Later  and  less  impressed, 
foundlj-  impressed. 

Symptoms  more  marked,  more  stormy  onset,  Signs  more  marked,  as  meteorism,  less  water 

more  vomiting,  more  pain.     Fluoroscopic  can  be  injected,  more  peristaltic  effort  and 

tests.  palpable  rigid  coUs,  more  results  bj^  rectal 

or  vaginal  examination,  more  tenesmus. 

Indicanuria. — Earlier  and  marked.  Develops  later  or  not  at  all. 

Urine. — Much  decreased.  Little  decreased. 

3.  Of  its  Nature. — (a)  It  is  practically  impossible  to  recognize 
obstruction  by  bonds,  adhesions,  jMeckel's  diverticulum,  clefts  and 
internal  hernias  (except  diaphragmatic).  (6)  Invagination  is  not  only 
the  most  frequent  but  also  most  characteristic  in  its  clinical  picture. 

(c)  Strangulation  is  differentiated  by  its  greater  and  earlier  collapse, 
pain  and  vomiting,  local  meteorism  and  hemorrhagic  peritoneal  effusion. 

(d)  Volndus  is  suggested  by  advanced  age,  constipation,  slower  course, 
infrequent  fecal  vomiting  and  meteorism,  which  is  greater  than  in  any 
other  form  and  is  accompanied  by  little  peristalsis.  The  small  amount 
of  fluid  which  can  be  injected,  the  hemorrhagic  peritoneal  fluid,  tenesmus 
and  slightness,  lateness  or  absence  of  indicanuria  are  also  suggestive. 

(e)  In  some  instances  of  gall-stones,  the  lack  of  shock,  of  increased  pulse 
and  of  meteorism,  and  the  paradoxical  intermittent  release  of  flatus  and 
feces,  fecal  vomiting,  combined  with  the  passage  of  flatus  and  feces,  may 
be  suggestive. 

4.  Differextiatiox. — Flatulent  colic,  gall-  or  kidney-stones  and  incar- 
ceration of  the  kidney,  uterus  or  testis  are  excluded  by  rapid  stoppage 


INTESTINAL   TUMORS  553 

of  the  bowels.  Acute  pancreatitis  must  be  considered.  Peritonitis 
is  characterized  by  earl}'^  fever,  tenderness,  meteorism,  cessation  of 
peristalsis,  abdominal  rigidity,  fluid  in  the  peritoneum  and  late  collapse, 
fecal  vomiting,  later  and  less  complete  obstruction. 

Treatment. — In  stenosis,  typified  by  ulcer  cicatrices,  a  concentrated 
fluid  or  semifluid  diet  is  given  and  thorough  mastication  of  solid  food 
and  avoidance  of  food  chafi^,  skins,  stone  or  gristle  should  be  insisted  on. 
Cathartics  are  inferior  to  enemata  of  oil. 

Thiosinamin,  recommended  to  dissolve  cicatricial  stenosis,  is  given  in 
10-drop  doses,  every  other  day,  hypodermically  (1  to  6  of  alcohol). 

Operative  measures  may  be  instituted  for  foreign  bodies  or  malignancy; 
the  outlook  is  best  in  lesions  of  the  colon  and  ileum. 

1.  Medical  Treatment  of  Obstruction. — In  every  case  the  physi- 
cian at  once  should  divide  responsibility  with  a  surgeon.  In  acute  cases 
food  causes  aggravation.  Early  gastric  lavage  afi^ords  transitory  relief. 
Chronic  fecal  obstruction  should  be  eliminated  by  colonic  flushings,  given 
with  the  body  inverted;  hard,  desiccated  feces  must  be  dug  out  with 
the  finger,  with  enemata  to  bring  away  fragments.  High  enemata, 
colonic  inflation  with  air,  laxatives,  massage  and  puncture  of  the  gut 
with  an  exploring  needle,  are  always  contra-indicated.  Opium  is  useful 
only  in  the  early  stage  to  relieve  shock.  Stimulants  are  frequentl}' 
indicated.    Atropine,  eserine  and  physostigmine  sometimes  help. 

2.  Operative  Treatment. — Medical  treatment  of  strangulation, 
intussusception  or  volvulus  is  of  little  value.  A  most  convincing  statis- 
tical argument  for  early  operation  is  Naunyn's  series  of  288  cases,  in  which 
75  per  cent,  of  recoveries  were  obtained  by  operation  in  the  first  two 
days,  Mobile  each  successive  day  lowered  the  patient's  chances  to  40 
per  cent.,  30  per  cent.,  etc.  In  1074  recent  cases,  Wiltnei"  reports  recover}'^ 
in  53  per  cent.  In  100  cases  of  intussusception  in  children  63  per  cent, 
of  operated  recoveries  are  reported  by  Clubbe;  40  per  cent,  of  adults 
and  80  per  cent,  of  childi*en  die  under  medical  treatment.  Fifty-two 
per  cent,  of  obstruction  by  gall-stones  recover  under  expectant  and  33 
per  cent,  under  surgical  treatment. 

INTESTINAL    TUMORS. 

Carcinoma,  the  only  neoplasm  of  clinical  importance,  constitutes  22 
per  cent,  of  all  cancers.  Previous  ulceration  is  predisposing.  It  is  most 
frequent  in  males  over  forty  years  of  age;  17  per  cent,  occur  between 
thirty  and  forty  and  14  per  cent,  under  thirty  years  of  age. 

Pathology. — According  to  Leube,  80  per  cent,  occur  in  the  rectum,  15 
per  cent,  in  the  cecum  and  colon  and  5  per  cent,  in  the  small  intestine. 
Hausmann,  in  268  cancers  of  the  bowel  (excluding  the  rectum),  found 
91  per  cent,  in  the  large  and  9  per  cent,  in  the  small  bowel;  if  figured 
more  in  detail,  37  per  cent,  occur  in  the  sigmoid,  18  per  cent,  in  the 
cecum,  11  in  the  descending  colon,  9  in  the  transverse  and  8  per  cent, 
in  the  ascending  colon,  8  per  cent,  in  the  ileum,  4  in  the  splenic  and  3  in 
the  hepatic  flexure  and  2  per  cent,  in  the  jejunum.  The  sigmoid,  splenic 
and  hepatic  flexures  are  especially  predisposed,  probably  because  more 


554  DISEASES  OF  THE  INTESTINES 

fixed  and  exposed  to  irritation.  It  is  usually  primary,  sometimes  second- 
ary by  contiguit}',  but  very  rarely  metastatic.  Originating  in  the 
intestinal  glands,  it  is  usually  annular  in  form  and  causes  stenosis  and 
ultimate  occlusion  of  the  bowel;  it  is  less  often  nodular  and  very  rarely 
diffuse  and  flat.  Histologically  it  may  be  an  adenocarcinoma  (especially 
in  the  duodenum),  scirrhus  (in  the  sigmoid),  medullary,  cylindrical- 
celled  (in  the  cecum  and  sigmoid),  colloid  or  flat-celled  (in  the  rectum). 
Beginning  in  the  mucosa,  early  involvement  of  the  other  coats  and  lymph 
vessels  is  followed  by  later  invplvement  of  the  peritoneum  and  metas- 
tasis, especially  in  the  liver.  McWilliams  finds  in  the  literature  105 
appendiceal  cancers,  but  many  reports  are  indecisive. 

Symptoms. — 1.  Disturbance  of  the  Intestinal  Function. — (a) 
There  is  usually  coiistipation,  resulting  from  narrowing  of  the  intestinal 
lumen;  it  is  most  marked  in  tumors  of  the  large  intestine.  Ulceration 
frequently  causes  diarrhea,  (b)  The  stools  are  irregular  and  band-like 
or  sheep-like,  to  which,  however,  undue  importance  has  been  attached. 
(c)  Blood,  mucus  and  pu^  are  common  in  the  feces,  though  equally 
frequent  in  other  ulcerations  and  in  enteritis.  The  evacuations  may  be 
stinking,  (d)  Fragments  of  tissue  are  uncommon  and  are  diagnostic 
only  when  showing  carcinomatous  arrangement  of  the  cells,  (e)  Pain, 
due  to  enterostenosis,  is  usual;  it  may  be  sacral  when  due  to  sigmoid 
cancer.  (/)  Sudden  complete  occlusion  of  the  bowel  may  follow  previous 
gradual  narrowing  of  the  lumen,  (g)  The  lower  the  tumor  in  the  intes- 
tinal tract  the  greater  is  the  tympany  and  fecal  retention  and  the  purer 
the  pus  and  blood  {i.  e.,  the  less  mixed  with  the  feces).  Above  the  stric- 
ture the  bowel  is  dilated  and  its  muscle  is  hypertrophied  {visible  peris- 
talsis), (h)  Bismuth,  given  by  mouth  and  by  rectum  ma^^  localize  the 
digitated  markings  of  the  stenosis  in  a;-ray  plates. 

2.  Cachexia  and  marasmus  are  most  suggestive. 

3.  Tumor. — A  tumor  is  best  felt  if  the  bowel  is  empty;  it  may  be 
confused  with  a  normal  contracted  colon,  the  edge  of  the  ileopsoas  or 
with  fecal  masses;  it  is  irregularly  oval  in  clear  cases;  annular  forms 
escape  detection,  for  they  merely  constrict  the  bowel.  It  is  usually 
tender  and  is  movable  or  immovable  accordingly  as  the  bowel  involved 
is  naturally  free  or  fixed,  or  is  adherent  to  other  structures  by  adhesions 
or  extension  by  contiguity.  Whether  free  or  fixed,  the  tumor  is  generally 
below  the  navel.  Gas  and  fluid  are  sometimes  felt  or  heard  to  escape 
through  the  stenotic  point  and  distention  of  the  large  bowel  by  introduc- 
tion of  air  or  fluid  per  rectum  may  aid  in  localization.  If  the  tumor  grows 
from  movable  gut  it  may  disappear  and  reappear  from  time  to  time. 
A  rectal  and  vaginal  examination  always  should  be  made. 

4.  Complications. — The  malignancy  of  primarily  ambiguous  symp- 
toms may  be  declared  by  (a)  icterus,  especially  in  duodenal  cancer;  (6) 
hemorrhage  from  the  bowels;  (c)  rupture  into  the  bladder  or  vagina 
or  into  the  stomach,  with  fecal  vomiting  and  diarrhea  from  partially 
digested  food  entering  the  colon. 

Diagnosis. — Diagnosis  is  often  difficult,  except  in  rectal  localization, 
for  many  symptoms  indicate  stenosis  without  declaring  its  nature. 
Differentiation  is  required  from: 


ENTEROPTOSIS  555 

1.  Movable  Tumors. — (a)  These  may  be  pyloric,  requiring  differ- 
entiation from  duodenal  cancers.  (6)  The  corset  liver,  movable  spleen 
and  kidney,  (c)  Omental  and  mesenteric  tumors  produce  less  entero- 
stenosis.     {d)  Scybala  may  coexist  with  malignancy. 

2.  Immovable  Tumors. — (a)  Renal  and  retroperitoneal  tumors  lie 
beyond  the  colon,  on  its  inflation,  and  rarely  cause  the  same  degree  of 
obstruction.  (6)  Encapsulated  peritoneal  exudate;  the  author  has  seen 
chronic  appendicitic  abscesses  in  individuals  over  sixty  years  of  age 
diagnosticated  as  tumor,  (c)  Ovarian  or  uterine  tumors  are  less  obstruc- 
tive, {d)  Localized  inflammatory  infiltration  of  the  intestinal  wall  and 
circumscribed  inflammation  of  the  sigmoid  flexure  and  colon. 

Rectal  cancer  demands  special  consideration.  It  is  usually  annular  and 
when  developed  is  rigid,  frequently  resembles  an  inverted  funnel,  becom- 
ing narrow  upward.  The  colloid  form  extends  upward  and  downward, 
is  often  tubular  and  causes  much  regional  invasion.  Digital  or  procto- 
scopic examination — unaccountably  neglected  more  often  than  any 
other  simple  method  of  physical  examination — saves  many  lamentable 
errors.  The  early  stricture  may  yield  when  ulceration  develops,  with 
discharge  of  blood,  often  ichorous  pus  and  sometimes  malignant  tissue. 
Tenesmus,  piles,  morning  diarrhea,  sacral  pain,  and  abdominal  pain 
before  and  during  the  movement  are  common.  Cachexia  usually 
develops  with  great  rapidity;  death  may  result  from  acute  obstruction 
with  preservation  of  color,  nutrition  and  energy.  Intoxication  symptoms, 
as  stupor,  are  frequent. 

Sj^philitic  strictures  are  slower  and  subject  to  greater  variations; 
tuberculous  ulcers  are  flatter,  softer  and  more  undermined. 

Sarcoma,  of  which  Corner  and  Fairbanks  collected  175  cases  involving 
the  small  bowel,  is  more  rapid  and  seldom  stenoses  the  lumen.  Hells- 
trom  found  45  lipomata  and  Stetten  74  myomata  recorded. 

Prognosis. — ^IMarasmus,  coma,  anasarca,  thrombosis,  secondary  infec- 
tions, stenosis  or  perforation  causes  death. 

Treatment. — Treatment  is  that  of  enterostenosis,  in  regard  to  diet. 
Opium  must  be  used  toward  the  end.  Operation,  either  palliative 
enterostomy,  colostomy  or  curative  enterectomy,  may  be  indicated. 
Hochenegg  (1902)  in  194  radical  operations,  reports  a  mortality  of  but 
12  per  cent,  and  estimates  his  recoveries  at  16  per  cent. 

ENTEROPTOSIS. 

Enteroptosis  is  not  a  disease,  but  only  a  condition  in  which  the 
abdominal  viscera  prolapse  in  the  abdomen,  as  the  stomach  (gastrop- 
tosis),  intestine  (enteroptosis),  colon  (coloptosis)  or  solid  viscera  (splanch- 
noptosis), as  the  liver,  kidney  or  spleen.  The  condition,  first  described 
by  Morgagni,  is  known  as  Glenard's  disease.  Whatever  causes  relaxa- 
tion of  the  abdominal  wall  or  of  the  intra-abdominal  suspensory  struct- 
ures may  induce  prolapse,  as  trauma,  coughing,  loss  of  weight,  pregnancy, 
tumors  of  the  liver,  spleen  or  kidney,  spinal  deformity  and  corsets. 
Seventy-five  per  cent,  of  the  cases  occur  in  women.  Stiller  maintains 
that   splanchnoptosis   is   a   congenital   asthenic   condition   whose   most 


556  DISEASES  OF   THE  IXTESTIXES 

frequent  stigmata  are  a  floating  tenth  rib  (cosia  fluduam  decima),  found 
in  SO  per  cent,  of  cases,  and  a  habitus  enteroptoticits,  some-^'hat  resembling 
the  habitus  plithisicus;  in  the  normal  chest  the  vertical  line  drawn  from 
the  ensiform  to  the  navel  is  short,  compared  T^ith  the  distance  from  the 
median  line,  horizontally,  to  the  tips  of  the  floating  ribs;  in  the  hahitus 
enter optoticus  the  vertical  line  is  much  longer  and  the  horizontal  line  is 
shorter  than  normal  and  shorter  compared  with  the  vertical  hne. 

Sjrmptoms. — 1.  Stomach  Fixdixgs. — Gastroptosis  is  characterized  by 
falling  of  the  organ  to  a  lower  point  in  the  abdomen,  whereby  both 
its  upper  and  lower  limits  are  abnormally  low,  the  epigastrium  is  flat- 
tened and  the  hypogastriimi  is  distended.  Eichhorst  finds  it  in  35  per 
cent,  of  women  and  in  5  per  cent,  of  men.  Dilatation  of  the  stomach 
is  excluded  by  finding  the  lesser  curvatm-e  at  a  lower  point  than  normal. 
Gastric  symptoms  may  be  noted,  as  pain  in  the  left  hypochondrimn  from 
tension  and  increased  by  hea\y  meals,  eructations,  nausea  and  gastric 
or  intestinal  hyperesthesia,  or  as  complications,  vomiting,  hyperacidity 
or  motor  insufiiciency.  In  many  cases  gastric  and  other  sjTnptoms  are 
entirely  lacking.  Radiographs  demonstrate  the  ptosis,  showing  sagging 
of  the  middle  portion  of  the  stomach  and  pyloroptosis. 

2.  IxTESTES^AL  FiNDrN'GS. — Entcroptosis  or  coloptosis  is  frequently 
found  with  gastroptosis.  The  transverse  colon  sinks  in  its  central  seg- 
ment so  as  to  assume  the  form  of  the  letter  U  or  V,  as  shown  by  radi- 
ography.    Constipation  is  frequent. 

3.  Floating  kidxey,  liver  and  spleen  will  be  described  separately. 

4.  Xervous  sy:\iptoms  occur  in  50  per  cent,  of  cases.  Many  subjects 
are  nervous,  slight  and  delicate  women,  who  exhibit  depression,  cephalic 
pressure,  backache,  throbbing  of  the  abdominal  aorta,  emaciation,  con- 
stipation and  anemia. 

Treatment. — (a)  The  treatment  cjutlined  under  Xeurasthenia  {q.  v.) 
is  indicated.  The  diagnosis  should  not  be  disclosed  to  the  patient,  for 
suggestion  initiates  a  long  train  of  additional  symptoms,  (b)  Increase 
in  weight  is  effected  by  full  feeding  and  the  rest  cure,  (c)  Supports  to 
press  upward  and  inward  and  maintain  the  \'iscera  in  their  normal  loca- 
tion often  give  considerable  relief.  Operations  shortening  the  mesentery, 
resecting  parts  of  the  recti,  suture  of  the  liver,  stomach  and  other  organs 
to  fixed  tissues  can  as  yet  receive  no  general  commendation. 

DILATATION    OF    THE    COLON. 

Coledasia  may  be  classified  as  follows:  (a)  Gaseous  distention,  which 
may  occiu'  in  acute  toxemias;  death  resulted  from  heart  paralysis  (r. 
Typhoid  .and  Exteeitis).  (b)  Cases  which  are  due  to  obstruction  by 
feces,  foreign  bodies,  aoIvuIus.  (c)  Hirschsprung's  disease  or  idiopathic 
colectasia,  which  occiu"s  in  children  (in  80  per  cent,  of  cases)  as  a  con- 
genital lesion  or  in  male  adults  over  fifty  years.  It  is  due  to  obstruction, 
spasm,  abnormal  valves  or  long  colon;  in  Formad's  case  there  was 
great  h^'pertrophy  of  the  muscularis;  the  circumference  of  the  colon 
was  30  inches  and  its  weight,  with  the  contained  feces,  was  47  pounds. 
The  leading  symptoms  are  obstinate  constipation  and  meter)rism.     Of 


PILES  557 

223  reported  cases  about  25  per  cent,  recovered  under  medical  treatment 
and  57  per  cent,  after  resection.  Death  results  from  marasmus,  auto- 
intoxication, obstruction,  perforation  or  peritonitis. 

INTESTINAL   HEMORRHAGE. 

Etiology. — There  are  five  groups:  (a)  Ahnormal  intestinal  contents, 
as  hard  feces,  foreign  bodies,  gall-stones,  caustic  poisons  or  parasites. 
(6)  Intestinal  lesions,  as  the  various  ulcerations,  inflammation,  invagina- 
tion, etc.  (c)  General  affections;  stasis,  amyloidosis,  mesenteric  infarc- 
tion, aneurysmal  rupture,  scurvy,  uremia  and  cholemia.  {d)  Infections, 
including  typhoid,  dysentery,  hemorrhagic  exanthemata  and  sepsis 
(see  Hemorrhagic  Diseases  of  the  Newborn),  {e)  Blood  from  the 
stomach. 

Symptoms. — (a)  Blood  in  the  feces  may  be  manifest,  or  "occult,'"  i.  e., 
found  only  microscopically,  chemically  or  spectroscopically  (generally 
present  hours  before  it  is  seen  by  the  naked  eye).  It  is  mixed  with  feces 
and  dark,  tarry  and  offensive  when  it  comes  from  the  small  gut;  it  may 
coat  the  movements  and  be  bright  in  color  when  it  comes  from  the  lower 
intestine.  (6)  Acute  anemia  follows  profuse  hemorrhage,  evidenced  by 
pallor,  syncope  and  slight  fever. 

Diagnosis. — The  diagnosis  of  enterorrhagia  concerns  (a)  the  detection 
of  hlood,  which  may  be  simulated  by  bismuth  or  blueberries;  (6)  the 
question  whether  the  blood  comes  from  the  bowel,  mouth  or  stomach; 
(c)  whether  it  comes  from  the  large  or  small  gut  {d.-s.)  ;  and  {d)  its  cause, 
most  often  hemorrhoids,  typhoid,  dysentery  or  cancer  of  the  lower 
bowel.  No  extended  examination  of  the  abdomen  is  permissible  at  the 
time  of  the  hemorrhage. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  are  involved 
in  the  basic  lesion  (i).  page  55). 

PILES. 

Etiology. — Hemorrhoids  result  from  (a)  stasis;  portal  stasis  operates 
through  t^he  superior  hemorrhoidal  and  inferior  mesenteric  veins  and  is 
more  potent  than  cardiac  stasis,  which  congests  the  middle  hemorrhoidal 
and  internal  iliac  veins;  (6)  from  constiyation,  pregnancy  and  obstruc- 
tive lesions,  as  cancer  of  the  rectum.  Vigorous  contraction  of  the  abdom- 
inal muscles  is  a  more  potent  cause  than  constipation  (Duret).  Usually 
spoken  of  as  varices,  piles  are  cavernous  angiomata. 

Symptoms. — External  piles  appear  as  tender,  painful,  purple  swellings 
outside  the  sphincter  ani,  singly  or  in  a  circle  around  the  anus;  they  may 
be  soft  or  hard.  The  pain  is  throbbing  and  often  severe.  Itching  is  very 
common.  They  may  bleed,  atrophy,  ulcerate  or  suppurate.  Piles  which 
bleed  are  called  "open"  and  those  which  do  not,  "blind."  Internal 
piles  occur  above  the  sphincter,  below  which  they  may  prolapse  and 
strangulate.  Tenesmus,  mucus  secretion  and  dull  pain  sometimes  referred 
to  the  back  and  the  sacro-iliac  articulation,  may  be  noted. 

Diagnosis. — Inspection  excludes  prolapse,  condylomata,  papillomata, 
etc.    Causal  carcinoma  should  be  borne  in  mind. 


558- 


DISEASES  OF   THE  INTESTINES 


Treatment. — (a)  General  factors,  sedentary  habits,  and  constipation 
are  considered.  (6)  Local  treatment:  a  small  injection  of  cold  icater 
before  each  movement  softens  the  irritating  hard  passage,  constricts 
the  piles  and  favors  their  reduction.  Cleanliiiess  relieves  itching,  for 
which  also  a  1  per  cent,  phenol  salve  is  of  value.  The  following  formula 
is  astringent  and  anodyne,  but  must  be  given  with  reserve,  (c)  Surgical 
treatment  is  indicated  when  local  measures  fail.  Boas  lauds  Bier's 
stasis,  till  edema  appears;  atrophy  ensues. 


I^ — Extract!  opii 

•       ■       .       .      gr.  ij 

Extracti  belladonnse 

.      .       .       .      gr.  ij 

Cocainge  (alkaloid) 

.      .       .       .      gr.  iij 

Acidi  tannici 

.      3ss 

Olei  theobromatis 

.      .      q.  s. 

M.  et  ft.  in  suppositoria  no.  x. 

S. — One  at  bedtime. 

DIARRHEA. 

Definition. — Increased  frequency  of  the  stools  with  decreased  con- 
sistence. Diarrhea  is  not  synonymous  with  intestinal  catarrh.  In 
some  individuals  two  or  three  movements  a  day  are  physiological. 

Etiology. — (a)  Irritation;  cathartics  (some,  as  the  aromatics,  increase 
peristalsis  and  others,  as  salts,  cause  increased  transudation);  diarrhea 
dyspeptica;  diarrhea  stercoralis;  diarrhea  entozoica.  In  general  there 
are  two  mechanisms:  (i)  the  stools  are  hurried  through  the  bowel  by 
increased  peristalsis,  in  which  case  bile  is  found  in  them;  and  (ii)  there 
is  increased  serum  transudation  into  the  intestine  when  little  or  no  bile 
is  found.  (6)  Nervous  diarrhea  causes  from  two  to  fifteen  thin  move- 
ments, containing  no  increased  mucus;  it  is  attended  by  peristaltic 
unrest  and  is  chiefly  observed  after  excitement  or  in  neurotics;  some 
cases  are  reflex,  as  from  uterine  irritation,  (c)  Toxic  substances  in  the 
blood  may  irritate  the  ganglia  or  brain,  e.  g.,  in  uremia,  typhoid  or 
sepsis. 

Treatment. — Opium  is  the  most  valuable  remedy,  except  in  stercoral 
and  dyspeptic  types;  it  acts  less  by  checking  secretion  than  by  sus- 
pending peristalsis  and  mitigating  spasm;  the  crude  drug  is  superior 
to  its  alkaloids,  as  its  absorption  from  the  bowel  is  slower  and  its  effect 
more  marked;  f  of  a  grain  of  the  extract  or  a  dram  of  the  camphorated 
tincture  should  be  given  with  bismuth  in  massive  doses  as  in  enteritis. 
Important  adjuncts  are  local  heat,  rest  and  a  spare  diet,  as  in  enteritis. 
In  nervous  diarrhea  two  drops  of  Fowler's  solution  before  meals  is 
advantageous. 

CONSTIPATION.    • 


Constipation  is  insufficient  or  unsatisfactory  defecation. 

Etiology. — (1)  "Physiological"  constipation  results  from  irregularity 
in  going  to  stool,  as  in  travel,  from  obesity,  insufficient  exercise  or  water, 
loss  of  fluid  by  sweating,  a  dietary  rich  in  proteids,  as  milk,  and  from 
overmedication.     (2)   Constipation  may  be  symptomatic  of  other  affec- 


CONSTIPATION  559 

ticms,  as  gastric  ulcer,  cancer,  dilatation  or  hyperacidity;  intestinal 
obstruction,  cancer,  adhesions,  catarrh,  passive  congestion  or  enterop- 
tosis;  x^elvic  conditions,  as  pregnancy,  ovarian  or  uterine  disease  or 
enlarged  prostate;  infections  which  stimulate  the  inhibitory  nerves; 
nervous  disease,  as  meningitis,  tumors,  myelitis,  the  neuroses;  diabetes 
and  old  age.  (3)  Habitual  constipation  may  be  familial.  It  may  result 
from  insufficient  nervous  energy  in  the  large  intestine;  atony  of  the 
intestinal  muscle  may  result  from  general  debility,  neurasthenia,  etc., 
but  seldom  from  atrophy  or  degeneration.  Nervous  constipation  may 
be  due  to  a  spastic  condition  of  the  bowels. 

Symptoms. — Symptoms  other  than  constipation  are  often  absent, 
and  when  present  are  less  often  general  than  local  (anorexia,  coated 
tongue,  bad  taste  in  the  mouth  or  abdominal  uneasiness). 

Two  or  three  movements  in  one  day  or  a  movement  every  two  or  three 
days  come  within  physiological  limits.  The  stools  normally  accumulate 
in  the  sigmoid  and  pass  each  day  into  the  rectum,  causing  a  desire  to 
defecate,  usually  at  the  same  hour.  The  constipated  stool  accumulates 
in  the  haustra  of  the  colon  or  ampullse  of  the  rectum.  It  is  difficult  to 
state  the  quantity  of  the  normal  passage,  which  does  not  depend  wholly 
on  the  amount  of  food  ingested;  feces  consist  largely  of  mucus  and 
bacteria  and  form  even  during  starvation.  The  stools  may  resemble 
sheep's  dung,  probably  due  to  intestinal  muscular  spasm.  Retained 
feces  are  usually  voided  spontaneously  in  a  few  days  with  a  serous 
diarrhea  or  as  scybala  covered  with  mucus  which  results  from  irritation. 
Fecal  colic  is  due  to  peristalsis  above  the  obstruction;  there  may  be 
stercoral  fever  and  meteorism.  Marked  obstruction  rarely  simulates 
enterostenosis,  being  marked  by  collapse,  vomiting  and  great  vesical 
or  rectal  tenesmus,  which  should  always  excite  suspicion.  Neglected 
cases  may  result  fatally,  especially  in  the  old,  debilitated  or  insane  or 
when  defecation  causes  great  pain,  as  from  fistula  or  piles. 

Fecal  concrevients  (coproliths)  occur  in  the  large  intestine,  even  simu- 
lating tumors  of  the  intestine,  omentum,  kidney  or  spleen,  from  which 
differentiation  may  be  possible  only  after  thorough  purging  and  flushing. 
They  may  be  soft  and  easily  indented  with  the  finger,  or  hard,  nodular 
and  tender  from  the  bowel  ulceration  they  incite.  Fecal  tumors  may 
develop  with  daily,  though  inadequate,  movements.  On  pressure  the 
bowel  may  at  first  seem  to  adhere  to  the  fecal  masses  and  then  become 
free  (Gersuny's  sign). 

General  symptoms  are  uncommon.  Nervous  symptoms  are  causal 
rather  than  coprostatic,  as  in  the  neurasthenic  who  believes  he  would 
be  well  if  his  bowels  would  move  and  who  has  most  unpleasant  sensations 
when  they  do.  Vertigo,  pressure  in  the  head  and  mild  dyspnea  are 
always  neurotic.  Copropsychiatry  is  grossly  exaggerated.  Intoxication 
is  rare,  but  has  been  considered  causal  of  neuralgia,  marasmus,  c'hlorosis 
and  numerous  other  concomitant  conditions.  The  aromatic  sulphates 
of  the  urine  may  be  increased,  due  to  formation  of  indol,  skatol  and 
pyrocatechin. 

Lane's  Kink.  Lane  places  great  stress  upon  the  development  of 
accessory  peritoneal  bands,  which  produce  kinks  at  the  pylorus,  lower 


560  DISEASES  OF   THE  INTESTINES 

ileum,  hepatic  and  splenic  flexures  and  sigmoid.  It  is  claimed  that 
profound  intestinal  toxemia  and  constipation  result,  which  induce  dila- 
tation of  the  duodenum,  vomiting  and  even  gall-stones,  gastric  ulcers, 
changes  in  the  breasts,  arthritic  changes  and  tuberculosis.  To  avert 
these  disasters,  he  recommends  ileosigmoidostomy  or  excision  of  the 
colon. 

The  :/'-rays  determine  the  rate  of  passage  of  bismuth;  leaving  the 
stomach,  it  should  reach  the  cecum  in  four  hours,  the  hepatic  flexure 
in  six  and  the  splenic  flexure  in  nine  hours;  visceroptosis  and  kinks  are 
apparent;  intestinal  constipation  and  dyschesia  (difficult  evacuation 
of  the  rectum;  are  differentiated  (i'.  i.). 

Treatment. — Treatment  of  causal  factors  {v.  s.)  is  important. 

1.  Diet. — (a)  Coarse  foods,  as  whole  wheat,  Graham,  rye,  cornmeal 
and  bran  breads,  act  less  mechanically  than  chemically  by  the  produc- 
tion of  lactic  or  oleic  acid,  (b)  Fruits  relax  the  bowels,  because  of  the 
malic,  tartaric  and  citric  acids  they  contain,  as  plmns,  raisins,  apples, 
peaches,  pears  and  prunes;  grapes  sometimes  and  bananas  and  per- 
simmons usually  cause  constipation.  Fruits  operate  best  when  eaten 
at  bedtime;  it  may  be  best  to  remove  the  excess  of  seeds  or  skins,  (c) 
Vegetables  act  by  the  acids  and  gases  they  form;  melons,  sprouts,  cabbage, 
cauliflower,  cucumbers,  turnips,  carrots,  spinach,  tomatoes,  asparagus, 
onions,  cress,  celery  and  squash  should  be  given  freely;  excessive  amounts 
may  cause  fatigue  of  the  bowel,  fermentation  and  constipation.  Agar- 
agar,  Sij  daily,  may  be  given  in  mashed  potatoes  or  apple  sauce,  (d) 
Sweets  are  laxative ;  if  they  do  not  cause  indigestion,  sugars,  syrup,  candy, 
sauces,  molasses,  jellies,  jams,  marmalades  and  honey  are  valuable  laxa- 
tives, (e)  Fats. — ^Moderate  amounts  of  butter  and  olive  oil  are  superior 
to  animal  fats,  which  tend  to  derange  digestion,  (j)  Cold  or  charged 
water,  taken  on  rising  and  tln-ough  the  day,  excites  peristalsis.  Hard 
water  constipates,  ig)  The  following  are  to  be  avoided:  red  wines  fcon- 
taining  tannic  acidj,  excess  of  meat,  eggs  or  rice,  buckwheat,  macaroni 
and  other  carbohydrates  containing  little  water,  tea,  milk  (sometimes 
laxative  when  not  taken  in  sips  but  swallowed  in  larger  quantities), 
chocolate  and  cocoa.  The  diet  recommended  affords  material  for  bac- 
terial action,  which  follows  the  idea  advanced  by  Schmidt,  Strassburger 
and  Lohrisch,  that  constipation  results  from  too  complete  utilization 
of  the  average  diet  by  the  intestinal  bacteria.  Some  individuals  digest 
all  kinds  of  vegetables;  others  pass  unchanged  even  cooked  vegetables. 
Hydrochloric  acid  partly  digests  and  loosens  the  middle  sheath  of  the 
cellulose,  so  that  the  duodenal  and  pancreatic  juices  operate  more  readily 
on  it.  This  explains  the  constipation  of  hyperchlorhydria.  Diet  and 
copious  drinking  of  water  cure  most  cases. 

2.  PuxcTUALiTY  AT  Stool. — The  best  time  is  immediately  after  break- 
fast; piles  or  prolapse  ma}'  come  down  during  the  day,  whence  in  these 
cases  the  bowels  should  be  moved  at  bedtime. 

3.  Posture  at  Stool. — Squatting,  the  natural  posture,  may  be  approx- 
imated by  leaning  forward  or  by  placing  the  feet  on  a  foot-stool;  the 
thighs  support  and  compress  the  abdomen,  a  matter  of  importance  when 
it  is  relaxed. 


CONSTIPATION  561 

4.  Massage. — Gentle  massage  along  the  course  of  the  colon  for  a 
quarter  of  an  hour,  before  breakfast,  may  give  relief  if  continued  for 
months.  Sahli  rolled  over  the  abdomen  a  7-pound  cannon-ball.  Massage 
is  contra- indicated  in  spastic  constipation. 

5.  Mild  Fakadization. — ^Weak  applications  arouse  short  contrac- 
tions in  the  colon  and  are  given  with  a  moist  sponge.  The  cold  compress 
to  the  abdomen  is  a  good  adjunct. 

6.  Exercise. — ^Exercise  to  develop  and  contract  the  abdominal 
muscles,  as  in  tennis  or  rowing  or  by  lifting  the  legs  while  lying  on  the 
back  or  lifting  the  rigid  body  from  the  lying  to  the  erect  posture  solely 
by  the  abdominal  muscles,  is  superior  to  walking,  bicycle  and  horse-back 
riding.  In  ovarian  and  uterine  disease  exercise  increases  constipation, 
due  to  reflex  inhibition  of  peristalsis,  as  shown  by  the  laxative  effect  of 
narcotics.  It  is  claimed  that  constipation  is  spastic  (not  atonic)  in  25 
per  cent,  of  female  cases,  as  evidenced  by  colic,  palpable  or  visible  knots 
in  the  intestine  and  sometimes  by  ribbon-like  passages;  in  these  cases 
an  irritating,  coarse  diet,  massage,  cold  and  electricity  are  to  be  avoided. 
The  radiograph  may  show  the  spastic  sigmoid  or  colonic  flexures,  etc. 
Hot  baths  or  hot  compresses  to  the  abdomen  for  colic  are  indicated ;  an 
enema  of  warm  oil  is  given  each  evening;  extract  of  belladonna  gr  f  in 
a  suppository  relieves  spasm  and  tenesmus;  the  diet  should  consist  of 
fine  carbohydrates,  butter  and  cooked  fruit. 

7.  Enemata. — Enemata  excite  peristalsis,  lessen  intestinal  hyperemia 
and  apparently  benefit  the  hepatic  circulation.  They  do  not  derange 
digestion  as  do  cathartics,  but  may  lose  their  effect  by  dilating  the  colon, 
whence  the  indication  for  their  intermittent  use.  Water  and  olive  or 
linseed  oil  may  be  used;  oil  enemata  (five  to  eight  ounces)  are  especially 
indicated  in  spastic  constipation  and  colica  mucosa,  in  which  the  oil 
may  be  left  in  the  bowel  over  night.  Antiperistaltic  movements  in  the 
colon  carry  the  oil  to  the  cecum,  in  the  low  as  well  as  in  the  "high" 
enema.  In  ordinary  constipation,  the  passage  of  feces  through  the 
intestines  is  delayed,  while  defecation  is  normal;  in  dyschesia,  there  is 
no  delay  in  the  arrival  of  feces  in  the  pelvic  colon,  though  their  final 
expulsion  is  not  adequately  performed;  diet,  abdominal  massage  and 
aperients,  appropriate  for  intestinal  constipation,  are  useless  in  dyschesia, 
attention  to  the  hygiene  of  the  bowels  and  reeducation  of  the  defecation 
reflex  by  means  of  graduated  enemata  being  the  correct  treatment. 
Dyschesia  leads  to  secondary  retention  of  feces  in  the  pelvic  colon,  and 
in  severe  cases  in  still  higher  parts  of  the  large  intestine;  unless  enemata 
are  given,  the  rectum  is  never  empty,  and  in  spite  of  its  dilated  condition 
there  is  insufficient  room  for  all  the  retained  feces.  Glycerin  supposi- 
tories are  valuable,  if  used  alternately  with  other  methods.  Fecal  impac- 
tion indicates  enemata,  cathartics  and  digital  evacuation  of  the  hardened 
masses. 

8.  CATHA.RTICS. — (tt)  Cathartics  should  be  administered  only  after 
failure  of  the  measures  enumerated  above;  (6)  their  most  successful  em- 
ployment is  intermittent  and  alternating;  (c)  drastics,  hydragogues  and 
cathartics  producing  secondary  constipation  are  avoided,  save  in  extreme 
cases.    Every  new  remedy  is  the  best  for  a  short  while. 

36 


562 


DISEASES  OF   THE  IXTESTIXES 


Varieties. — Aloes,  found  in  nearly  all  proprietary  and  official  pills, 
.-hoiild  be  avoided  in  piles  and  uterine  hemorrhage,  because  it  congests 
the  pelvic  vessels;  it  is  given  in  combination,  e.  g. — 


I^ — Extr.  aloes gr.  ss 

Extr.  rhei gr.  ij-v 

Extr.  nucis  vomicae 
Resinae  podophylli 

Extr.  belladonnae    ...        gr.  4 

(or  extr.  hyoscyami) 
Extr.  taraxaci   ....        gr.  j 

M.  et  ft.  pil.  i. 


gr.  t 
gr.i^ 


Acting  in  15  to  20  hours,  on  the  large  bowel 
chiefly,  increasing  tonus. 

Actively  purgative  in  4  to  8  hours;  stom- 
achic and  tonic. 

Acting  on  peristalsis  and  combating  atony. 

Acting  in  10  hours,  producing  "bilious 
stools." 

Relie\'ing  .spasm  (griping)  and  operating  on 
the  intestinal  nerves. 


Jihuharh  gripes  and  produces  secondary  constipation,  caused  by  its 
tannic  acid,  ^vhence  it  should  never  be  given  alone: 

I^ — Pulveris  rhei  compositi 3iv 

Sodii  sulphatis Ji'^' 

Sodii  bicarbonatis 3J 

M.  et  S. — One  teaspoonful  at  bedtime. 

Cascara  sarrrada  improves  digestion  and  produces  little  constipation 
afterward;  the  fluidextractum  rhamni  pur.shian8e,  TUxv,  is  very  bitter; 
the  extractum  is  given  in  doses  of  from  two  to  eight  grains.  Licorice 
is  given  as  pulvis  glycyrrhizae  compositus,  5ss-j.  Castor  oil  is  a 
soothing  laxative,  relieving  irritation  and  spasm,  in  nervous  or  lead 
constipation,  in  the  latter  combined  Avith  opium  gr.  J;  its  offensive 
taste  may  be  partly  overcome  as  follows: 

P» — Olei  ricini g  i j 

Olei  gaultherise gtt.  xl 

Glycerini gij 

M.  et  S. — One  teaspoonful  to  one  tablespoonful. 

In  anemic  patients  the  following  formula  is  recommended: 


R — Ferri  sulphatis 

gr.  x 

Extracti  aloes 

gr.  V 

Extracti  rhamni  purshianse 

gr.  XX 

Extracti  belladonnse 

gr.  uj 

Extracti  nucis  vomicae 

gr.  iij 

ISl.  et  ft.  piltilae  no.  x. 

S. — One  after  meals. 

Calomel  should  be  given  in  the  evening  in  fractional  doses,  combined 
with  podophyllin,  which  also  acts  in  eight  hours,  and  followed  the  next 
morning  by  half  an  ounce  of  magnesium  sulphate;  calomel  increases  the 
peristalsis  of  the  large  and  small  intestines.  Senna  easily  deranges  diges- 
tion; it  acts  upon  the  large  bowel;  a  small  amount  may  be  cooked  with 
prunes;  confectio  senncB  is  given  in  dram  doses.  Cathartics  often  cause 
blood  in  the  stools.  Tobacco  smoJcing  and  co^^f  in  the  morning  are  bene- 
ficial, but  tea  promotes  flatulency  and  constipation.  Consideration  of 
the  salines  and  drastics  (v.  Xephritis)  is  omitted,  as  their  use  is  contra- 


NERVOUS  AFFECTIONS  OF   THE  BOWEL  563 

indicated  except  for  emergencies;  table  salt,  5ss,  well  diluted  and  taken 
on  rising  frequently  moves  the  bowels.  Hormonal,  a  peristalsis  hormone 
discovered  by  Zuelzer  in  the  intestines,  spleen,  etc.,  promotes  peristalsis, 
given  intramuscularly  or  intravenously;  it  is  prone  to  lower  blood-pressure, 
even  to  the  point  of  collapse. 


INTESTINAL   DIVERTICULA. 

Telling  tabulated  105  cases  (1908).  They  may  be  congenital  or  acquired, 
false  or  true,  in  type.  They  may  be  the  site  of  inflammation  or  malig- 
nancy. Occurring  in  the  colon  or  sigmoid,  the  symptoms  may  resemble 
those  of  left-sided  appendicitis.  Infection,  ulceration  or  gangrene  may 
lead  to  peritoneal  disasters.  Pain,  leukocytosis,  fever,  vomiting,  diarrhea 
or  constipation,  blood  in  the  stools  and  a  low,  perhaps  pelvic,  tumor 
which  appears  and  disappears,  are  suggestive  symptoms. 


NERVOUS    AFFECTIONS    OF    THE   BOWEL. 

1.  Neuroses  of  Motility. — (a)  Nervous  diarrhea  has  been  considered. 
It  may  occur  in  the  neuroses,  reflex  irritation  during  dentition  or  in  the 
crises  of  tabes ;  it  is  usually  transient  and  is  marked  by  absence  of  inflam- 
matory symptoms,  as  mucus,  pus  or  blood.  Nervous  diarrhea  may  be 
confused  with  organic  disease,  (b)  Enterospasm  is  caused  by  simulta- 
neous contraction  of  the  circular  and  longitudinal  muscles,  which  normally 
contract  alternately.  (See  Dyxajwic  Ileus,  Spastic  Constipation  and 
CoLiCA  Mucosa.)  (c)  Sphincter  spasm,  aside  from  local  rectal  or  anal 
lesions,  results  from  sensory  hyperirritability  or  decreased  cerebral  inhibi- 
tion; it  is  most  common  in  hysteria  and  tabes,  {d)  Peristaltic  unrest 
may  be  associated  with  diarrhea  if  the  colon  is  involved,  but  more  com- 
monly affects  the  small  bowel  only,  when  constipation  or  normal  move- 
ments are  usual,  (e)  Nervous  constipation  (atony)  may  result  from  the 
neuroses,  intoxication  from  carbon  dioxide  and  organic  cerebrospinal 
diseases,  in  which  conditions  (/)  sphincter  paralysis  may  also  result. 

2.  Neuroses  of  Sensation. — Neuralgia  mesenterica  (enteralgia,  entero- 
dynia)  is  most  important;  strictly  speaking,  it  is  always  nervous,  i.  e., 
not  due  to  organic  causes;  practically,  other  forms  of  abdominal  pain 
are  frec[uently  included  under  enteralgia.  The  chief  symptom  is  the 
abdominal  pain,  which  is  usually  umbilical,  sometimes  relieved  by  press- 
ure and  sometimes  not;  the  abdominal  wall  may  be  hyperesthetic. 
Reflex  disturbances  in  other  organs  may  aid  in  establishing  its  functional 
character,  as  hiccough,  vomiting,  dyspnea,  palpitation,  rectal  or  vesical 
tenesmus,  muscular  twitchings,  etc.  The  diagnosis  necessitates  exclusion 
of  innumeraV)le  afl'ections,  chiefly  abdominal  but  also  general:  (a)  rheuma- 
tism of  the  abdominal  muscles  which  is  superficial;  (h)  lumbo-abdominal 
neuralgia,-  in  which  Valleix's  three  tender  points  are  found  (see  Neu- 
ralgia) ;  (c)  hysteria,  distinguishable  by  its  stigmata;  (d)  tabetic  crises; 
(e)  intestinal  affections,  as  appendicitis,  peritonitis,  coprostasis,  para- 


564  ~   DISEASES  OF  THE  INTESTINES 

sites,  flatulent  colic,  excessive   catharsis,  lead  colic  or  colica  mucosa; 
(/)  gout;  malaria  and  typhoid;  renal  and  bilary  calculi. 

Its  treatment  and  that  of  the  motor  disturbances  is  of  the  fundamental 
nervous  state.  Symptomatically,  hypodermics  of  narcotics  produce  the 
quickest  but  most  dangerous  relief;  atropine  is  much  safer. 

I^ — Spiritus  chloroformi 5ij 

Tincturse  opii  camphoratse 3iv 

Tincturse  asafcetidse 3iv 

M.  et  S. — One  tablespoonful  in  hot  water  every  fifteen  minutes  for  three  or  four  doses. 

3.  Neuroses  of  Secretion. — The  secretion  neuroses  are  important. 
The  chief  types  are  serous  nervous  diarrhea  and  colica  mucosa  (v.  s.). 


AFFECTIONS    OF   THE   MESENTERY. 

I.  Inflammation. — Mesenteritis  is  chiefly  important  in  its  relation  to 
ascites,  tuberculous  peritonitis  and  other  peritonitides  (g.  v.). 

II.  Hemorrhage. — Primary  hemorrhage  is  most  rare.  It  is  generally 
secondary  to  acute  hemorrhagic  pancreatitis,  retroperitoneal  hematoma, 
aneurysmal  extravasation  or  the  hemorrhagic  fevers. 

III.  Diseases  of  the  Mesenteric  Vessels. — (a)  Infarction  by  embolism 
or  thrombosis  involves  chiefly  the  arteria  mesenterica  superior,  essentially 
a  terminal  vessel.  Most  cases  develop  in  men  past  middle  life;  360 
cases  are  reported.  Its  onset  is  sudden,  with  intense  abdominal  pain, 
collapse,  vomiting  (usually  bloody  and  perhaps  fecal,  due  to  intestinal 
obstruction),  diarrhea  (40  per  cent.)  and  bloody  stools  (40  per  cent.). 
Unless  there  is  an  apparent  cause  for  embolism,  as  valvular  disease,  the 
diagnosis  is  rarely  made,  for  peritonitis  or  obstruction  is  usually  suspected. 
The  usual  outcome  is  early  death  from  collapse,  but  if  the  patient  lives 
long  enough  acute  peritonitis  sets  in,  with  distended  abdomen  and  diffuse 
tenderness.  In  very  rare  cases  collateral  circulation  allows  of  recovery; 
94  per  cent,  are  fatal.  The  treatment  is  purely  symptomatic  and  suppor- 
tive, but  operation  was  successful  in  46  per  cent,  of  Boinet's  series,  (b) 
Periarteritis  nodosa  {v.  page  410).  (c)  Dilatation  of  the  mesenteric  veins 
and  phlebosclerosis  occur,  especially  in  liver  cirrhosis,  (d)  Suppuration 
(thrombophlebitis  suppurativa)  may  mark  umbilical  pyemia  of  the  new- 
born or  may  carry  infection  from  the  appendix  or  rectum,  (e)  Of  simple 
thrombosis  of  the  mesenteric  veins,  Kraft  collected  16  cases;  in  over  half 
of  the  cases  syphilis  or  liver  cirrhosis  was  the  cause. 

IV.  Affections  of  the  Chyle  Vessels. — These  vessels  may  become 
varicose  or  even  hyperplastic  (chylangioma).  Cysts  containing  chyle 
may  cause  tumors  and,  by  rupture,  may  result  in  chylous  extravasation 
in  the  mesentery  or  chylous  ascites  {q.  v.).  Twenty-four  chylous  cysts 
are  described  by  Broca. 

V.  Mesenteric  Tumors. — These  may  be  dermoid,  hydatid,  serous, 
sanguineous,  chylous  or  malignant,  and  may  fill  the  abdomen.  Their 
symptoms  are  those  of  an  abdominal  tumor,  which  is  centrally  located, 
movable  and  covered  with  a  zone  of  resonant  intestine. 


ACUTE   YELLOW  ATROPHY  565 


DISEASES  OF  THE  LIVEK. 


ACUTE    YELLOW   ATROPHY. 

Definition. — An  acute  degeneration  of  the  liver  cells,  accompanied  by 
shrinking  of  the  liver,  icterus  and  fatal  nervous  toxemia.  Ballonius 
(1600)  reported  the  first  case.    Best  collected  500  cases. 

Etiology. — (a)  Sixty-six  per  cent,  occur  in  women  and  50  per  cent, 
between  the  years  of  twenty  and  thirty;  but  22  cases  occurred  under  10 
years  of  age.  (&)  Thirty-three  per  cent,  of  women  with  the  disease  were 
in  the  last  half  of  pregnancy;  it  is  infrequent  in  the  first  three  months  and 
the  puerperium.  (c)  Ten  soldiers  were  affected  in  Arnould's  epidemic 
series,  (d)  Infections,  as  osteomyelitis,  diphtheria,  sepsis,  erysipelas, 
typhoid,  recurrent  fever  and  secondary  syphilis  (in  about  50  cases) ;  or 
(e)  poisoning,  as  from  phosphorus,  alcohol  and  chloroform  narcosis,  may 
antedate  the  disease,  which  may  occur  primarily  in  a  sound  or  secondarily 
in  a  diseased  liver.  Worry  is  a  predisposing  factor  in  pregnancy  or 
syphilis. 

Pathology. — The  liver  is  small,  the  minimum  record  being  400  grams; 
it  is  often  so  lax  that  it  can  be  rolled  up;  the  capsule  is  wrinkled,  the  color 
yellow  {atrophia  hepatis  fusca)  and  the  lobular  markings  obscure.  The 
liver  cells  are  granular,  fatty,  or  tinged  with  bile;  some  are  necrotic  and 
others  show  regeneration.  Foci  of  red  tissue  represent  an  advanced 
stage  in  which  the  fatty  necrotic  cells  have  been  absorbed;  the  left  lobe 
is  often  red,  homogeneous  and  composed  of  detritus,  showing  the  most 
advanced  process,  and  the  right  lobe  is  yellow,  showing  more  recent 
changes.  Crystals  of  tyrosin  are  found.  The  apparent  increase  of  the 
connective  tissue  is  relative  only.  Icteric  staining,  small  hemorrhages 
and  fatty  degeneration  are  found  in  the  heart,  kidneys,  muscles,  lungs 
and  digestive  tract. 

The  disease  is  rather  a  necrotic  process  than  an  acute  parenchymatous 
hepatitis.  It  is  not  determined  whether  the  disease  is  an  infection,  to 
which  it  has  some  resemblance,  or  an  intoxication,  which  initiates  auto- 
lysis of  the  liver. 

General  Clinical  Picture. — Acute  yellow  atrophy  begins  with  a  prodromal 
stage  in  which  gastric  disturbance  predominates;  icterus  develops  in  a 
few  days  when  the  second  stage  suddenly  begins  with  cerebral  symp- 
toms, delirium,  vomiting  and  convulsions;  shrinking  of  the  liver,  hepatic 
tenderness,  enlarged  spleen,  hemorrhages,  and  abortion,  if  pregnancy 
exist;  urinary  symptoms,  as  bile,  albumin,  leucin,  tyrosin  and  other 
unusual  products  in  the  urine;  and  subnormal  or  normal  temperature. 
The  issue  is  fatal. 

Individual  Symptoms. — The  prodromal  stage  lasts  a  few  days  (to  three 
weeks  or  more)  and  is  not  characteristic.  In  the  latter  half  of  gestation, 
icterus  and  hepatic  tenderness  or  enlargement  are  suspicious  symptoms. 
Gastric  irritability  prevails.  Icterus,  absent  only  in  extremely  rapid 
cases,  is  obstructive  from  intrahepatic  changes  and  increases  with  the 
second  stage;  the  stools  are  acholic. 


5G6  DISEASES  OF   THE  LIVER 

In  the  second  stage  (a)  the  hepatic  dulness  shriiiks  first  in  the  left  lobe, 
to  one-half  or  one-quarter  of  its  former  dimensions,  or  the  liver  falls  back 
toward  the  spine  so  that  there  is  no  liver  dulness.  The  liver  dulness  may 
remain  normal  if  death  is  rapid,  as  from  hematemesis,  or  if  the  liver  is 
cirrhotic  or  adherent  to  the  abdominal  wall.  The  liver  is  tender  and  pain- 
ful, and  may  feel  flabby  or  pit  to  the  finger.  The  liver  region  may  appear 
sunken.  (6)  The  spleen  is  enlarged  in  66  per  cent.;  it  is  not  enlarged 
when  profuse  hemorrhage  or  diarrhea  is  present,  (c)  Vomiting  is  almost 
invariable,  the  vomitus  consisting  of  mucus,  bile  and  finally  blood;  it  is 
accompanied  by  hiccough,  dry  tongue,  sordes  and  constipated,  uncolored 
stools,  (d)  Nervous  symptoms  come  on  gradually  with  headache,  or  abruptly 
with  delirium,  anxiety,  meningeal  symptoms,  trismus,  wide  pupils,  amau- 
rosis, cerebral  vomiting  and  convulsions  (in  33  per  cent,  of  adults  and 
almost  constantly  in  children).  The  nervous  symptoms  are  due  to  hepatic 
insufficiency  (hepatargia),  the  degenerated  liver  being  unable  to  protect 
the  nervous  system,  as  it  does  in  health,  against  various  toxic  products. 
(e)  The  urine  is  decreased  or  even  suppressed.  Bile  pigment,  albumin, 
casts  and  epithelial  cells  are  found.  Unusual  products  are  found  in  the 
urine,  due  to  the  autolysis  of  the  liver  cells;  leucin  and  tyrosin  occur  most 
frequently,  though  neither  constant  nor  pathognomonic;  sarcolactic 
acid,  oxyamygdalic  acid,  peptone  and  albumose  are  also  found.  The 
urea  is  decreased,  perhaps  absent.  The  ammonium  compounds,  normally 
2  to  5  per  cent,  of  the  nitrogen  excretion,  are  increased,  even  to  17  to 
20  per  cent.,  to  neutralize  the  acidosis.  The  uric  acid  and  xanthin  are 
increased.  Indicanuria  may  be  noted.  Glycosuria  is  rare,  though  the 
glycogenic  function  of  the  liver  can  hardly  be  normal.  (/)  The  temperature 
is  usually  normal  or  subnormal  at  the  height  of  the  process.  The  pulse 
at  first  may  be  slow,  but  later  becomes  very  rapid  and  dyspnea  develops. 
{g)  Hemorrhages  occur  in  the  majority  of  cases,  largely  from  the  stomach 
and  into  the  skin.  Hemorrhages  from  the  bowel,  nose,  mouth  and  genitals 
are  less  frequent.  Uterine  hemorrhages  occur  if  pregnancy  exist.  Hemor- 
rhages in  the  retina  are  frequent,  together  with  white  flecks  due  to 
tyrosin  deposit  and  fatty  change.  Erythematous  eruptions,  muscular 
pain,  articular  swellings  and  herpes  may  occur. 

Course. — Fifty  per  cent:  of  cases  die  between  the  fifth  and  fourteenth 
day  and  30  per  cent,  between  the  third  and  fifth  week.  The  more  abrupt 
and  severe  the  cerebral  symptoms  the  more  rapid  is  the  course.  Preg- 
nancy hastens  the  issue.  Remissions  may  be  observed.  The  pulse 
becomes  rapid,  the  breathing  difficult  and  irregular  and  nervous  excitation 
is  followed  by  paralysis  of  the  brain  centres. 

Diagnosis. — Diagnosis  is  based  upon  the  icterus,  nervous  symptoms 
and  shrinkage  of  the  liver.  Diminution  of  the  liver  may  be  simulated  by 
tympanites  or  by  the  colon  lying  over  the  liver.  The  urinary  findings 
are  valuable  with  the  above  symptoms.  Confusion  may  occur  in  icterus 
gravis  or  in  the  so-called  bilious  typhoid,  pneumonia,  recurrent  fever, 
puerperal  fever,  yellow  fever,  or  Weil's  disease,  most  of  which  afifections 
are  febrile,  while  yellow  atrophy  is  afebrile;  the  intensity  of  the  icterus, 
shrinking  of  the  liver,  severe  cerebral  symptoms  and  the  urinary  findings 
are  diagnostic.  The  greatest  difficulty  in  diagnosis  is  oc^ite  phosphorus 
poisoning,  for  which  the  etiology  alone  is  distinctive. 


2.  Vascular. 


PORTAL  CIRRHOSIS  567 

Recovery  usually  indicates  error  in  diagnosis.  Ascites  in  acute  yellow 
atrophy  occurred  in  but  eight  instances  (Tileston)  {v.  page  587). 

Treatment. — Treatment  is  directed  to  the  heart  depression,  vomiting 
and  nervous  excitement  (v.  Typhoid).  Two  recoveries  under  salvarsan 
are  alleged. 

PORTAL   CIRRHOSIS. 

Synonyms. — Laennec's  cirrhosis,  alcoholic  or  atrophic  cirrhosis. 

Definition. — Portal  cirrhosis  is  a  fibrosis  of  the  liver,  characterized 
(a)  etiologically  by  alcoholism;  (b)  anatomically  by  induration  around 
the  portal  vein  radicles  enclosing  numbers  of  liver  lobules,  whose  cells 
degenerate;  and  (c)  clinically  by  portal  obstruction  (dyspepsia,  hema- 
temesis,  enlarged  spleen  and  ascites)  and  often  by  signs  of  hepatic 
insufficiency. 

Classification. — Cirrhosis  may  be  classified  as  follows: 

1     /-,  ^  f  Portal  vein  syphilis. 

1.  Capsular  or  Glissonian.  \    r^-u       ■  -^       .■.■ 

[   Chronic  perihepatitis. 

Portal  vein  cirrhosis,  first  in  clinical  importance; 
its  leading  type  is  the  alcoholic,  atrophic  type 
of  Laennec.  (A  subtype  is  a  hypertrophic 
cirrhosis,  like  the  atrophic  save  that  the  liver 
remains  large.) 

Hepatic  vein  cirrhosis,  occurring  in  stasis  (cy- 
anotic induration),  and,  according  to  French 
[        authors,  with  portal  vein  cirrhosis. 

.3.  Biliary  Cirrhosis.  Hanot's  disease. 

4.  Mixed  Cirrhosis.  (Portal  vein  and  biliary  cirrhoses  combined.) 

Of  these,  two  main  forms  are  conspicuous— the  portal  and  biliary. 

Etiology. — (a)  Sixty  to  75  per  cent,  of  cases  are  found  in  7nen  between 
forty  and  fifty  years  of  age.  Musser  collected  685  cases  in  children.  (6) 
Alcoholism  is  the  chief  cause;  cirrhosis  may  be  due  to  whisky,  wine,  beer 
or  absinthe,  especially  in  sedentary  individuals;  alcohol  is  absorbed  by 
the  gastro-intestinal  veins  and  conveyed  to  the  portal  vein  radicles, 
where  its  toxic  effects  are  expended  on  the  liver  cells  or  interstitial  tissue, 
but  in  what  sequence  it  is  not  known,  (c)  Syphilis  is  a  cause,  especially 
in  the  young,  in  whom  the  spirochetes  are  conveyed  by  the  umbilical 
vein  to  the  liver,  (d)  Other  infections,  as  malaria,  typhoid,  tuberculosis, 
etc.,  are  possible  causes;  experimentally  cirrhosis  has  been  induced  by 
the  Bacillus  pyocyaneus,  B.  coli  and  staphylococcus;  and  lactic,  acetic 
and  butyric  aci,ds;  local  mycotic  necrosis  is  thought  to  be  followed  by 
fibrosis,  the  toxins  probably  entering  by  the  hepatic  artery,  (e)  Unknown 
toxemias.  Spices,  drastics,  lead,  phosphorus,  arsenic,  hemochromatosis, 
anthracosis,  silicosis,  repeated  protein  intoxication  and  possibly  gastro- 
enteric auto-intoxication  are  exceptional  etiological  factors.  It  rnay  be 
associated  with  gout,  diabetes  or  other  constitutional  affections.  There 
may  be  multiple  causes,  e.  g.,  syphilis  plus  malaria  or  alcoholism. 

Pathology. — The  essential  change  is  fibrosis  around  the  branches  of 
the  portal  vein;  either  the  connective-tissue  growth  is  primary,  causing, 
as  it  contracts,  atrophic  or  fatty  alteration  of  the  liver  cells,  sometimes 


568  DISEASES  OF  THE  LIVER 

with  pigmentation;  or  the  cells  are  first  injured  and  are  replaced  by  fibrous 
tissue.  The  connective  tissue  surrounds  several  lobules  at  a  time  {multi- 
lobular cirrhosis).  Histologically  the  cirrhosis  is  atrophic,  and  this  point 
is  emphasized  first,  because  some  clinicians  maintain  that  the  liver  is 
first  large  (the  so-called  hypertrophic  stage)  and  later  is  shrunken;  and 
a  normal-sized  or  enlarged  cirrhotic  liver  is  histologically  atrophic. 
An  atrophic  liver  may  be  large  from  fat  deposit,  congestion  or  compen- 
satory parenchymatous  hyperplasia.  The  weight  is  as  often  increased 
as  decreased,  ranging  from  2000  gm.  to  1000  gm.  or  less.  Its  edge  is 
rough,  i.  e.,  granulations  can  be  felt  which  represent  the  remaining 
relatively  normal  liver  tissue.  Regeneration  of  the  parenchymatous 
cells  is  active  but  somewhat  disorderly,  irregular  and  unstable,  the  cells 
again  wasting.  The  surface  is  sometimes  smooth,  and  cirrhosis  may 
appear  only  on  microscopic  examination.  Granulations  also  occur 
in  fatty  liver,  pylephlebitis  and  passive  congestion.  Its  consistence  is 
increased.  The  liver  is  gritty  to  the  knife;  its  color  is  yellow^  (cirrhosis), 
perhaps  green  or  brown.  The  connective  tissue  is  increased  and  prominent, 
encroaching  on  the  parenchyma.  Injections  of  the  organ  through  the 
portal  vein  are  not  successful,  i.  e.,  there  is  portal  obstruction;  there 
is  a  narrowing  of  the  capillary  vessels;  these  and  the  increased  arterial 
pressure  in  the  organ  account  for  many  of  the  clinical  symptoms 
{v.  page  574). 

General  Clinical  Picture. — The  disease  often  exists  for  years  without 
symptoms;  this  latency  is  marked  by  enlargement  of  the  liver,  and  is 
due  to  compensatory  cellular  hyperplasia.  In  the  minority  of  cases, 
transient  swelling,  pain  or  active  hyperemia  of  the  liver,  dyspepsia  and 
fever  or  icterus  are  observed;  they  are  not  characteristic.  With  marked 
shrinking  there  are  symptoms  (a)  of  disturhance  of  nutrition,  as  emaciation, 
w^hich  is  often  not  noticed  because  the  abdomen  remains  obese  and  a 
sallow  skin,  in  which  dilatation  of  the  small  arterioles  (toxemia  or  alco- 
holism), dryness  and  hemorrhages  are  also  observed;  (h)  of  portal  con- 
gestion, as  early  hematemesis,  epigastric  pressure,  ascites,  large  spleen 
and  disturbed  breathing,  circulation  and  digestion;  (c)  of  intoxication, 
resulting  from  functional  failure  of  the  heart,  liver  and  kidneys;  and 
(d)  of  complications,  as  hemorrhage,  diarrhea  or  cholemia. 

Symptoms. — 1.  The  Livek. — The  liver  is  enlarged  as  often  as  it  is 
decreased  in  size;  the  left  lobe  suffers  greater  and  earlier  contraction. 
Its  edge  is  hard,  but  often  cannot  be  felt,  even  after  tapping,  on  account 
of  its  shrinkage  or  because  the  bowels  cover  it.  The  edge  is  uneven; 
its  granulations  may  be  confused  with  the  small  islets  of  fatty  tissue 
in  the  abdominal  wall,  due  to  unequal  wasting  of  the  adipose  tissue. 
Palpation  of  the  liver  is  the  only  certain  way  of  determining  its  lower  limit, 
the  results  of  percussion  being  unreliable.  In  infantile  forms  of  portal 
cirrhosis  the  liver  and  spleen  are  larger  than  in  adult  types  {v.  i.  for 
symptoms  of  impaired  hepatic  function). 

2.  Portal  Stasis. — Obstruction  to  the  portal  circulation  causes:  (a) 
The  peritoneum  is  thickened,  edematous  and  the  seat  of  transudation, 
i.  e.,  ascites,  which  occurs  in  85  per  cent,  when  the  patient  dies  of  the 
cirrhosis  itself  and  in  50  per  cent,  when  he  dies  from  other  causes. 


PORTAL  CIRRHOSIS  569 

It  is  more  common  in  small  than  in  large  livers.  Ascites  appears  first 
loithout  general  edema,  though  later  the  legs  may  become  swollen  as  the 
ascites  compresses  the  inferior  cava;  pre-ascitic  edema  of  the  legs  or 
abdominal  wall  may  develop  from  cardiac  or  renal  complications,  involve- 
ment of  the  cava  by  perihepatitis  or  from  thrombosis  of  the  iliac  veins. 
Under  ascites  its  physical  signs  will  be  more  closely  considered.  The 
amount  of  fluid  may  be  enormous  (nine  gallons.) 

The  fluid  is  usually  amber-colored,  seldom  red  from  admixture  of  blood 
or  very  rarely  turbid  from  fat  (adipose  ascites)  or  lecithin  (chyliform 
ascites).  The  specific  gravity  is  1.008  to  1.015,  with  0.6  to  1  per  cent, 
albumin.  The  patient  may  die  before  ascites  develops.  A  slowly  develop- 
ing collateral  circulation  may  permanently  relieve  an  earlier  ascites.  It 
may  disappear  after  hemorrhage  or  diarrhea.  (6)  The  spleen  is  enlarged 
two-  to  sixfold,  due  to  the  early  toxemia  and  the  later  stasis,  in  75  per 
cent,  of  cases;  it  is  a  fair  measure  of  the  degree  of  liver  cirrhosis.  Its 
capsule  and  trabeculse  are  hard  and  thickened  (sometimes  preventing 
splenic  enlargement),  and  a  systolic  murmur  is  sometimes  heard,  (c) 
Gastro-intestinal  catarrh  is  due  to  stasis  and  alcoholism.  Pain  after  eating, 
a  coated  tongue,  vomiting,  achylia,  constipation,  piles,  diarrhea  toward 
the  end  of  the  course  and  meteorism  also  occur,  (d)  A  collateral  circula- 
tion may  be  evidenced  by  enlargement  of  the  veins  about  the  navel 
(cirsomphalos  or  caput  Medusce).  Prominence  of  the  epigastric  veins 
results  from  compression  of  the  inferior  cava.  Anastomoses  occur  (i) 
between  the  middle  and  inferior  hemorrhoidal  veins  (passing  by  the 
hypogastric  to  the  cava)  on  the  one  hand,  and  the  superior  hemorrhoidal 
(passing  by  the  superior  mesenteric  to  the  portal  vein)  on  the  other  hand ; 
(ii)  betw^een  the  coronary  veins  of  the  stomach  on  the  one  hand  and  the 
esophageal  and  phrenic  veins  on  the  other,  which  empty  into  the  vena 
azygos;  (iii)  between  the  veins  in  the  ligaments  of  the  liver  and  new 
adhesions  and  the  phrenic  veins;  between  the  veins  of  the  ligamentum 
teres  and  the  veins  of  the  abdominal  wall  and  epigastric  veins,  which 
may  sometimes  be  felt  and  may  produce  murmurs;  (iv)  the  mesenteric, 
peritoneal  and  parumbilical  veins  also  communicate  with  those  of  the 
abdominal  wall.  A  well-developed  collateral  circulation  is  both  a  favor- 
able and  an  unfavorable  symptom;  it  relieves  the  portal  stagnation  and 
helps  the  overtaxed  liver  to  perform  its  functions;  on  the  other  hand, 
the  dilated  collateral  vessels  are  likely  to  rupture  and  they  convey  directly 
into  the  general  circulation  toxic  substances  which  the  liver  normally 
destroys  or  alters;  this  failure  of  detoxication  causes  the  frequent  arterio- 
sclerosis, granular  kidneys  and  more  acute  toxemia,  which  resembles 
uremia,  (e)  The  kidneys  are  congested,  degenerated  and  often  show  hyper- 
trophy. The  urine  is  decreased  in  amount,  darker  and  of  higher  specific 
gravity,  because  the  arterial  tension  is  low  in  cirrhosis.  More  urine  is 
often  secreted  during  fasting  than  during  digestion  (opsiuria),  which  is 
the  converse  of  normal  conditions.  The  urobilin  may  he  increased  two- 
fold, indicating  failure  of  hepatic  function,  if  there  is  lessened  urobilin 
in  the  stools  (and  hemolysis  is  excluded).  The  chlorides  are  decreased, 
as  they  accumulate  in  the  ascitic  transudate.  The  urea  is  often  decreased, 
but  the  ammonium  compounds  are  often  increased,  less  from  interference 


570  DISEASES  OF   THE  LIVER 

with  the  Hver  functions  than  from  increase  of  acid  products  in  the  blood 
(acidosis),  which  the  ammonium  salts  seek  to  neutralize.  The  amino- 
acids  are  regularly  increased.  Glycosuria  is  uncommon  save  in  the  pig- 
mentary cirrhosis  (see  Diagnosis).  Alimentary  glycosuria  may  be  pro- 
duced by  administration  of  100  gm.  of  grape-sugar  or  of  levulose  and 
galactose  (in  50-86  per  cent,  of  cases).  In  the  writer's  experience, 
physical  signs  are  far  more  weighty  than  functional  tests.  Albuminuria 
may  result  from  stasis  or  nephritis  (v.i.).  Blood  may  be  found  in  the 
urine  as  a  result  of  stasis  in  the  bladder. 

3.  General  Symptoms. — Loss  in  weight,  anemia  and  an  earth-like 
color  are  explained  (a)  by  the  inability  of  the  liver  to  handle  the  carbo- 
hydrates, proteids,  etc.,  (6)  by  the  diversion  of  toxins  through  the  col- 
lateral circulation  into  the  general  circulation,  and  (c)  stasis  catarrh. 
In  4  cases  with  well-developed  collateral  circulation,  scurvy  developed 
which  the  writer  interpreted  as  toxemic.  It  was  once  thought  that  bile 
salts  entered  the  blood  and  produced  "  cholemia,"  or  that  substances 
were  retained  which  the  bile  normally  excreted,  producing  "acholia;" 
now  liver  insufficiency  (hepatargia)  is  considered  responsible  for  toxemic 
symptoms  (adynamia,  headache,  itching,  delirium,  stupor,  convulsions, 
paralysis,  contractures  or  coma);  the  writer  twice  observed  Kussmaul's 
breathing.  Much  depends  upon  the  integrity  of  the  kidneys,  which 
may  for  a  time  maintain  adequate  excretion. 

Complications. — 1.  Hemorrhage. — (a)  Cachectic  capillary  hemorrhage 
from  the  nose,  mouth,  lungs  or  stomach  is  less  frequent  than  in  biliary 
cirrhosis.  Epistaxis  occurs  from  dilatation  of  the  vessels  on  the  anterior 
part  of  the  septum.  (6)  Of  mechanical  congestive  hemorrhages  from 
the  esophagus,  stomach,  bowels,  kidneys,  bladder  or  uterus,  those  from 
the  esophagus  are  most  important.  Their  rupture  causes  hematemesis 
(which  occurs  in  23  per  cent,  of  cirrhosis  cases),  chiefly  in  adults;  if 
very  profuse,  blood  may  come  up  without  vomiting;  one  of  Osier's 
cases  bled  10  pounds;  it  often  causes  blood  in  the  stools.  It  may  form 
dark  clots;  it  is  usually  attended  by  less  collapse  than  in  hemorrhage 
from  gastric  ulcer.  In  33  per  cent,  the  first  hemorrhage  is  fatal;  in  66 
per  cent,  hemorrhages  occur  over  a  period  of  months  to  even  eleven 
years.  Varices  are  present  in  80  per  cent,  and  in  over  half,  macroscopic 
rupture  is  detected;  fatal  hemorrhage  may  occur  solely  from  capillary 
rupture.    Hemorrhage  may  be  the  first  symptom  of  cirrhosis. 

2.  Peritonitis. — (a)  Chronic  peritonitis  (15  per  cent.)  may  occur 
with  retraction  of  the  mesentery  and  intestines;  it  prevents  absorption 
of  the  ascites.  (6)  Tuberculous  peritonitis  (20  per  cent.),  often  with  an 
hemorrhagic  exudate,  follows  the  ascites  of  cirrhosis  and  hastens  the 
fatal  outcome.  One  would  think  that  stasis  would  prevent  the  develop- 
ment of  tuberculosis. 

3.  Nephritis. — Nephritis  occurs  in  33  per  cent,  of  cases. 

4.  Heart. — The  heart  is  "arteriosclerotic"  in  60  per  cent.;  chronic 
myocarditis,  endocarditis,  fatty  degeneration  and  dilatation  of  the 
right  ventricle  often  occur.    The  arterial  tension  is  low  in  cirrhosis. 

5.  Lungs. — Bronchitis,  emphysema  and  in  28  per  cent,  pulmonary 
tuberculosis  occur.     Right-sided  hvdrothorax  occurs  from  stasis  in  the 


PORTAL  CIRRHOSIS  571 

vena  azygos  and  right  intercostal  veins;  right-sided  pleurisy,  due  to 
extension  of  perihepatitis  through  the  diaphragm,  occurs  in  10  per  cent, 
of  cases. 

G.  Brain. — Pachymeningitis,  or  progressive  degeneration  of  the  corpus 
striatum  (see  diagnosis  of  cerebral  thrombosis)  occasionally  occurs. 

7.  Fever. — "Intermittent  hepatic  fever'  may  result  from  hepatargia 
or  perihepatitis.  The  temperature  is  usually  subnormal  in  advanced 
cases,  though  fever  and  leukocytosis  are  observed  in  terminal  infections. 

8.  Icterus. — In  atrophic  cirrhosis  jaundice  is  a  genuine  complication, 
due  to  duodenal  catarrh  or  a  radicular  cholangitis;  few  pass  through 
the  disease  without  a  muddy,  yellow  areola  under  the  eyes.  If  present 
it  is  incomplete.    Its  frequency  is  15  per  cent. 

9.  Anasarca. — Anasarca  results  from  pressure  on  the  cava  by  an 
extensive  ascites,  from  perihepatitis  with  cicatricial  involvement  of  the 
cava  and  from  complicating  cardiac  or  renal  disease  and  marasmus. 

10.  Other  Complications. — These  are  rarer,  pylethrombosis,  clubbed 
fingers,  multiple  neuritis  or  delirium  tremens. 

Course  and  Prognosis. — ^The  clinical  course  seldom  exceeds  two  or  three 
years,  but  more  often  months  than  years;  the  maximum  is  fifteen  years. 
There  is  no  acute  cirrhosis.  Compensatory  factors  include  (a)  the  col- 
lateral circulation,  though  this  may  throw  toxins  directly  on  the  nervous 
centres  and  produce  symptoms  like  uremia;  (6)  hyperplasia  of  the  liver 
cells,  which  may  produce  veritable  adenomata.  As  Hanot  puts  it,  the 
diagnosis  is  based  on  the  condition  of  the  connective  tissue,  but  the  prog- 
nosis depends  on  that  of  the  liver  cells,  (c)  The  kidneys  may  compen- 
sate to  a  small  degree.  Hale  White  holds  that  ascites  is  ominous,  the 
patient  rarely  surviving  the  second  tapping;  though  ascites  is  a  late 
symptom,  the  author  has  seen  numerous  cases  which  survived  frequent 
tappings,  excluding  perihepatitis,  which  White  considers  explanatory 
of  these  cases.  The  prognosis  is  relatively  favorable  in  subjects  under 
forty  years  with  large  livers  and  small  spleens.  Recovery  is  possible. 
In  advanced  stages  death  is  the  usual  outcome. 

Death  results  from  hepatargia  (cholemia),  marasmus,  hemorrhage, 
ascites  or  intercurrent  terminal  infections;  exhausting  diarrhea  or  vomit- 
ing; cardiac,  renal  or  other  complications  {v.  s.). 

Differential  Diagnosis. —  Two  classes  of  conditions  require  difteren- 
tiation:  those  in  which  the  liver  is  large  and  those  in  which  it  is  small. 

1.  When  the  Liver  is  Large. — (a)  The  fatty,  amyloid,  congested, 
cancerous  and  luetic  livers  are  difi^erentiated  on  page  587.  (6)  Leukemic 
deposits  cause  hepatic  intumescence,  but  the  blood  examination  is  deci- 
sive, (c)  Pericarditic  pseudocirrhosis,  described  by  Pick  (1896),  occurs 
in  young,  rheumatic  and  cardiac  subjects  and  is  characterized  by  symp- 
toms which  on  the  one  hand  resemble  disproportionately  extreme  passive 
congestion  of  the  liver  and  on  the  other  a  capsular  cirrhosis;  the  liver  is 
large  and  firm,  there  is  recurrent  ascites  without  edema  of  the  extremities 
and  little  or  no  icterus;  contracting  pericarditic  adhesions  may  perhaps 
cause  dilatation  of  the  right  auricle  and  vena  cava  inferior,  thereby  dis- 
tending the  hepatic  vein  system;  or  possibly  the  inflammation  extends 
down  the  cava  inferior  to  the  liver,     (d)  In  Banti's  disease  the  spleen  is 


572  DISEASES  OP  THE  LIVER 

enlarged  first  and  there  is  early  icterus  and  splenic  anemia,  while  the 
cirrhosis  and  hematemesis  occur  later. 

2.  When  the  Liver  is  Small. — The  following  possibilities  should  be 
considered:  (a)  Syphilis,  characterized  by  stellate  scars,  nodes,  pain  and 
a  positive  Wassermann.  (6)  Passive  congestion;  the  nutmeg  liver  may 
atrophy,  but  anasarca  is  observed  first  and  there  are  primary  character- 
istic heart  findings,  (c)  In  simple  marantic  atrophy  the  liver  is  small, 
there  is  no  portal  stasis  and  arteriosclerosis  is  found,  (d)  Pylethrombosis 
is  characterized  by  a  rapid  onset  with  swelling  of  the  spleen,  severe  or 
repeated  hematemesis,  dilated  veins  and  rapid  recurrence  of  the  ascites 
after  tapping;  it  is  due  to  tumor,  nearby  ulcers,  suppuration  or  gall- 
stones, (e)  Perihepatitis  has  a  very  much  slower  course  than  has  cirrhosis 
and  often  results  from  pericarditis.  (/)  In  chronic  peritonitis  the  fluid 
is  turbid,  often  hemorrhagic,  with  high  specific  gravity  and  many  leuko- 
cytes; for  differentiation  see  pages  615  and  616.  (g)  The  peculiar  p>W- 
mentary  cirrhosis  of  hemochromatosis  (diabete  bronze)  was  described  by 
Troisier  (1871),  named  by  Recklinghausen  and  elaborated  by  Hanot, 
Chauffard  and  Letulle.  Some  toxic  substance  destroys  the  red  blood 
cells  (hemolysis),  and  so  operates  on  the  cells  of  the  liver,  pancreas  and 
other  organs  that  they  transform  the  soluble  blood  pigment  into  insoluble 
hemosiderin  and  iron-free  hemofuscin.  These  pigments  are  found  in  the 
muscles,  intestine,  heart,  liver  and  pancreas,  whose  cells  become  pig- 
mented, degenerated  and  necrotic;  the  pigment  passes  into  the  connective 
tissue  of  the  liver,  skin  and  pancreas,  with  these  sequels — cutaneous 
pigmentation  like  Addison's  disease;  cirrhosis  of  the  liver  and  of  the 
islands  of  Langerhans  in  the  pancreas,  causing  the  diabetes,  which 
occurred  in  all  but  five  of  the  French  cases,  but  less  commonly  in  this 
country;  94  per  cent,  are  males. 

Treatment. — 1.  Causal  Therapy  and  Prophylaxis. — These  have  but 
limited  application,  save  in  preventing  further  injury  by  syphilis  and 
liquors  or  medicinal  tinctures.  Antisyphilitic  treatment  may  help  all 
forms  of  cirrhosis. 

2.  Medicinal  Treatment. — Cirrhosis  cases  come  under  observation 
only  after  contracting  connective  tissue  has  formed.  Naunyn  and  Rol- 
leston  advocate  potassium  iodide  and  ammonium  chloride. 

3.  Diet. — ^]\Ieat  is  tolerated  not  as  well  as  skimmed  milk.  Rich  or 
highly  seasoned  foods  are  to  be  avoided. 

4.  Symptomatic  Treatment. — The  treatment  instituted  in  chronic 
gastritis  or  alcoholism  {q.  v.)  may  be  indicated.  Flatulence  is  met  by 
calomel  in  fractional  doses,  and  salol  10  grains  p.  c,  though  it  may  cause 
renal  irritation.  Diarrhea  should  not  be  checked  until  the  bowels  have 
been  cleansed,  for  it  is  eliminative.  Unusual  splenic  intumescence  may 
be  treated  by  purging,  for  it  is  often  a  forerunner  of  hematemesis.  Hema- 
temesis indicates  absolute  rest,  horse  serum  and  rectal  feeding,  as  in 
gastric  ulcer.  Pain  is  controlled  by  local  heat,  calomel  and  salines. 
Nervous  symptoms  necessitate  the  same  treatment  as  uremia,  with 
sodium  bicarbonate  for  the  acidosis. 

5.  Ascites. — Ascites  is  seldom  benefited  by  the  cardiants,  sweats, 
diuretics  or  purges.  Early  repeated  punctures  may  induce  adhesions 
and  consequent  collateral  circulation  (see  page  616). 


BILIARY  CIRRHOSIS  573 

6.  Operation. — Talma  and  Van  der  Meulen  (1889)  recommended 
operative  measures,  which  were  later  amplified  in  various  ways,  to  induce 
a  collateral  circulation;  these  consist  of  sewing  the  omentum  to  the 
abdominal  wall,  abrading  the  surface  of  the  liver  to  promote  adhesions 
and  Widal  reports  a  successful  Eck's  fistula.  Bircher  collected  (1908) 
343  operations;  the  immediate  mortality  was  6  per  cent.;  of  the  sur- 
viving cases,  13  per  cent,  were  improved,  33  per  cent,  recovered  and  48 
per  cent,  were  not  improved.  The  ascites  and  collateral  circulation 
involve  vital  as  well  as  mechanical  considerations;  perhaps  lessening 
of  venous  tension  in  the  portal  circuit  helps  the  liver  function. 


BILIARY   CIRRHOSIS. 

Definition. — A  cirrhosis  characterized  by  fibrosis  of  an  intralobular 
type,  enlargement  of  the  liver  without  contraction,  splenic  enlargement, 
chronic  icterus  without  gross  obstruction  of  the  bile  vessels,  paroxysmal 
fever  and  absence  of  portal  stasis.  It  is  known  as  Hanoi's  disease  (1876). 
The  term  hypertrophic  cirrhosis  is  unfortunately  ambiguous. 

Etiology. — Its  etiology  is  obscure.  Alcoholism  is  not  a  factor.  Some- 
times it  apparently  results  from  (a)  infection,  either  hematogenous,  or 
an  ascending  cholangitis,  (b)  Age.  Most  cases  develop  between  the 
twentieth  and  thirtieth  years;  it  is  rare  after  forty;  a  considerable 
percentage  occurs  in  the  young,  especially  in  India,  {c)  Sex.  Over  80 
per  cent,  of  adult  cases  are  males. 

Symptoms. — The  onset  is  characterized  by  early  icterus,  less  often  by 
asthenia,  fever,  dyspepsia,  diarrhea,  splenic  or  abdominal  pain. 

Cardinal  Symptoms. — 1.  The  liver  is  uniformly  enlarged  and  may 
weigh  2000  to  4000  gm.  Its  surface  is  smooth  and  its  edge  even,  though 
somewhat  blunt.  Its  pathology  is  considered  under  diagnosis.  Its  dul- 
ness  extends  from  the  fourth  rib  in  the  nipple  line  to  the  umbilicus  or 
even  to  the  iliac  crest;  it  visibly  bows  outward  the  right  costal  arch  and 
its  weight  drags  down  the  right  shoulder.  The  gall-bladder  is  not 
enlarged.  The  liver  progressively  increases,  often  paroxysmally  with 
fever,  pain  and  increased  icterus.  It  never  shrinks,  except  when  com- 
bined with  portal  cirrhosis. 

2.  Icterus  develops  early  and  is  constant,  permanent  and  characteristic. 
It  is  usually  intense.  It  is  due  to  obstruction  of  the  smaller  bile  vessels; 
perhaps  also  to  oversecretion  of  bile  (polycholia)  or  bile  pigments 
(polychromia) .  The  skin  may  become  green  or  brown,  frequently  with 
itching,  xanthelasma  and  eczema. 

3.  The  spleen  is  hypertrophied,  usually  relatively  more  than  the  liver, 
averaging  400  to  1000  gm.  in  weight,  but  sometimes  actually  outweighs 
it  (2600  gm.),  especially  in  infantile  forms.  It  is  hard,  smooth  and 
evenly  increased  in  all  its  elements  and  dimensions.  It  is  distinctly 
palpable  and  often  clearly  visible. 

Other  Symptoms. —  Digestive. — ^Nausea,  vomiting,  dyspepsia  and  tym- 
panites are  uncommon.  Diarrhea  is  frequent.  The  normal  or  diarrheal 
movements  contain  bile  in  over  90  per  cent,  of  cases. 


574  DISEASES  OF   THE  LIVER 

Nutritive. — Nutrition  is  maintained  for  years,  but  wasting  subse- 
quently appears.  Infantilism  may  be  as  marked  as  in  cretinism  or  con- 
genital syphilis.  Gilbert  and  Lereboullet  collected  40  cases  of  clubbed 
fingers  from  hyperplasia  of  the  soft  tissues. 

Urinary. — The  urine  is  highly  colored,  bile-stained,  increased  in 
amount,  and  may  contain  urobilin,  indican  or  albumin. 

Circulatory. — The  pulse  is  not  slow;  the  often  dilated  heart  may 
reveal  a  systolic  murmur;  dyspnea  is  frequent  from  pressure  on  the 
diaphragm  by  the  swollen  liver  and  spleen;  the  blood  shows  secondary 
anemia,  decreased  coagulability  and  moderate  leukocytosis.  xA.rthritis 
and  neuritis  are  rare  complications. 

Diagnosis. — The  following  table  shows  the  essential  pathological  and 
clinical  points  of  contrast  with  the  portal  type: 

PoBTAL  (Atrophic)   Cirrhosis. vs. Biliary  (Hypertrophic)   Cirrhosis. 

1.  Etiology;    alcoholism;    over  forty  years       Infection;   under  forty  years. 

of  age. 

2.  Liver,  large  or  small   (possibly  both  in       Always  large  and  to  greater  degree.      Never 

succession) ;   often  shrinks.  shrinks  in  pure  forms. 

Granulations;   larger.  Small;   very  fine. 

Yellow.  Dark,  icteric,  green. 

3.  Connective      tissue      ensnaring  several       Begins  in  lobule    (monolobular    or   insular) 

lobules     (multilobular     or     annular),  around  smaller  bile  radicles  (cholangitis), 

and  around  portal  radicles.  in  early  stages  at  least. 

Distinction   between   connective   tissue  Not  sharp, 
and  lobules  sharp. 

Connective  tissue  firmer,  more  fibrous;  More  delicate,  reticular,  richer  in  cells,  em- 
more  elastic  tissue.  bryonal. 

Contracts.  No  contraction  (elephantiasis  hepatis.) 

4.  Liver  cells,  early  fatty,   degenerate,  dis-  Seldom  fatty,  normal  for  long  time,  regeu- 

appear.  erate,  pigmented. 

5.  Portal  system  cannot  be  injected  Easily  injected. 

6.  Bile  vessels.     (Proliferating  bile  vessels  in  biliary  form  are  not  characteristic,  and  are 

probably  merely  compressed  rows  of  Hver  cells.) 

7.  Jcteriis  infrequent,  a  complication;  when       Constant    throughout    course,    though    the 

present,  usually  catarrhal.  stools   contain    bile. 

8.  Ascites  rarely  absent  in  advanced  cases.       Absent  in  all  (except  mixed  forms). 

9.  Collateral  circulation — -usual.  Never. 

10.  Hematemesis,  frequent,  early,  mechanical.  Very  rare,  late,  cachectic  or  toxemic. 

11.  Constipation  usual."  Diarrhea  frequent. 

12.  Duration  of  two  or  three  years.  Five  to  ten  years. 

13.  Death  results  from  hematemesis,  neph-  Rare;     death   from    hepatargia    (cholemia) 

ritis,  tuberculosis,  peritonitis.  with  fever,  delirium,  typhoid  state. 

It  is  a  rare  affection  and  a  diagnosis  of  biliary  cirrhosis  is  too  often 
made.  If  the  cardinal  features  under  its  definition  are  borne  in  mind 
it  is  differentiated  with  ease  from  hepatic  cancer,  echinococcus  (q.  v.),  fatty 
and  amyloid  liver  and  Banti's  disease  (see  diagnosis  of  portal  cirrhosis). 
Ohstruction  of  the  hile  ducts  may  produce  an  enlarged  gall-bladder  (v. 
Icterus)  ;  the  stools  are  usually  but  not  necessarily  acholic  (e.  g.,  in  stone 
of  the  common  duct).  The  spleen  is  not  large.  (It  may  be  stated  that 
some  recognize  a  biliary  cirrhosis  due  to  chronic  obstruction  of  the  duct; 
simple  mechanical  obstruction  never  causes  fibrosis,  though  it  may  follow 
ascending  cholangitis.  The 'liver  is  far  less  large  in  this  obstructive  type  . 
and  is  seldom  hard.)  In  hemochromatosis  and  pigmentary  cirrhosis 
icterus  is  absent  and  glycosuria  is  present  in  about  85  per  cent,  of  cases, 
(See  Differentiation,  page  587). 


ABSCESS  OF   THE  LIVER  575 

Treatment. — The  treatment  is  that  of  portal  cirrhosis;  no  known 
means  stops  the  formation  of  connective  tissue.  A  generous  diet  may  be 
given.  Cold  and  dampness  are  especially  to  be  avoided.  Calomel  in  small 
doses  (grain  -gV^^o"  *.  i.  d.)  may  be  given  for  weeks  at  a  time  and  the 
salicylates  and  simple  salines  are  sometimes  beneficial.  Operative 
relief  by  drainage  of  the  gall-bladder  is  unwarranted  and  in  the  reported 
cases'^  the  true  biliary  cirrhosis  is  often  confused  with  obstructive  icterus. 

ABSCESS    OF    THE   LIVER. 

Suppurative  hepatitis  occurs  in  1.5  per  cent,  of  autopsies;  97  per  cent, 
occur  in  males. 

Varieties. — 1.  In  the  septic  type  (55  per  cent,  of  cases)  the  hepatic 
artery  is  the  usual  carrier  of  infection;  the  primary  focus  is  usually  in 
the  external  parts,  especially  the  skull  (Hippocrates),  osteomyelitis, 
pulmonary  abscess  or  gangrene,  putrid  bronchitis  and,  less  often,  from 
ulcerative  endocarditis.  Liver  abscess  occurs  in  15  per  cent,  of  surgical 
septicopyemias.  Infected  thrombi  in  the  peripheral  veins  may  become 
detached,  infarct  the  lungs  and  thence  reach  the  arterial  circulation.  In 
rare  cases  infective  material  may  fall  back  from  the  cava  into  the  hepatic 
vein,  known  as  retrograde  embolism.  The  bacteria  are  those  enumerated 
under  sepsis — the  pyogenic  organisms,  pneumococcus,  colon  and  typhoid 
or  paratyphoid  bacilli. 

The  symptoms  are  obscured  by  the  general  toxemia  and  multiple 
abscesses  scattered  through  the  liver  usually  produce  few  decisive  local 
symptoms.  The  liver  enlargement  is  uniform  and  generally  indistin- 
guishable from  the  cloudy  swelling  of  sepsis;  fluctuation  is  rare;  the 
portal  circulation  is  rarely  obstructed;  pain  and  tenderness  are  usually 
present;  jaundice  is  inconstant;  the  spleen  is  swollen  from  sepsis;  the 
course  is  rapid. 

2.  The  second  variety,  from  infectign  through  the  portal  vein  (31  per 
cent.),  has  been  known  since  Morgagni's  time  and  is  clinically  the  most 
important  type.  Any  ulcerative  or  suppurative  affection  in  parts  con- 
taining the  portal  branches  may  be  causal,  for  instance,  amebic  dysentery 
(the  most  frequent  cause),  appendicitis  (in  6  per  cent,  of  its  fatal  cases), 
neglected  hemorrhoids,  gastric  ulcer  or  cancer  and  disease  of  the  bile 
vessels.  Pyogenic  organisms,  the  Ameba  dysenterise,  foreign  bodies 
(as  fish-bones,  pins  and  parasites)  may  enter  by  the  portal  circulation. 
Pus  organisms  may  infect  tuberculous,  echinococcic  or  actinomycotic  foci, 
of  which  latter  40  cases  are  recorded.  The  lesion  is  (a)  the  solitary  or 
tropical  liver  abscess  {v.  i.)  or  (6)  there  may  be  suppurative  pylephlebitis, 
which  is  less  a  suppuration  of  the  liver  substance  than  an  inflammation 
in  the  portal  vein  itself,  following  in  a  dendritic  fashion  through  all  of 
its  intrahepatic  ramifications;  its  branches  are  distended  and  present 
small  accumulations  of  pus,  which  may  appear  as  yellowish  foci  through 
the  capsule,  but  show  more  clearly  on  section  as  portal  vein  suppuration; 
the  whole  liver  may  be  involved  or  certain  areas  may  be  exempted  by 
total  thrombotic  occlusion  of  the  larger  branches.  In  some  cases  the 
purulent  thrombophlebitis  may  be  traced  back  to  the  original  lesion  in 


576  DISEASES  OF   THE  LIVER 

the  stomach  or  intestine;  the  Hver  is  enlarged  but  the  diagnosis  is  rarely 
more  than  a  probable  one. 

3.  The  third  variety  is  infection  by  the  bile  vessels  (10  per  cent.),  in 
which  an  ascending  cholangitis  (q.  v.),  often  calculous  in  origin,  produces 
multiple  small  abscesses  throughout  the  liver  substance;  this  is  rather 
similar  in  appearance  to  the  pylephlebitic  form. 

4.  Infection  in  infants  through  the  navel  is  infrequent. 

5.  Direct  involvement  of  the  liver  hy  contiguity,  may  occur  in  suppuration 
of  the  gall-bladder  or  gastric  ulcer. 

Solitary  or  Tropical  Abscess. — The  abscess  is  solitary  in  75  per  cent, 
of  cases;  in  11  per  cent,  there  are  two  and  in  14  per  cent,  more  than  two 
foci.  Twenty  to  30  per  cent,  of  cases  of  amebic  dysentery,  by  far  the 
most  common  cause,  are  complicated  by  liver  abscess.  Amebic  abscess 
may  even  occur  without  intestinal  ulceration,  though  amebse  are  found 
in  the  stools;  in  5  out  of  27  of  Futcher's  cases  there  were  no  intestinal 
symptoms.  Bacillary  dysentery  is  rarely  a  cause,  and  trauma,  pyemia, 
typhoid  or  hydatid  cysts  occasionally.  Though  seen  in  the  Southern 
States  and  sometimes  in  the  North,  it  occurs  chiefly  in  the  tropics,  and 
among  Europeans;  alcoholism  and  a  rich  diet  are  predisposing  factors; 
97  per  cent,  occur  in  males  and  50  per  cent,  in  those  between  twenty  and 
thirty  years  of  age. 

Pathology. — Amebse  reach  the  liver  by  the  portal  vein  and  cause 
necrosis  by  their  toxins,  followed  by  suppuration.  The  smaller  foci 
contain  glairy,  gelatinous,  translucent  fluid ;  the  larger  foci  contain  white, 
yellow,  green,  reddish  (like  anchovy  sauce)  or  serous,  bloody  or  viscid, 
chocolate-colored  fluid.  Absence  of  leukocytes  in  the  walls  and  contents 
is  pathognomonic.  Red  disks  and  necrotic  liver  cells  are  frequent  and 
the  pus  is  usually  sterile.  The  amebse  are  more  abundant  in  the  abscess 
wall  than  in  its  contents  and  may  be  found  outside  of  the  abscess, 
necrosing  the  liver  cells.  In  contrast  to  other  abscesses,  the  walls  of  the 
amebic  type  are  soft,  ragged  and  show  little  granulation  or  fibrous  tissue. 

Symptoms. — Latency  occurs  in  13  per  cent,  of  cases. 

1.  Septic  Symptoms. — (a)  Fever  is  remittent  or  intermittent,  less 
often  continuous  and  in  chronic  cases  there  may  be  a  normal  or  sub- 
normal register.  (6)  Rigors  and  sweats  are  frequent,  even  independent 
of  fever  (Lafleur).  (c)  Leukocytosis  occurs  in  50  per  cent,  only.  In  43 
uncomplicated  dysentery  cases  the  leukocyte  count  was  above  the 
average  count  of  the  abscess  cases  in  23.4  per  cent,  (Futcher),  (d)  The 
jmlse  is  small  and  frequent,  (e)  Progressive  emaciation  is  usual,  and 
the  facies  is  a  combination  of  hectic,  subicterus  and  cachexia.  (/)  The 
urine  is  febrile  and  may  contain  albumin  or  albumose. 

2.  Hepatic  Symptoms. — (a)  The  liver  is  enlarged  from  the  abscess  and 
from  sepsis.  The  abscess  in  70  per  cent,  is  located  in  the  right  lobe;  venous 
blood  from  the  pancreas  and  intestine  is  conveyed  to  the  right  lobe 
(whence  its  involvement  in  intestinal  ulceration  or  cancer),  while  the 
blood  from  the  stomach  and  spleen  finds  its  way  to  the  left  lobe.  The 
enlargement  is  more  often  upivard  than  downward,  wherein  abscess  differs 
from  cancer  and  resembles  echinococcus.  The  swelling  is  often  localized, 
occasioning  a  dome-like  dulness  on  the  upper  border  of  the  liver  (Frerichs), 


ABSCESS  OF   THE  LIVER  577 

which  may  be  corroborated  by  the  a;-rays,  and  may  also  give  Grocco's 
dulness  to  the  left  of  the  vertebrae;  in  other  cases  there  is  bulging  of  the 
lower  interspaces  or  of  the  hypochondrium.  The  entire  organ  may  be 
greatly  swollen,  as  in  one  abscess  which  contained  2f  gallons  of  fluid. 
When  it  occurs  below  the  ribs,  fluctuation  in  the  liver  and,  less  often, 
edema  of  the  abdominal  wall  may  be  noted.  The  liver  consistence  may 
be  increased  at  first,  (b)  Pain  is  usually  present  and  is  due  to  increased 
weight  or  to  capsular  tension  and  perihepatitis  or  pleurisy,  causing  a 
friction  rub,  or  adhesions  in  more  chronic  cases.  The  patient  usually 
lies  on  the  back  or  right  side  (to  avoid  pain  caused  by  sagging  of  the 
liver  in  the  left  lateral  decubitus).  Pain  is  referred  to  the  right  shoulder 
in  17  per  cent.,  being  reflected  from  the  phrenic  filaments  on  the  liver 
convexity  along  the  phrenic  nerve  to  the  acromial  branch  of  the  fourth 
cervical  nerve;  in  rare  cases  the  deltoid  may  waste,  (c)  Tenderness 
over  the  liver  is  usually  circumscribed.  The  right  rectus  is  frequently 
tense. 

3.  Other  Symptoms;  Complications. — (a)  Icterus  occurs  in  16  per 
cent,  of  cases;  it  may  be  slight  from  sepsis  or  compression  of  some 
bile  ducts  within  the  liver,  or  it  may  be  complete  from  catarrh  of  the 
common  duct.  (6)  The  spleen  is  seldom  enlarged,  except  from  a  causal 
septicopyemia,  (c)  A  dry  spasmodic  reflex  cough  may  be  noted  (tussis 
hepatica).  (d)  Rupture  may  be  the  first  sign  of  abscess  of  the  liver.  In 
Waring's  300  cases,  56  per  cent,  remained  intact,  16  per  cent,  were 
operated  on  and  28  per  cent,  ruptured,  (i)  It  occurs  into  the  lungs  in 
43  per  cent.;  lung  abscess  results  more  often  from  direct  rupture  than 
from  indirect  metastasis.  The  patient  presents  signs  of  lung  abscess 
(q.  V.)  and  expectorates  chocolate-,  anchovy-  or  cream-colored  pus  con- 
taining amebse,  often  liver  and  lung  tissue,  hematoidin  crystals  and 
perhaps  bile.  Death  may  be  caused  by  profuse  hemoptysis,  (ii)  Rup- 
ture into  the  pleura  causes  empyema  (15  per  cent.).  Pleurisy,  both 
fibrinous  and  serous,  may  also  result  from  infection  passing  through 
the  lymphatics  of  the  diaphragm;  a  right-sided  friction  rub,  serothorax 
or  empyema  always  suggests  the  possibility  of  an  hepatic  etiology,  (iii) 
Rupture  into  the  peritoneum  causes  localized  or  diffuse  peritonitis  (15 
per  cent.).  A  subacute  serofibrinous  peritonitis  or  an  encapsulated 
serous  effusion  over  the  liver  rarely  results,  (iv)  Rupture  into  the 
bowels  (colon  2  per  cent,  and  duodenum  1  per  cent.)  gives  pus,  some- 
times in  large  amounts  in  the  stools,  (v)  Less  frequent  are  ruptures 
into  the  stomach,  pericardium,  pelvis  of  the  kidney,  portal  or  hepatic 
vein,  inferior  cava,  bile  vessels  or  abdominal  w^all.  {e)  Less  frequent 
complications  are  pyloric  obstruction  (from  abscess  of  the  left  lobe), 
pseudorheumatism  or  clubbed  fingers  (from  toxemia),  cerebral  abscess 
and  intestinal  obstruction. 

Diagnosis. — Diagnosis  is  based  on  (a)  an  etiological  factor;  (h)  symp- 
toms of  sepsis;  (c)  hepatic  signs,  e.  g.,  localized  enlargement,  pain  and  ten- 
derness; the  .r-rays  may  be  useful  when  the  bulging  of  the  convexity  is 
covered  by  the  lung;  (d)  exploration  with  the  aspirating  needle,  which 
the  author  has  seen  result  in  two  deaths  from  peritonitis  and  one  from 
an  enormous  hemorrhage  into  the  peritoneum;  puncture  should  be 
37 


578  DISEASES  OF   THE  LIVER 

performed  only  when  an  operation  can  be  done  immediately  after  pus 
is  found;  pus  is  far  less  often  withdrawn  in  multiple  small  abscesses 
than  in  the  large  solitary  form. 

Differentiation. — Five  types  of  liver  abscess  are  often  described: 
(a)  The  latent,  (b)  typhoid  (page  46),  (c)  malarial,  intermittent,  (d) 
phthisic,  and  (e)  a  type  declared  by  rupture. 

Subphrenic  abscess  simulates  pnemnothorax  {q.  v.)  rather  than  liver 
abscess,  because  of  the  presence  of  tympany;  in  its  etiology  and  treat- 
ment it  resembles  liver  abscess  (see  page  611).  In  gall-stones,  with  or 
without  suppuration,  the  fever  usually  occurs  in  parox^'sms  separated 
by  long  intervals,  the  history  is  dififerent  and  marasmus  is  rare.  Dif- 
ferentiation from  pleurisy,  echinococcus  and  cancer  is  considered  under 
these  topics  and  on  page  587. 

Prognosis  and  Treatment. — Xinety-three  per  cent,  of  unoperated  cases 
die  from  rupture  (peritoneal,  pleural,  pulmonary),  sepsis  and  amyloid 
disease.  It  is  possible  for  an  abscess  to  desiccate  or  to  heal  after  break- 
ing into  the  lung  or  bowel,  .but  this  cannot  be  depended  upon.  The 
treatment  is  solely  operative;  Solonoff  estimates  the  mortality  of  1094 
cases  at  30  per  cent. 

TUMORS    OF    THE   LIVER. 

Tumors  of  the  liver  are  chiefly  carcinomata.  Benign  tumors  possess 
little  clinical  interest,  as  fibroma,  lipoma,  teratoma,  adenoma  or  angioma ; 
single  adenoma  may  develop  from  the  liver  cells  or  bile  ducts;  multiple 
adenomata  occur  chiefly  in  cirrhosis.  Three  cases  are  reported  of  adrenal 
"rests,"  and  scant  20  of  sarcoma;  it  may  develop  as  a  single  primary 
tumor,  multiple  primary  'tumors  or  diffuse  infiltration;  a  melanotic 
growth  is  almost  always  secondary  to  melanotic  sarcoma  of  the  eye  or  skin. 

Cancer  of  the  liver  occurred  in  2.7  per  cent,  of  Virchow's  autopsies, 
and  ranks  fourth  among  internal  cancers  (in  order  of  frequency,  uterus, 
stomach,  mamma  and  liver),  (a)  Primary  cancer  is  20  to  48  times  as 
infrequent  as  secondary  cancer;  66  per  cent,  occur  in  males.  It  originates 
from  the  liver  cells  (88  per  cent.)  or  bile  vessels  (12  per  cent.).  The  main 
forms  are  observed  (i)  as  a  sharply  outlined  massive  local  swelling  (in 
23  per  cent,  of  Eggel's  163  cases);  (ii)  as  sharply  demarked  multiple 
nodes  of  moderate  size  (in  65  per  cent.)  of  which  one  of  the  tumors  is 
primary  and  the  rest  secondary;  (iii)  as  diffuse  infiltration,  fusing  with 
the  parenchyma  (in  12  per  cent.) ;  (iv)  the  last  form  develops  in  hepatic 
cirrhosis  (or  hepatic  cyst).  jNIetastases  occur  in  66  per  cent.  (6)  Second- 
ary cancer  results  from  primary  cancer  in  the  stomach  (33  per  cent.), 
colon  (12  per  cent.),  esophagus,  pancreas,  gall-bladder,  uterus,  ovaries, 
mamma,  etc.,  by  metastasis  or  contiguity;  cancer  cells  may  enter  by 
the  portal  vein  and  hepatic  artery,  much  less  frequently  by  retrograde 
metastasis  through  the  hepatic  vein  and  never  by  the  h'mph  vessels, 
as  their  current  flows  from  within  to  without  the  liver. 

Symptoms. — 1.  Hepatic  Sy^iptoms. — (a)  The  liver  enlarges  rapidly, 
even  to  eight  times  its  normal  size  and  may  weigh  30  to  40  pounds.  Its 
edge  is  uneven;  on  its  surface  are  lumps  which  may  present  a  central 


TUMORS  OF   THE  LIVER  579 

umbilication.  Great  unevenness  is  more  characteristic  of  secondary  than 
of  primary  tumor,  in  which  the  hver  is  more  uniformly  swollen.  The 
enlargement  is  chiefly  downward,  though  sometimes  upward  from  ascites, 
tympanites  or  adhesions.  Nodules  in  the  falciform  ligament  may  be 
felt  near  the  navel  or  linea  alba.  Sudden  increase  in  size  occasionally 
results  from  hemorrhage  due  to  icterus.  There  is  no  enlargement  when 
the  nodules  are  few  and  small,  and  the  liver  is  smaller  than  normal  in 
10  per  cent,  of  cases  (liver  cirrhosis  plus  malignant  adenomata).'  (b) 
Hepatic  pain  is  more  conspicuous  than  in  any  other  liver  lesion,  from  cap- 
sular tension,  perihepatitis,  pleuritis  or,  less  frequently,  from  rupture  of 
tumor  particles  into  the  bile  passages,  simulating  gall-stones.^  (c)  The 
liver  is  often  tender,  id)  Exceptionally  there  may  be  pulsation  trans- 
mitted from  the  aorta  or  a  venous  hum  over  the  liver. 

2.  Cachectic  Symptoms. — These  are  adynamia,  marasmus,  anorexia, 
secondary  anemia,  leukocytosis  (in  any  carcinoma,  but  especially  in 
hepatic),  stupor  and  illusions,  probably  from  the  katabolic  toxins  elabo- 
rated by  the  tumor,  and  hepatargia.  Fever  may  result  from  the  tumor 
alone,  or  terminal  infection. 

3.  Compression  Symptoms. — (a)  Jaundice  occurs  in  over  50  per  cent., 
more  frequently  in  secondary  than  in  primary  cancer  and  usually  from 
mechanical  pressure  on  the  larger  bile  ducts  by  the  tumor  or  carcinoma- 
tous glands.  Pressure  on  the  ducts  within  the  liver  often  produces 
moderate  jaundice  and  some  bile  then  appears  in  the  stools;  complete 
icterus  may  result  from  concomitant  catarrhal  or  calculous  obstruction, 
especially  significant  when  there  is  no  ascites.  Exceptionally  the  tumor 
grows  into  and  along  the  bile  ducts,  thereby  totally  obstructing  them. 
(6)  Ascites  is  present  in  50  per  cent,  of  cases.  It  is  usually  moderate  in 
degree  and  results  from  pressure  on  the  portal  vein,  peritonitis  or  pyle- 
thrombosis;  occasionally  it  is  due  to  the  cirrhotic  form  of  cancer,  growing 
of  the  tumor  into  the  hepatic  or  portal  vein,  rupture — perhaps  with 
syncope  and  great  hemorrhage — of  a  cancer  nodule  into  the  peritoneum, 
or  rarely  to  plugging  of  the  liver  capillaries  by  the  pigment  of  a  melano- 
sarcoma.  A  collateral  circulation  or  perihepatic  friction  may  be  noted. 
The  fluid  is  usually  serous  or  hemorrhagic,  rarely  adipose,  chylous, 
opaque  or  melanotic. "  (c)  Other  compression  symptoms  include  splenic 
tumor  from  marantic  pylephlebitis  (14  per  cent.),  hydronephrosis,  vom- 
iting, dyspnea  and  edema. 

4.  Other  Symptoms. — The  cervical  glands  are  seldom  swollen  unless 
there  is  coincident  gastric  cancer.  Carcinomatous  nodes  in  the  navel 
or  skin  over  the  liver  are  due  to  regional  extension.  In  liver  cancer 
combined  with  cirrhosis  any  cirrhotic  symptom  may  occur.  The  urine 
shows  increased  destruction  of  the  tissue  nitrogen;  acetone  and  diacetic 
and  beta-oxybutyric  acids,  indican,  leucin  and  tyrosin  are  not  infrequent. 
The  urine  is  decreased,  high-colored  and  often  icteric.  Albuminuria  is 
due  to  stasis  and  toxemia.  Melanuria  (sarcoma)  is  sometimes  detected 
by  adding  to  the  urine  a  solution  of  ferric  chloride;  the  pigment  exists 
in  the  blood  as  melanin  or  melanogen;  melanuria  nearly  always  indicates 
a  melanotic  tumor  of  the  liver  and  is  often  confounded  with  indicanuria 
and  alkaptonuria. 


580  DISEASES  OF  THE  LIVER 

Diagnosis. — The  chief  features  are  rapid  enlargement  of  the  hver, 
irregular  tumors,  pain,  icterus,  ascites,  cachexia  and  in  50  per  cent,  of 
cases  the  recognition  of  the  primary  tumor.     (See  page  587.) 

Differentiation. — -Cirrhosis  (see  both  forms);  syphilis  (q.  v.);  the 
amyloid  liver  is  equally  large  and  causes  confusion  only  when  complicated 
by  gummata;  amyloidosis  of  the  spleen,  kidneys  and  intestines  usually 
coexists  with  amyloid  liver.  Hydatid  cysts  develop  more  slowly  and 
earlier  in  life  and  cachexia  appears  late,  if  at  all.  The  rare  multilocular 
echinococcus  produces  enlarged  liver,  ascites  and  icterus,  but  the  spleen 
is  also  enlarged;  puncture  may  give  characteristic  findings.  Puncture 
often  excludes  those  doubtful  cases  of  cancer  in  which  fever,  leukocytosis 
and  semifluctuation  of  the  necrotic  neoplastic  nodes  simulate  liver  abscess. 
Congested  liver;  the  writer  saw  4  cases  of  nutmeg  liver  in  which  stasis 
caused  more  local  than  general  hepatic  enlargement.  The  corset  liver 
can  be  easily  differentiated  if  the,  general  symptoms,  such  as  cachexia 
and  the  compression  symptoms  of  cancer,  are  duly  considered.  Cancer 
of  the  stomach  (q.  v.)  is  readily  differentiated  by  its  chemism  and  stag- 
nation; gastric  cancer  may  cause  hepatic  involvement.  Renal  or  adrenal 
tumors  are  covered  by  the  inflated  colon,  encroach  less  upon  the  thorax, 
evert  the  ribs  less,  and  often  are  separable  from  the  liver  by  an  interven- 
ing strip  of  tympany,  which  occurs  in  but  13  per  cent,  of  hepatic  tumors. 

Differentiation  hetiveen  primary  and  secondary  tumors  is  somewhat 
irrelevant,  as  the  causal  growth  leading  to  hepatic  metastasis  is  latent 
in  50  per  cent.;  the  following  characteristics  are  subject  to  many  excep- 
tions: the  solitary  tumor,  its  rapid  growth,  less  emaciation,  more  rapid 
course  and  death  in  less  than  four  months.  Secondary  tumors  cause 
death  within  seven  months  from  cachexia,  ascites  and  intercurrent  disease, 
as  pneumonia — or  in  a  shorter  period,  from  hemorrhage,  peritonitis,  icterus, 
galloping  carcinosis  or  acidosis. 

Treatment. — Treatment  is  palliative  for  the  pain  and  ascites  except 
when,  in  very  exceptional  cases,  early  operation  (for  primary  growths) 
can  be  performed.  Liicke  reported  the  first  recovery,  which  afterward 
proved  to  be  a  gumma;  Keen  collected  76  operated  neoplasms  with  63 
recoveries. 

ECHINOCOCCUS   CYSTS    OF   THE   LIVER. 

The  parasite  is  considered  on  page  305.  Its  hepatic  localization  con- 
stitutes 60  per  cent,  of  echinococcus  disease. 

Symptoms. — Fidly  half  the  cases  of  liver  echinococcus  are  clinically 
latent.  Cases  with  symptoms  show  the  following  liver  findings:  (i)  A 
cyst  on  the  loiver  border  or  anterior  surface  may  produce  a  visible,  palpable, 
round  and  smooth  bulge  which  everts  the  right  costal  arch  or  much  less 
often  distends  the  left  lobe;  cysts  in  the  right  lobe  may  lead  to  com- 
pensatory hypertrophy  of  the  left  lobe.  The  tumor  is  as  large  or  larger 
than  an  orange.  It  is  tense,  elastic  and  dull;  on  percussion  it  may  fluc- 
tuate and  give  the  "hydatid  thrill,"  a  vibration  elicited  by  laying  three 
fingers  over  the  cyst  and  tapping  with  the  middle  one;  the  thrill  may 
also  occur  in  ascites  and  sarcoma.    The  cysts  rarely  contain  gas,  due  to 


ECHINOCOCCUS  CYSTS  OF   THE  LIVER  581 

the  Bacillus  coli.  In  large  cysts  (36  to  70  pints  are  reported),  the  liver 
may  tip  so  that  the  right  lobe  is  lower  and  the  left  higher  than  normal. 
(ii)  Cysts  071  the  convexity  crowd  the  diaphragm  upward,  cause  symptoms 
resembling  pleurisy  {q.  v.),  produce  a  dome-like  dulness,  as  in  cancer  and 
may  compress  the  lung  or  heart,  (iii)  Lker  imin  and  tenderness  are  rare 
without  suppuration,  which  may  induce  perihepatitis;  pain  may  be 
referred  to  the  right  shoulder,  (iv)  Exploratory  puncture  ma,y  precipitate 
severe  nervous  toxemia  and  cardiac  collapse,  as  described  on  page  306, 
where  also  the  finding  of  pus,  membrane,  chemical  contents  and  booklets 
are  enumerated. 

Rupture  may  occur  into  the  lungs  (in  11  per  cent,  of  liver  echino- 
coccus);  it  may  simulate  phthisis  or  gangrene  of  the  lungs;  cysts  may 
rupture  into  the  pleura,  peritoneum  (witheosinophilia),  kidney,  stomach, 
bowel,  bile  passages,  pericardium,  portal  vein  and  cava;  heart  embolism 
or  external  rupture  may  occur. 

Pressure  symptoms  are  rare,  as  icterus  (5  per  cent.),  ascites,  albumin- 
uria, caput  Medusce,  edema  of  the  legs,  dyspnea  or  vomiting.  In  some 
cases  there  is  a  distaste  for  fat  or  meat.  The  eosinophiles  are  usually 
increased  in  non-suppurating  cysts.  Urticaria  may  occur  after  puncture 
or  rupture  or  without  either  incident. 

Diagnosis. — Diagnosis  depends  on  the  history  of  the  case,  including 
contact  with  dogs;  the  smooth,  round  tumor;  the  thrill;  slow  develop- 
ment; the  infrequency  of  constitutional  disturbance,  pain  and  fever, 
the  signs  predominating  over  the  symptoms. 

Differentiation. — (a)  From  other  liver  cysts;  the  small  cysts  in 
cirrhosis  and  obstructive  icterus  are  of  no  clinical  importance.  Simple 
serous  cysts  may,  in  exceptional  cases,  hold  several  (even  13)  pints; 
they  rarely  cause  symptoms,  rupture  or  hemorrhage.  Diffuse,  congenital, 
cystic  disease  may  cause  dystocia;  in  adults  also  the  cysts  are  probably 
developmental  in  origin  and  are  associated  with  cystic  kidneys,  in  15 
per  cent,  of  cases;  Moschcowitz  collected  85  cases;  they  are  usually 
multiple  and  subcapsular  and  are  often  associated  with  other  congenital 
anomalies,  such  as  hare-lip,  and  are  due  to  inflammatory  hyperplasia  of 
aberrant  bile  ducts  or  to  congenital  obstruction  in  them.  Hoffman 
reported  18  operated  cases,  (b)  Malignant  disease  causes  cachexia, 
more  pain  than  echinococcus,  multiple  tumors,  ascites  and  icterus,  (c) 
Syphilis  of  the  liver  (q.  v.).  (d)  From  pleurisy;  the  a^-rays  may  show 
the  localized  tumor  on  the  liver  convexity ;  the  upper  line  of  pleuritic 
dulness  is  much  less  often  convex  upward;  there  may  be  thoracic  symp- 
toms, as  hemoptysis,  when  there  is  rupture  into  the  lung;  the  sputum 
or  aspirated  fluid  shows  the  diagnostic  booklets,  (e)  In  rare  cases  a 
pendulous,  pedunculated,  movable  cyst  may  resemble  a  pancreatic  cyst, 
enlarged  kidney,  gall-bladder  or  ovarian  cyst.  Rupture  into  the  bile 
passages  may  simulate  the  pain  of  gall-stones,  (f)  Liver  abscess;  there 
may  be  doubt  in  suppurating  cysts;  the  eosinophiles  are  not  increased 
in  liver  abscess  (page  587). 

Prognosis. — Cysts  may  calcify  or  indurate.  The  mortality  of  rupture 
into  the  peritoneum  is  90  per  cent.,  into  the  pleura  80,  bile  ducts  70, 
bronchi  57,  stomach  40,  intestines  15  and  externally  10  per  cent. 


582  DISEASES  OF   THE  LIVER 

Treatment. — AA'heii  drainage  by  the  trochar  is  performed  (Hippo- 
crates), 60  per  cent,  of  cases  recover.  A  few  die  suddenly  from  a  tox- 
albimiin,  formed  when  the  parasite  dies;  it  causes  urticaria,  convulsions, 
cardiac  faikire  and  other  symptoms  similar  to  mussel-poisoning.  Direct 
surgical  iniervcnfion  is  attended  with  the  least  risk. 

Multilocular  or  Alveolar  Echinococcus. — This  form  is  due  to  another 
parasite  (see  page  307) ;  100  cases  are  recorded. 

Symptoms. — The  right  lobe  of  the  liver  alone  is  involved  in  65  per 
cent,  of  cases  and  the  left  alone  in  10  per  cent.  The  liver  is  fibrosed, 
nodular  and  seldom  fluctuates.  This  rare  affection  is  attended  by  splenic 
tiunor  (90  per  cent.;,  icterus  (80  per  cent.),  dyspepsia,  ascites  and,  less 
commonly,  by  fever,  polyuria,  collateral  circulation,  emaciation  and 
metastases  in  the  heart  and  lungs;  death  may  occur  after  years  from 
cholemia  or  gastro-intestinal  hemorrhages.  The  diagnosis  is  very  diffi- 
cult, especially  from  cancer.    The  only  hope  of  recovery  is  in  extirpation. 


FATTY  LIVER. 

"Fatty  liver"  (hepar  adiposiim)  includes  infiltration  and  degeneration; 
they  may  be  considered  together. 

Etiology. — (a)  Obesity  and  (6)  decreased  oxygenation  from  carcinosis, 
rickets,  profound  anemia,  stasis  and  kindred  causes  may  produce  fatty 
liver,  (c)  Toxemias,  as  tuberculosis,  the  acute  infections,  infantile 
diarrhea,  acute  yellow  atrophj^  or  suppuration,  (d)  poisons,  as  phosphorus, 
arsenic  or  chloroform,  and  (e)  local  diseases  of  the  liver,  as  cirrhosis  or 
nutmeg  liver,  are  etiological  factors. 

Pathology. — The  fat  may  amount  to  over  -10  per  cent,  (normally  2 
to  5  per  cent,  of  its  weight).  The  liver  is  enlarged  and  may  weigh  4500 
gm.  Its  surface  is  smooth,  its  edges  rounded,  consistence  is  decreased 
and  its  color  yellow.  On  section  it  is  anemic,  smooth  and  yellow  when 
oleic  acid  predominates  or  pale  when  there  is  more  palmitin  and  stearin. 
Slight  quantities  are  detected  only  on  microscopic  examination.  When 
cut  -^ith  a  warm  knife  the  fat  is  seen  on  the  blade.  ^Microscopically,  fat 
is  seen  which,  in  fatty  infiltration,  is  located  principally  in  the  periphery 
of  the  lobules  and  obscures  the  Hver  cells;  when  the  fat  is  dissolved  by 
ether,  the  normal  liver  cells  are  clearly  seen.  In  fatty  degeneration,  fat 
forms  at  the  expense  of  the  liver  cells,  i.  e.,  the  percentage  of  albumin  is 
decreased.  The  statement  that  fatty  infiltration  occms  in  large  and 
fatty  degeneration  in  smaller  globules  is  not  whoUy  correct.  Pathologists 
consider  infiltration  more  important. 

Symptoms. — (a)  The  positive  findings  are  as  follows:  the  liver  is  sym- 
metrically enlarged  and  smooth  and  rarely  extends  below  the  navel.  Its 
edge  is  rounded,  soft  and  usually  palpable,  even  in  obese  persons.  (6)  The 
negative  findings  are  absence  of  pain,  tenderness,  icterus,  splenic  tumor, 
ascites  or  gastro-intestinal  hemorrhage. 

The  diagnosis  is  considered  on  page  587. 


AMYLOID  LIVER  58' 


AMYLOID   LIVER. 


Amyloid  degeneration  was  first  clearly  described  by  Rokitansky. 

Etiology. — (a)  Ulcerative  tuberculosis  of  the  lungs  or  bones  causes 
over  50  per  cent,  of  amyloidosis,  and  (6)  inveterate  syphilis,  particularly 
ulcerative  and  osseous  tj^es,  25  per  cent,  (c)  Chronic  suppuraiion  has 
become  uncommon  since  the  introduction  of .  antisepsis.  Krawkow 
produced  amyloid  degeneration  experimentally  by  inoculations  of  the 
staphylococcus.  {d)  As  exceptional  causes,  intestinal  ulcerations, 
exhausting  diarrheas,  rickets,  leukemia,  pseudoleukemia  and  ulcerating 
neoplasms  may  be  mentioned;  78  per  cent,  of  cases  occur  in  males. 

Pathology. — Amyloid  degeneration  is  much  less  frequent  in  this  countr}' 
than  in  Europe.  Its  localization,  in  order  of  frequency,  is  in  the  spleen, 
kidneys,  liver  and  intestines.  The  liver  is  uniformly  enlarged  and  may 
weigh  5000  to  6000  gm.,  even  in  a  child.  It  is  hard,  smooth  and  very 
pale.  Its  edges  are  blunt.  On  section  the  appearance  is  wax^',  speckled, 
resembling  raw  ham,  the  edges  slightly  translucent  and  the  lobules 
indistinct.  If  a  thin  slice  is  placed  in  diluted  LugoFs  solution,  the  amyloid 
areas  assume  a  bro-^m  color  (Virchow),  the  name  (amyloid)  referrihg  to 
this  starch-like  reaction;  the  waxA^  substance,  however,  is  a  proteid  and 
reaches  the  liver  by  the  hepatic  capillaries,  whence  it  is  first  deposited 
in  the  middle  zone  of  the  lobule,  and  later  infiltrates  the  central  and 
peripheral  zones.    It  is  essentially  an  infiltration. 

Symptoms. — The  large,  tense,  symmetrical,  painless,  smooth  liver, 
with  rounded  edges,  is  characteristic.  Its  dimensions  may  attain  those 
of  cancer.  The  onset  and  development  are  usually  slow,  but  acute 
amyloid  may  develop  in  a  month.  Splenic  amyloid  enlargement  is  usually 
also  noted,  as  weU  as  albuminuria  from  renal  amyloidosis  (g.  v.) .  In  only 
0.8  per  cent,  of  amyloid  degeneration  is  the  liver  alone  involved.  Gastro- 
intestinal symptoms,  as  nausea,  vomiting  and  diarrhea,  may  result  from 
amyloidosis  of  the  alimentary  capillaries.  In  advanced  cases  cachexia, 
edema  and  ascites  may  develop.    Hepatargia  is  rare. 

Diagnosis. — Diagnosis  depends  on  (a)  the  recognition  of  a  cause; 
(b)  the  characteristic,  smooth,  symmetrical  enlargement,  which  is  less 
hard  than  that  of  cirrhosis;  (c)  the  associated  amyloid  disease  of  the 
spleen,  kidney  and  alimentary  tract;  (d)  the  absence  of  icterus  (very 
rarely  from  amyloid  portal  glands)  and  of  portal  stasis  (ascites  is  an  in- 
frequent, late  and  renal  symptom) ;  and  (e)  the  small  amount  of  urobilin 
in  the  stools.  Differentiation  from  cirrhosis  (q.  v.)  and  cancer  (q.  v.) 
presents  no  difficulties.  Gummata  in  the  liver  plus  amyloid  disease 
may  cause  confusion.  Xo  diagnosis  is  possible  in  the  exceptional  cases 
in  which  the  liver  is  slightly  enlarged  (because  slightly  diseased)  or  in 
which  splenic  tumor  and  albuminuria  are  absent  (v.  page  587). 

Prognosis. — The  prognosis  of  pronounced  cases  is  unfavorable  though 
light  grades  may  exceptionally  regress. 

Treatment. — Treatment  is  prophylactic  and  symptomatic. 


584  DISEASES  OF   THE  LITER 


ANOMALIES    OF    FORM   AND    LOCATION    OF    THE   LIVER. 

In  situs  viscerum  inversus  the  liver  lies  on  the  left  side.  Fenger  en- 
countered a  case  of  icterus  and  gall-stones  in  situs  inversus  which  was 
diagnosticated  as  acute  yellow  atrophy  I 

Tilting  of  the  liver,  dislocaiion  downward  by  pleuritis,  pneumothorax 
or  tumors,  or  upward  luxation  require  but  passing  mention. 

"Wandering  Liver. "^Hepar  migrans  s.  mobile  occurs  in  women  (88 
per  cent.),  usually  in  multiparse.  Its  causes  are  those  of  enteroptosis, 
with  which  it  usually  occurs,  viz.,  flaccid  abdominal  walls,  congenitally  lax 
suspensory  ligaments,  lacing  or  very  rarely  from  traction  by  a  tumor. 
Clark  and  Dolley  collected  118  cases;  1  had  a  mesohepar  attached  to  the 
diaphragm  and  absence  of  the  coronary  and  right  lateral  ligaments. 

Symptoms. — The  onset  is  usually  gradual;  in  5  per  cent,  it  is  acute. 
Subjectively,  oppression  over  the  liver,  gastro-intestinal  or  nervous 
symptoms  may  be  present.  Objectively,  there  is  sometimes  cardioptosis, 
usually  gastroptosis  and  in  20  per  cent,  nephroptosis.  The  hepatic  notch 
can  be  distinctly  felt,  often  also  its  convex  surface  and  sometimes  the 
tense,  stretched  ligaments.  It  can  be  replaced.  In  a  recent  case  there 
was  tvTQpany  between  the  left  costal  arch  and  the  prolapsed  spleen  and 
tympany  between  the  right  arch  and  the  liver,  even  though  the  patient 
was  five  months  pregnant.  In  very  rare  instances  there  may  be  pain 
similar  to  gall-stones  and  ascites  or  splenic  tumor  from  torsion  of  the 
portal  vein. 

Treatment. — The  treatment  is  (a)  meclianical,  replacing  and  supporting 
the  liver  with  binders;  (6)  symptomatic,  for  the  neurasthenia;  (c)  dietetic, 
to  increase  the  body  weight  and  (d)  operative;  hepatopex}'  ciu-es  about  75 
per  cent. 

Corset  Liver. — The  corset  liver  is  found  in  25  per  cent,  of  female 
cadavers,  but  much  less  frequently  here  than  abroad.  Corsets  cause 
pressm-e  atrophy  of  the  liver  substance,  followed  by  induration,  deformity 
and  peritoneal  thickening,  most  conspicuously  and  usually  in  the  right 
lobe.  The  liver  may  be  merely  constricted,  dislocated  upward  or  the  part 
below  the  constricting  zone  may  hang  loosely  as  upon  a  hinge,  causing 
confusion  with  floating  kidney  or  other  tumors.  The  gall-bladder  is 
dilated  in  60  per  cent.,  but  icterus  is  infrequent.  Corset  liver  is  regarded 
as  a  factor  in  gall-stone  formation.  Subjective  manifestations  are  often 
absent.  Sometimes  parox^'smal  syncope  and  vomiting  may  occur,  due 
to  congestion  of  the  snared-oft'  portion.  Respiratory  excursion  prevails 
in  most  cases.  Confusion  arises  when  the  intervening  gut  causes  a 
narrow  zone  of  tympany  between  the  hard,  hinged  segment  and  the  liver 
proper,  but  even  then  careful  palpation  frequently  demonstrates  its 
continuity  with  the  liver.  Congenital  tongue-like  lobes  may  be  con- 
fused clinically  with  corset  liver;  they  are  often  the  seat  of  cirrhosis, 
malignancy,  suppuration  or  syphilis.     Treatment  is  seldom  important. 


AFFECTIONS  OF   THE  BLOODVESSELS  OF   THE  LIVER        585 


AFFECTIONS    OF    THE    BLOODVESSELS    OF    THE    LIVER. 

I.  Active  Hyperemia  of  the  Liver. — A  degree  of  arterial  hyperemia 
is  physiological  during  digestion.  An  accentuation  of  this  condition  is 
common  in  heavy  eaters  and  drinkers  and  acute  infections,  in  which  it 
may  be  combined  with  venous  hyperemia.  Heat  is  probably  not  the 
cause  of  "tropical  hyperemia."  The  alleged  vicarious  hyperemia  from 
suppressed  menstruation,  the  menopause  or  diseases  of  the  internal 
female  genitalia  is  based  on  theory.  The  symptoms  resemble  those  of 
passive  hyperemia  (v.  i.).  A  simple  or  milk  diet,  calomel  and  saline 
purgation  are  indicated. 

II.  Passive  Hyperemia  of  the  Liver. — Etiology. — Passive  congestion  of 
the  liver  results  from  stasis,  the  stress  of  which  is  felt  in  the  efferent 
intrahepatic  (sublobular)  veins.  It  results  (a)  from  cardiac  insufficiency, 
valvular,  particularly  mitral  diseases,  myocardial  or  pericardial  lesions; 
(6)  from  pulmonary  stasis,  emphysema,  chronic  bronchitis,  asthma, 
induration  or  obliterative  pleurisy;  (c)  from  stasis  caused  by  spinal 
deformity,  aneurysm,  mediastinal  tumor,  perihepatitis  or  pressure  on  the 
cava  inferior. 

Pathology. — The  essence  of  passive  congestion  is  overfilling  of  the 
sublobular  or  the  hepatic  venous  circtdation,  malnutrition  of  the  liver 
cells  {fatty  degeneration)  and  in  some  advanced  cases,  increased  con- 
nective tissue.  The  liver  is  usually  symmetrically  enlarged,  firmer  and 
darker  red  than  normal,  though  hepatic  hyperemia  lessens  after  death. 
The  capsule  is  often  thickened  or  edematous.  On  section  the  so-called 
nutmeg  appearance  is  noted,  but  seldom  over  the  entire  liver.  The 
central  veins  with  their  radiating  offsets  are  dark  and  cyanotic,  while  the 
periphery  of  the  lobule  is  yellowish-white  from  cloudy  or  fatty  change 
(malnutrition  or  impaired  oxygenation).  Long-standing  congestion 
results  in  atrophy  and  pigmentation  of  the  cells  in  the  periphery  of  the 
lobule  (Virchow's  red  atrophy) ;  there  is  usually  increased  connective  tissue 
with  fine  granulations,  the  atrophic  cyanotic  liver  or  cardiac  cirrhosis  of  the 
French;  fibrosis  is  for  the  most  part  relative  or  apparent,  for  the  liver 
parenchyma  atrophies;  true  cirrhosis  may  coexist  with  cardiac  disease. 

Symptoms  and  Diagnosis. — (a)  The  causal  heart  (or  lung)  lesion  has 
its  appropriate  symptoms,  (b)  The  liver  is  evenly  enlarged,  on  palpation 
and  sometimes  on  inspection;  if  ascites  is  present  thrusting  palpation 
with  the  finger-tips  usually  outlines  the  organ;  the  liver  may  reach  below 
the  navel  or  evert  the  ribs.  Its  edges  are  firmer,  somewhat  rounded, 
sensitive  (from  capsular  tension)  and  descend  with  inspiration;  the  incis- 
ure is  clearly  felt.  If  there  is  relative  tricuspid  insufficiency,  a  systolic 
expansile  pulsation  is  detected  by  palpating  with  both  hands,  which  are 
separated  from  each  other  with  each  systole,  and  is  differentiated  from  the 
non-expansile  pulsation  transmitted  from  the  aorta,  (c)  The  hepatic 
intumescence  varies  greatly,  as  the  heart  responds  to  rest  and  digitalis,  or 
compensation  fails,  {d)  The  skin  shows  cyanosis  and  slight  icterus;  to  the 
experienced  eye  it  has  a  characteristic  appearance,  probably  due  to  a 
static  catarrh  of  the  finer  intrahepatic  bile  radicles,    {e)  For  other  symp- 


586  DISEASES  OF   THE  LIVER 

toms  and  treatment  see  Valvular  Disease;  the  spleen  is  seldom  enlarged 
save  from  cardiac  infarcts  or  complicating  liver  cirrhosis.  Ascites  is 
usually  late  in  onset  and  moderate  in  degree ;  a  cardiac  ascites  sometimes 
occurs  without  general  edema.  Before  death  there  may  be  signs  of  renal 
and  hepatic  insufficiency.  In  some  cases  with  somnolence,  delirium  and 
a  terminal  toxemia,  Oertel  describes  a  cytolytic  necrosis  of  the  liver  with 
stasis,  fatty  infiltration  of  the  middle  zone  and  hemorrhagic  extravasations. 

Differentiatio7i  is  seldom  complicated,  for  the  fundamental  heart 
lesion,  the  evenly  enlarged,  tender  liver,  which  varies  in  size  from  time 
to  time,  and  the  slight  icterus  with  cyanosis  are  usually  unmistakable. 
Certain  features  may  sometimes  mislead,  as  the  occasional  unequal  dis- 
tribution of  the  liver  changes,  which  may  suggest  tumor,  or  the  tender- 
ness which  may  resemble  suppuration.     (See  page  587.) 

III.  Pylethrombosis — Pylephlebitis. — Thrombosis  or  phlebitis  of  the 
portal  vein  is  practically  always  secondary  to  comfression  or  obstruction, 
as  liver  cirrhosis,  with  which  33  per  cent,  of  pylephlebitis  cases  occur; 
to  cancer,  ulceration,  abscess  or  inflammation  of  contiguous  structures, 
gall-stones,  cholangitis  and  proliferative  peritonitis;  and  to  diseases  of 
the  intima,  as  phlebosclerosis  and  syphilitic  endophlebitis.  Pylephlebitis 
occurs  chiefly  in  males  over  forty  years  of  age. 

Symptoms. — These  may  be  entirely  absent  because  of  collateral  com- 
pensation through  the  hepatic  artery  or  Sappey's  accessory  portal  vein. 
The  onset  is  usually  sudden,  with  symptoms  of  acute  portal  stasis.  The 
spleen  is  enlarged  in  75  per  cent.,  unless  fibrous  changes  in  its  pulp  or 
capsule  prevent  its  swelling.  Ascites  develops  in  66  per  cent,  and  rapidly 
recurs  after  tapping.  G astro-intestinal  symptoms  are  usual,  as  hemor- 
rhage (44  per  cent.),  intense,  sudden  epigastric  pain,  vomiting,  diarrhea 
or  sometimes  acute  intestinal  obstruction.  The  portal  vein  is  sometimes 
varicose  below  and  is  generally  obliterated  at  and  above  the  point  of 
obstruction  (pylephlebitis  adhesiva) ;  this  leads  to  shrinking  of  the  liver, 
particularly  if  the  hepatic  artery  is  sclerotic,  in  which  rare  event  the 
entire  liver  may  be  hemorrhagically  infarcted.  Liver  lobulation  results 
from  antecedent  syphihs.  Hepatargia  and  alimentary  glycosuria  may 
develop.  Edema  of  the  abdominal  wall,  development  of  a  collateral 
circulation  and  icterus  are  uncommon. 

Diagnosis. — Diagnosis  is  difficult,  unless  the  onset  is  typically  sudden; 
otherwise  the  findings  are  those  of  atrophic  cirrhosis;  a  caput  Medusae 
indicates  occlusion  of  the  portal  radicles.  The  ascites  may  suggest  carci- 
noma or  peritonitis  or  the  hemorrhage  may  simulate  gastric  ulcer  or 
hepatic  cirrhosis. 

Course  and  Treatment. — Death  may  occur  in  a  few  days  or  six  to 
twenty  years.  Treatment  is  ineffectual,  save  in  early  syphilis.  Citric 
acid  (5j)  may  be  given  to  lessen  thrombosis. 

Pylephlebitis  suppurativa  is  a  pyemia  of  the  portal  vein;  metastasis 
or  extension  occurs  in  the  main  portal  trunk  and  its  branches  from  infec- 
tion of  its  radicles  of  origin;  inflammations  in  the  gastro-intestinal  tract 
are  its  cause  in  75  and  appendicitis  in  40  per  cent,  ("appendicular  liver") 
and  gall-stones,  infected  piles  and  pancreatic  or  umbiHcal  suppuration 
cause  most  of  the  other  cases  {v.  page  575). 


DIAGNOSIS  OF  AFFECTIONS  OF   THE  LIVER 


587 


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588      DISEASES  OF   THE  GALL-BLADDER  AND  BILE   VESSELS 

The  symptoms  are  those  of  the  original  disease,  sepsis  and  portal  stasis. 
In  very  rare  cases  the  thickened  vein  may  be  palpated.  The  spleen  is 
enlarged,  chiefly  from  sepsis,  the  liver  is  tender  and  somewhat  enlarged 
and  icterus  occurs  in  over  50  per  cent.  The  diagnosis  is  always  difficult, 
but  is  based  on  symptoms  suggesting  liver  abscess  (though  without  the 
findings)  and  sepsis.    Treatment  is  futile. 

IV.  Affections  of  the  Hepatic  Artery  and  Vein. — Infarction  of  the 
hepatic  artery  with  complete  necrosis  of  the  liver  is  very  rare.  Aneurysm 
(v.  page  409). 

Thrombosis  of  the  hepatic  veins,  of  which  only  12  cases  are  reported, 
may  follow  perihepatitis  or,  less  often,  compression  by  a  neoplasm  or 
fibrous  obliteration  of  the  inferior  cava.  Ascites  and  splenic  tumor 
sometimes  result.  Suppurative  thrombosis  is  always  secondary  to  liver 
suppuration.  Retrograde  embolism  (Heller)  is  mentioned  under  Liver 
Abscess, 


DISEASES  OF  THE  GALL-BLADDEE  AND  BILE 

VESSELS. 

ICTERUS. 

Jaundice  is  a  symptom  of  various  affections  of  the  liver  and  bile 
vessels;  it  is  characterized  by  staining  of  the  skin,  mucosae  and  urine  by 
retained  bile  pigments. 

Etiology. — ]\Iost  cases  of  icterus  are  due  to  obstruction  within  or  about 
the  liver  and  biliary  system;  little  obstruction  is  necessary  because  the 
bile  is  secreted  under  low  pressure,  (a)  Hepatic  diseases.  It  is  (i)  fre- 
quent in  acute  yellow  atrophy,  biliary  cirrhosis,  multilocular  echinococcus, 
carcinoma,  passive  congestion  and  syphilis;  (ii)  infrequent  in  atrophic 
cirrhosis,  unilocular  echinococcus  and  abscess;  (iii)  absent  in  fatty  and 
amyloid  liver  and  in  simple  pylephlebitis.  (See  page  587.)  Possibly 
functional  liver  disturbance  may  produce  icterus  (parapedesis  of  bile  or 
"diffusion-icterus"),  analogous  to  transient  albuminuria  (in  its  relation 
to  Bright's  disease).  (6)  Diseases  of  the  biliary  tract,  as  (i)  catarrhal, 
croupous  or  purulent  inflammation;  (ii)  calculous  obstruction;  (iii)  con- 
genital and  (iv)  cicatricial  occlusion;  (v)  malignant  growths;  (vi)  parasitic 
obstruction  by  ascaris,  distoma  or  hydatid  vesicles,  (c)  Disease  in 
contiguous  structures,  as  (i)  duodenal  ulcer,  cicatrix,  catarrh  or  cancer; 
(ii)  tumors  of  the  colon  or  lymph  glands ;  (iii)  tumors  or  inflammation  of 
the  pancreas,  stomach,  kidney,  omentum,  mesentery  and  peritoneum, 
and  (iv)  rarely  from  aneurysm,  {d)  Hematogenous  or  urobilin  icterus. 
It  was  formerly  maintained  that  toxic  and  toxemic  conditions,  breaking 
down  the  blood  cells  (hemolysis)  cause  hemolytic  icterus.  It  is  now 
thought  that  most  of  these  cases  are  due  to  blocking  of  the  capillaries 
by  fibrin,  thickening  of  the  bile  or  cholangitis  of  the  smallest  bile  radicles, 
though  the  obstruction  is  not  complete;  Eppinger  maintains  that  the 
smaller  bile  radicles  dilate  and  sometimes  rupture,  letting  the  bile  into 


ICTERUS  '  589 

the  lymph  vessels  which  absorb  it.  The  jaundice  in  these  cases  is  slight, 
bile  pigment  (bilirubin)  is  not  found  in  the  urine  and  the  stools  are  bile- 
stained.  This  type  occurs  in  various  infections,  pernicioiis  anemia,  and 
poisoning  by  phosphorus,  chloroform,  etc. 

Icterus  neonatorum,  (a)  The  'physiological  type  occurs  in  66  per  cent, 
of  children;  it  appears  on  the  second  day,  lasts  two  weeks  and  is  never 
fatal;  hemolysis,  increased  blood-pressure  within  the  liver,  etc.,  are 
suggested  as  causes.  Perhaps  every  jaundice  falls  under  (6)  the  patho- 
logical type,  caused  by  sepsis,  syphilis,  Winckel's  disease,  or  more  excep- 
tionally by  congenital  obstruction,  gall-stones,  acute  yellow  atrophy  or 
catarrhal  icterus.  Glaister  reported  a  family  in  which  6  cases  of  jaundice 
developed  after  birth  and  Rolleston  an  instance  in  which  the  mother,  and 
also  the  babes,  had  icterus  in  four  pregnancies  {v.  page  590). 

Symptoms. — Bilirubin,  found  normally  in  bile,  enters  the  blood  in  biliary 
obstruction,  by  the  bloodvessels  and  produces  the  following  symptoms: 

1.  Skin  and  Mucosa. — In  three  days  the  sclerse,  skin  and  mucosae 
become  yellow  and  in  chronic  cases  dark  brown.  The  skin  itches  because 
of  its  dryness  or  the  action  of  the  bile  on  the  nerves. 

2.  Urine. — The  urine  contains  bilirubin  before  icterus  is  seen  in  the 
skin.  Adding  nitroso-nitric  acid  to  the  urine  in  a  porcelain  dish  or  on 
filter  paper  gives  the  Gmelin  play  of  colors,  of  green,  yellow,  violet  and 
red.  If  the  urine  is  agitated  the  yellow  color  appears  in  its  foam.  Con- 
fusion is  possible  with  melanuria,  hematuria,  urobilinuria  or  staining  of 
the  urine  with  rhubarb,  picric  acid,  santonin,  senna,  etc.  Urobilinuria 
is  thought  to  indicate  disease  of  the  hepatic  cells;  urobilin  is  formed  in 
the  intestine  by  the  reduction  of  bilirubin,  whence  it  is  absorbed  and 
excreted  by  the  urine;  it  never  stains  the  skin  and  icterus  results  from 
bilirubin  alone.  There  are  three  classes  of  cases;  (a)  in  complete  biliary 
obstruction  with  icterus  only  bilirubin  is  found  in  the  urine,  for  none 
of  it  reaches  the  intestine  to  be  converted  into  urobilin;  (h)  in  partial 
obstruction  bilirubin  is  found  in  the  blood  and  urine  and  also  some 
urobilin;  (c)  in  slight  obstruction  there  is  no  bilirubin  but  much  urobilin 
in  the  urine.  Albuminuria  may  occur  or  cylindruria  alone  and  the 
hyaline  casts  and  desquamated  epithelium  are  then  bile-stained.  Increase 
in  the  sulphates  and  indicanuria  are  due  to  greater  intestinal  putrefaction. 

3.  The  Digestive  Tract. — The  coated  tongue,  disagreeable  breath, 
bitter  taste  in  the  mouth  and  nausea  are  toxemic.  There  may  be  an 
especial  aversion  to  fats  and  sometimes  to  proteids.  The  abdomen  is  dis- 
tended, possibly  from  absence  of  the  antiseptic  action  of  the  bile.  Starch 
and  albumin  digestion  are  impaired  and  fat  in  the  stools  (steatorrhea) 
reaches  50  or  80  per  cent,  (normally  7  to  10).  The  function  of  the  pan- 
creas in  this  respect  is  far  more  important  than  that  of  the  bile.  The 
stools  are  clay-colored,  constipated  and  stinking;  they  may  shimmer  when 
the  fatty  soap  crystals  are  abundant;  they  are  also  dry  (the  bile  normally 
amounts  to  nearly  a  quart  a  day) .  If  the  obstruction  is  incomplete — as 
in  many  intrahepatic  diseases — the  stools  are  merely  somewhat  lighter 
than  normal.  The  feces  may  appear  brown  from  a  nitrogenous  diet  or 
dark  if  voided  with  the  urine  which  lends  a  yellow  color  to  their  surface. 

4.  Cholemia. — Cholemia    (hepatargia   or  hepatic  insufficiency)   may 


590      DISEASES  OF   THE  GALL-BLADDER  AND  BILE   VESSELS 

finally  develop,  probably  from  injury  to  the  liver  cells  which  fail  to 
destroy  the  intestinal  toxins.  Its  symptoms  resemble  acute  yellow 
atrophy,  i.  e.,  nervous  excitation  followed  by  stupor,  irregular  breathing 
or  cutaneous  and  other  hemorrhages.  The  hemorrhages  are  thought  to 
result  from  pancreatic  involvement  (diminished  lime  salts  or  fat  necrosis) . 
Most  subjects  of  icterus  are  depressed,  irritable,  sleepless  and  somewhat 
emaciated. 

5.  Other  Symptoms. — (a)  The  heart  rate  is  slow,  particularly  in  catarrhal 
forms  or  recent  cases  and  in  the  absence  of  pain,  fever  and  intoxication; 
it  may  fall  to  21 ;  it  is  probably  caused  by  vagus  stimulation,  for  atropine 
raises  the  rate.  The  arterial  pressure  is  low  and  the  capillaries  wide.  A 
functional  heart  murmur  is  usually  caused  by  myocardial  weakness;  Potain 
holds  that  the  lung  capillaries  contract  reflexly,  thereby  causing  dilata- 
tion of  the  right  heart.  The  respiration  rate  is  decreased,  even  to  seven  a 
minute;  the  temperature  is  usually  normal.  (6)  The  blood  shows  the 
bile  stain  and  in  severe  cases  delayed  coagulation,  anemia,  leukocytosis 
and  sometimes  a  Widal  reaction  (typhoid  cholecystitis?),  (c)  The  lixer 
cells  may  suffer  mechanically  and  chemically  from  bile  stasis  and  may 
be  smaller,  altered  in  form,  pigmented,  necrotic  and  bile-stained.  The 
gross  and  minute  anatomy  varies  with  the  cause.  The  bile  vessels  are 
often  dilated,  sometimes  thickened  and  occasionally  ruptured.  The 
condition  of  the  gall-bladder  will  be  discussed  under  Gall-stones  and 
Pancreatic  Cancer.  Simple  biliary  stasis  never  causes  induration  of  the 
liver,  (d)  Splenic  tumor  is  no  part  of  bile  stasis  except  from  infection 
or  portal  stasis,  (e)  The  tissues,  secretions  and  excretions  are  bile-stained; 
the  muscles  and  nervous  tissues,  except  in  the  severe  type  of  icterus 
neonatorum,  are  seldom  icteric.  (/)  Xanthopsia,  yellow  coloring  of  objects 
seen,  is  due  to  the  action  of  the  bile  pigment  on  the  nervous  tissues.  The 
explanation  of  nyctalopia  and  hemeralopia  is  uncertain,  (g)  Of  xanthel- 
asma multiplex  23  cases  were  collected,  and  Futcher  in  1905  reported  3 
cases;  80  per  cent,  occur  in  chronic  icterus,  due  to  gall-stones,  stricture 
of  the  bile  ducts,  cirrhosis,  hydatids  and  cancer.  They  are  often  sym- 
metrical, often  begin  on  the  eyelids  or  the  folds  and  creases  of  the  skin,  in  1 
case  were  found  in  the  bile  ducts,  rarely  disappear  and  are  probably  toxemic. 

Diagnosis. — Icterus  is  not  noticed  in  artificial  light  and  daylight  is 
absolutely  essential  for  its  certain  detection.  It  is  seldom  confused  with 
anemia,  cachexia,  Addison's  disease  or  vagabondism.  Pingueculae  are 
only  mistaken  on  superficial  examination. 

In  ictero-anemia  (Widal's  syndrome)  there  are  icterus,  splenic  enlarge- 
ment, urobilinuria  and  blood  changes.  The  icterus  is  non-obstructive; 
the  splenic  tumor  results  from  hemolysis  and  urobilinuria  is  marked. 
The  anemia,  fatigue,  low  blood-pressure  and  hemorrhages  are  explained 
by  the  fragility  of  the  red  globules  (not  observed  in  ordinary  icterus); 
the  red  cells  number  1,000,000  to  3,000,000,  the  index  is  over  one  and 
the  leukocytes  are  increased  (to  over  40,000).  The  course  is  chronic  and 
attacks  like  gall-stones  are  common. 

In  chronic  family  jaundice  (Minkowsky)  also,  hemolysis  and  globular 
fragility  are  causal.  There  is  anemia  (1,000,000  to  4,000,000  reds),  with 
free  hemoglobin  in  the  plasma;   in  the  bone-marrow  there  is  intense 


CHOLELITHIASIS  591 

reaction,  with  normoblasts  and  myelocytes.  Icterus  is  congenital,  perhaps 
through  four  generations,  or  appears  early  in  life;  it  is  neither  intense  nor 
obstructive  and,  lasting  through  life,  the  patients  are  icteric  rather  than 
ill  (Chauffard).  The  spleen  is  enlarged,  the  urine  contains  no  bile  but 
urobilin,  the  stools  are  dark  and  attacks  of  gall-stone  colic  are  frequent. 
Over  100  cases  are  reported.  Iron  and  a;-rays  are  helpful  and  in  some 
instances  splenectomy  appeared  justifiable. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  cannot  be 
considered,  as  icterus  is  but  a  symptom  {v.  i.  Catarrhal  Jaundice). 
Icterus  may  subside  after  six  or  even  fifty-two  years. 

CHOLEUTHIASIS. 

Etiology. — 1.  Immediate  Cause. — The  causes  are  (i)  catarrhal  inflam- 
mation of  the  gall-bladder  or  bile  vessels  and  (ii)  stagnation  of  bile. 
Bacteria  play  an  important  role,  especially  the  typhoid  (found  in  33 
per  cent.)  and  colon  bacilli;  they  have  been  found  in  calculi,  and  cholelith- 
iasis has  been  experimentally  produced  by  their  inoculation;  the  Bacillus 
typhosus  may  live  seven  years  in  the  gall-bladder,  (iii)  Hypercholester- 
emia, in  typhoid,  pregnancy,  nephritis,  diabetes  and  obesity,  is  considered 
a  frequent  factor  by  Aschoff . 

2.  Predisposing  Factors. — (a)  Age;  75  per  cent,  of  cases  occur  in  persons 
over  forty  years  of  age  and  only  1  per  cent,  under  twenty  years.  (6)  Sex;  75 
per  cent,  occur  in  women,  in  whom  pregnancy,  menopause,  lax  abdominal 
walls  and  lacing  are  promoting  factors;  it  is  said  that  40  per  cent,  of 
women  who  have  gall-stones  also  have  the  corset  liver.  Gall-stones  are 
found  in  25  per  cent,  of  autopsies  on  women  over  sixty  years;  90  per 
cent,  of  women  affected  have  borne  children  (Naunyn) .  They  are  found 
in'8  per  cent,  of  autopsies. 

Properties  of  Gall-stones. —  (a)  Site;  calculi  are  formed  in  the  gall- 
bladder, very  rarely  in  the  intrahepatic  ducts.  (6)  Size;  they  range  up- 
ward from  the  size  of  sand  or  gravel;  a  calculus  12  inches  in  length  is 
recorded;  the  heaviest  reported  was  135  gm.  (c)  Form;  they  are  usually 
round  and  rarely  spinous;  when  multiple  they  are  polygonal  and  facetted. 
Intrahepatic  calculi  may  be  cylindrical  or  branching  like  coral,  (d) 
Their  number  averages  a  dozen;  according  to  Riedel  44  per  cent,  are 
single;  Otto  reports  7802  stones  in  1  case.  In  Chopart's  case  the  liver 
could  scarcisly  be  cut  because  of  the  numberless  stones  in  the  intrahepatic 
ducts,  (e)  Consistence;  gall-stones  can  usually  be  indented  by  the  finger. 
(/)  The  time  required  for  their  growth  is  about  six  months,  {g)  Chemistry; 
the  most  common  form  consists  of  cholesterin  and  bile  pigment  with  lime 
as  a  cementing  substance;  these  calculi  are  small,  numerous,  usually  yellow, 
laminated  and  contain  about  75  per  cent,  of  cholesterin.  Pure  choles- 
terin stones  are  not  common;  they  are  translucent,  become  opaque  when 
dry,  are  light  in  weight  and  color  and  are  combustible;  they  present  a 
crystalline  fracture  like  that  of  camphor,  they  dissolve  in  ether  and 
alcohol,  from  which  the  crystals  are  precipitated  and  produce  a  red 
tinge  on  addition  of  chloroform  and  sulphuric  acid;  cholesterin  comes 
from  the  blood,   bile  or  gall-bladder  mucosa.      Pigmentary  stones  are 


592      DISEASES  OF   THE  GALL-BLADDER  AND  BILE   VESSELS 

uncommon;  bilirubin  imparts  a  brownish  and  biliverdin  a  greenish  tint 
to  them.  Calcium  carbonate  stones  are  rare,  are  grayish  in  color  and 
heavy.  Stones  in  the  liver  are  constituted  of  calcium  and  bilirubin. 
Traces  of  magnesium,  bile  acids,  fatty  acids,  iron  and  copper  have  been 
found.  The  nucleus  is  mucin,  bacteria,  epithelium,  blood  clot,  cholesterin, 
calcium,  bile  pigment  or  rarely  a  foreign  body. 

Symptoms. — Kehr  and  Riedel  assert  that  95  per  cent,  of  persons  with 
gall-stones  have  no  symptoms,  especially  elderly  subjects  with  atrophic 
gall-bladders,  and  stones  very  rarely  may  be  felt  in  the  gall-bladder,  or 
be  found  in  the  feces  in  these  cases.  The  writer  believes  that  latency  is 
less  common  than  above  figured  and  that  gastric  symptoms  are  exceedingly 
common  (75  per  cent.). 

Biliary  Colic. — (a)  Colic  is  usually  sudden  in  onset  and  frequently  occurs 
at  night.  Many  women  state  that  the  pain  is  more  severe  than  labor  pains. 
It  begins  in  the  epigastrium  and  may  radiate  to  the  back,  navel,  hypo- 
gastrium,  left  side  and  even  to  the  arms,  legs,  testes  or  chest.  Irregular 
or  large  stones  cause  the  greatest  agony,  controlled  only  by  large  or 
repeated  hypodermics  of  morphine.  The  pain  usually  endures  for  a  few 
hours  and  may  soon  recur.  The  cause  of  biliary  colic  is  mechanical — 
the  attempt  of  the  stone  to  migrate  produces  the  spasm  of  the  cystic  and 
common  ducts  during  its  passage — or  inflammatory,  cholecystitis  starting 
the  stones  moving  by  the  exudation  it  induces;  pain  is  less  or  shorter 
if  the  ducts  are  patulous.  Quiescent  gall-stones  may  be  started  onward 
by  palpation  of  the  gall-bladder,  trauma,  exercise,  reduction  of  flesh, 
menstruation  or  delivery,  (b)  Reflex  nausea  and  vomiting  are  frequent; 
they  may  indicate  cholecystitis.  Vomiting  relieves  the  pain,  whence  the 
frequently  erroneous  diagnosis  of  gastralgia.  A  cramp  of  the  stomach 
has  been  seen  with  the  a'-rays.  Torsion  of  the  cystic  duct  may  cause  vom- 
iting but  not  colic,  (c)  Chills  and  fever  occur  in  66  per  cent,  and  indicate 
bacterial  inflammation,  {d)  The  gall-bladder  is  tender,  there  being  hyper- 
esthesia over  the  ninth  costal  cartilage  or  over  a  point  two-thirds  of 
the  distance  between  it  and  the  navel,  and  around  the  chest  to  the  spine. 
In  33  per  cent,  the  gall-bladder  is  palpable.  The  right  rectus  muscle  is 
rigid  (defense  musctdaire) .  (e)  Icterus,  present  in  but  15  per  cent.,  may 
be  calculous,  infectious  or  compressive.  (/)  Other  symptoms  of  the  par- 
oxysm are  rapid  pulse,  sweating,  prostration,  concentrated  urine,  con- 
stipation, abdominal  retraction  and,  after  the  seizure,  marked  prostration. 
Attacks  of  migraine  are  not  infrequent.  There  may  be  reflex  coughing 
or  reflex  contraction  of  the  pulmonary  capillaries,  which  overtaxes  and 
dilates  the  right  heart.  The  patient  may  collapse  and  the  writer  observed 
death  in  an  attack.  Glycosuria,  albuminuria,  leukocytosis  and  splenic 
swelling  are  inflammatory  in  origin.  The  stone  may  fall  back  into  the 
gall-bladder  or  pass  into  the  bowel  if  it  measures  under  1  cm. ;  confusion 
with  lumps  of  olive  oil,  given  to  relieve  the  colic,  is  unnecessary;  a  round 
calculus  suggests  that  it  is  the  only  one.  Stones  passing  into  the  bowel 
may  be  dissolved,  unless  coated  with  cholesterin.  The  great  importance 
of  gall-stones  lies  in  their  complications: 

Complications. — They  may  be  grouped  as  mechanical  or  inflammatory, 
but  are  best  combined  topographically. 


CHOLELITHIASIS  593 

1.  Gall-bladder. — Mechanical  complications  include  pressure  on  the 
duodenum  or  pylorus  and  rupture  of  the  gall-bladder,  which,  however, 
are  generally  inflammatory;  pressure  on  the  common  duct;  hyper- 
chlorhydria  and  hypersecretion  and  cancer  of  the  gall-bladder  {q.  v.). 
Inflammatory  complications  are  more  serious;  all  forms  and  sequences 
of  cholecystitis  (g.  v.)  may  develop,  as  hydrops,  empyema,  gangrene, 
ulceration,  deformity,  hemorrhage,  atrophy  or  calcification;  also  pyle- 
phlebitis, adhesions  producing  pyloric  obstruction  with  hyperchlorhydria, 
dyspepsia  and  sometimes  hemorrhage  into  the  stomach;  adhesions  caus- 
ing duodenal  obstruction;  and  peritonitis,  either  local  (near  the  gall- 
bladder or  subphrenic  abscess)  or  diffuse.  A  friction-rub  may  be  heard 
over  the  gall-bladder  a  day  or  two  after  the  colic.  The  distended  gall- 
bladder rarely  exceeds  the  size  of  the  fist,  is  pyriform,  can  be  moved 
laterally  and  moves  with  the  liver,  from  which  it  may  seem  separated  by 
a  groove;  it  may  be  confused  with  appendicitis,  the  kidney,  ovarian  cyst 
or  ascites  and  has  been  found  in  a  femoral  hernia. 

2.  Cystic  Duct. — Mechanical  impaction  causes  icterus  by  catarrh  of 
the  common  duct  (in  12  per  cent.)  or  by  directly  compressing  it.  The 
duct  may  become  twisted,  stenosed  or  obliterated. 

3.  Common  Bile  DucT.^-Its  mechanical  occlusion  is  usually  preceded 
by  colic;  impaction  occurs  oftenest  at  its  lower  end  (50  to  67  per  cent.), 
and  is  caused  most  frequently  by  1  stone;  88  have  been  found.  Per- 
manent occlusion  by  stone  in  the  common  duct  or  in  the  cystic  duct 
pressing  upon  it  causes  marked  icterus,  usually  without  sepsis.  The 
occlusion  may  be  partial  or  intermittent,  by  a  ball-valve  action  of  the 
stone,  described  by  Osier  and  Fenger,  which  allows  some  bile  to  enter 
the  gut  and  some  bacteria  to  enter  the  duct,  thus  adding  bacterial  to 
mechanical  injury.  Usually  the  icterus  is  sudden  in  onset  and  slow  in 
subsidence.  In  partial  or  intermittent  obstruction  there  is  often  the 
intermittent  hepatic  jewr,  first  described  by  Charcot  and  comparable  to 
urethral  fever.  During  the  paroxysms  the  fever  rises  to  103°  or  105°, 
often  with  chills,  sweats,  leukocytosis,  vomiting  and  increased  tender- 
ness, pain  and  icterus.  The  spleen  may  swell,  and  also  the  liver  from 
saccular  dilatation  of  the  channels  and  cholangitis.  Osier  correctly 
insisted  that  these  symptoms  occur  without  suppurative  cholangitis, 
though  with  infection.  The  gall-bladder  is  not  enlarged,  but  is  usually 
shrunken,  following  Courvoisier's  law;  Courvoisier  found  the  gall-bladder 
enlarged  in  92  per  cent,  of  non-calculous  obstruction  of  the  common  duct 
and  shrunken  in  80  per  cent,  of  calculous  obstruction;  this  is  caused  by 
infection  (Hanot) .  In  some  cases  suppurative  cholangitis  may  complicate 
stones  of  the  common  duct,  with  remittent  fever  (rather  than  intermittent 
fever),  enlarged  liver,  subcapsular  abscess,  septic  symptoms  and  more 
rapidly  fatal  course.  Cicatricial  stenosis  of  the  common  duct  is  rare; 
pylephlebitis  may  develop.  Malaria  is  excluded  by  examination  of  the 
blood;  malignancy  will  be  considered  under  tumors  of  the  pancreas, 
though  in  common  duct  obstruction  the  nutrition  is  little  impaired. 
Practically,  stress  may  be  placed  on  (a)  the  periodic  fever,  (6)  the  icterus, 
sudden  in  onset  and  subsiding  slowly,  and  (c)  tenderness  (without  pain 
over  the  liver). 

38 


594  DISEASES  OF  THE  GALL-BLADDER  AND  BILE   VESSELS 

BREWER'S    DIAGNOSIS   OF    DISEASE 


Pathological 
condition. 

Pain. 

Fever. 

Vomiting. 

Jaundice. 

Tumor  of  gall 
bladder. 

I.  Calculous  Disease. 

(a)   Stone     in     healthy 

No. 

No. 

No. 

No. 

May  be  presei 

gall-bladder,        ducts 

from        lar{ 

free. 

number        ( 
size  of  stone 

(6)    Stone     in     healthy 

May  be  absent;  gen- 

No. 

May  be  pres- 

No. 

May  be  presei 

gall-bladder,       cystic 

erally   present   dur- 

ent      when 

from     distei 

duct  temporarily  ob- 

ing obstruction ;  par- 

colic occurs. 

tion. 

structed. 

oxysmal. 

(c)    Stone    impacted    in 

No. 

No. 

No. 

No. 

Present;      ma 

cystic  duct. 

attain      larj 

(d)   Stone     in      hepatic 

Frequently     present; 

Occasionally 

May  be  pres- 

Frequent. 

size. 
No. 

duct. 

irregular  type. 

present. 

ent     during 
pain. 

(e)    Stone    in     common 

Present;     acute,   par- 

Generally 

Present. 

Present. 

No. 

duct;   acute   obstruc- 

oxysmal,    radiating 

present. 

tion. 

to  back. 

(/)    Stone    in    common 

Periodic     attacks     of 

Present  with 

Present. 

Present ;      in- 

Rarely presen 

duct ;     movable  ; 

acute  radiating  pain 

chills    and 

termittent. 

chronic. 

sweats. 

(g)   Stone    in     common 

May  be  absent;   fre- 

May be  pres- 

Often present. 

Present;  pro- 

Rarely presen 

duct;    impacted  ; 

quently     present 

ent;     vari- 

gressive; 

chronic. 

early;    may    be    in- 
termittent;        vari- 
able. 

able. 

may  vary  in 
intensity. 

II.  Inflammatory 

Disease 

(a)   Cholecystitis      sub- 

Present;   paroxysmal 

Present  dur- 

May be  pres- 

No. 

Present    du 

acute. 

during     periods     of 

ing  attacks 

ent. 

ing   attacl 

cystic   duct    closure 

of  colic. 

of  cystic  du 

from  stone  or  swol- 

obstruction. 

len    mucous    mem- 

brane. 

(6)   Cholecystitis  acute. 

Acute     paroxysmal 

Present  with 

Present  often ; 

No. 

Present;       te 

radiating   pain;    ex- 

chills   and 

severe. 

derness;     oi 

tending  to  back  and 

sweats. 

en     muscul 

shoulder ;    may    be 

rigidity. 

very  severe. 

(c)    Cholecystitis  chron- 

Severe radiating  pain 

Present ; 

Present        at 

No. 

Present;     wi 

ic  (empyema  of  gall- 

at first;  may  disap- 

severe     at 

first. 

tendernes 

bladder)  . 

pear  later;  tendency 

first,     may 

may     _  atta 

to  recur. 

diminish 
later. 

large  size. 

(d)   Cholecystitis  in  pre- 

Present; often  severe; 

Present; 

Present. 

No. 

No     (oocasio 

viously  diseased  and 

paroxysmal. 

often   with 

ally     presei 

contracted     gall- 

chills   and 

due    to    pel 

bladder. 

sweats. 

cystic       ex 
date) . 
No. 

(e)    Cholangitis  of  hepa- 

May  be  absent;  gen- 

Present; 

Present. 

Present;  vari- 

tic    and     common 

erally  present  when 

chills  ; 

able. 

ducts. 

obstruction     exists, 
or  severe  infection; 
tenderness  and  pain 
over  liver  in  intra- 
hepatic  cholangitis. 

sweats  ; 
severe 
prostra- 
tion ;    gen- 
eral sepsis. 

III.  New  Geowths. 

(a)   Carcinoma   of   gall- 

No;  may   occur  late 

No. 

No. 

Present     late 

Hard,      irreg 

bladder. 

in  disease. 

(portal 
glands) . 

lar,     movab 
tumor  at  firs 
later      diffu 
infiltration. 

(b)   Tumor      of      cystic 

No;  may  occur  late. 

No. 

No. 

No. 

Present     whe 

duct. 

obstructio 

exists. 

(c)    Tumor    of    hepatic 

No;  may  occur  late. 

No. 

No. 

Present;  pro- 

May be  presei 

or  common  duct. 

gressive  . 

from    _  diste 
,  tion  with  bil 

(rf)   Tumor  of  neighbor- 

No; may  occur  late. 

No. 

No. 

Present;  pro- 

Present;     ge 

ing  viscera  producing 

gressive  ; 

erally       fro 

chronic   obstruction 

may  become 

dis tentio 

of  common  duct. 

extreme. 

with  bile. 

CHOLELITHIASIS 

OF   THE   GALL-BLADDER   AND    DUCTS. 


595 


stools. 


Liver. 


Spleen. 


Ascites. 


Remarks. 


Normal. 


Normal. 


Normal. 


May  be  olay- 
colored  if 
obstruc- 
tion occurs. 

Clay-colored. 


Not  enlarged. 


Not  enlarged. 


Not  enlarged. 


Frequently 
enlarged. 


Not  enlarged. 


Contains  bile    Clay-colored.   May    be    en- 
pigment,  larged    dur- 
ing attack. 


Clay-colored. 


Normal. 


Normal. 


Normal. 


Normal. 


May  be  clay- 
colored. 


May  be  clay- 
colored 
late. 


Normal. 

Clay-colored. 

Clay-colored. 


Enlarged. 


Not  enlarge4. 


Not  enlarged. 


Not  enlarged. 


Not  enlarged. 


Enlarged. 


Enlarged 
late  in  dis- 


Not  enlarged. 


May    be    en- 
larged. 

Enlarged. 


Not    enlarged. 


Not     enlarged. 


Not  enlarged. 


Not  enlarged. 


Not  enlarged. 


May  be  enlarged 
from  pressure 
of  stone  on  vein. 

May  be  enlarged. 


No. 


No. 


No. 


No. 


No. 


No. 


No. 


Not  enlarged. 


May  be  enlarged 
(sepsis) . 


Not  enlarged. 


May  be  enlarged 


Enlarged  (sepsis) 


May  be  enlarged 
late  (pressure 
on  vein). 


Not  enlarged. 
Not  enlarged. 


May  be  enlarged 
late. 


No. 


No. 


No. 


No. 


No. 


Present 
late. 


No.  (?) 


May  be 
present 
late. 

Present 
late. 


Generally  discovered  by  accident; 
often  unrecognized. 


All   symptoms   promptly   relieved 
as  soon  as  obstruction  removed. 


Hydrops  of  gall-bladder  often 
unrecognized. 

Diagnosis  extremely  difficult; 
symptoms  generally  due  to  co- 
existing cholangitis. 

Symptoms  rapidly  disappear  when 
stone  passes  papilla. 

"Fievre  intermittente  h6patique" 
of  Charcot  resembles  malaria; 
all  symptoms  disappear  during 
interval. 

Condition  may  remain  for  many 
years;  may  only  be  jaundice 
with  digestive  disturbances  and 
loss  of.  weight;  history  of  pre- 
vious attacks  (?).  Ascites  may 
be  present  from  pressure  of 
large  stone  or  possibly  from 
hydremia. 


Tenderness  over  gall-bladder;  ten- 
dency to  recurrence;  genewklly 
associated  with  stones  in  gall- 
bladder. _ 


May  follow  typhoid  or  other  sep- 
tic diseases;  onset  often  sudden; 
rapid  development  of  severe 
symptoms  resembling  appendi- 
citis; may  be  necrosis  of  walls 
of  gall-bladder  with  perforation ; 
local  or  general  peritonitis. 

Frequently  follows  acute  chole- 
cystitis ;  occasionally  becomes 
quiescent,  presenting  practically 
no  symptoms. 

Generally  tenderness  over  gall- 
bladder area,  but  no  tumor; 
local  peritonitis;  diagnosis  "often 
extremely  difficult. 

Often  follows  severe  infections  of 
gall-bladder;  generally  associated 
with  stones  in  common  or  hepa-- 
tic  duct;  severe  sepsis ;_generally 
fatal  in  virulent  infectio"hs  (strep- 
tococcus) . 


Digestive  disturbances,  progres- 
sive loss  of  weight  and  asthenia; 
cachexia;  rapidly  fatal. 


Very  rare;  both  benign  and  ma- 
lignant growths  have  been  re- 
ported;    diagnosis    difficult. 

Very  rare;  diagnosis  difficult. 


Malignant  tumors  most  common; 
chronic  interstitial  pancreatitis 
from  previous  infection  of  biliary 
passages  may  remain  after  cause 
has  disappeared;  enlarged  portal 
Hodgkin's    disease. 


596      DISEASES  OF   THE  GALL-BLADDER  AND  BILE   VESSELS 

4.  Ampulla  of  Vater. — ^Calculous  retention  in  the  ampulla  may 
obstruct  the  flow  of  the  pancreatic  juice,  though  the  accessory  duct 
may  carry  it  into  the  intestine;  retention  may  allow  bile  to  enter  the 
pancreatic  duct,  and  result  in  (a)  acute  pancreatitis;  (b)  chronic  indu- 
ration of  the  head  of  the  pancreas  resembling  malignancy;  (c)  pancreatic 
fibrosis  with  pancreatic  calculi  due  to  stasis  and  infection;  or  {d)  rarely 
glycosuria. 

5.  Intestinal  Obstruction. — -The  obstruction  may  not  occur  for 
some  time,  the  stones  sometimes  receiving  new  layers  of  magnesia  or 
phosphates;  it  is  in  the  ileum  in  66,  duodenum  in  21,  ileocecal  valve  in  10 
and  sigmoid  in  3  per  cent. ;  50  per  cent,  of  cases  die.    (See  page  551.) 

6.  Fistula.  —  Courvoisier  assembled  499  cases.  The  external  form 
constitutes  about  50  per  cent,  of  cases;  they  are  most  often  located  near 
the  navel  and  about  40  per  cent,  of  them  heal.  In  the  duodenal  form  (28 
per  cent.)  the  fistula  is  between  the  duodenum  and  gall-bladder  and  less 
often  between  the  common  duct  and  gall-bladder.  In  13  per  cent,  there 
is  a  fistulous  opening  into  the  colon.  Courvoisier  and  Graham  collected 
34  cases  of  bronchial  fistula.  In  rare  cases  stones  enter  the  stomach 
(5  cases  recorded,  Snively,  1903),  portal  vein  (as  in  the  autopsy  upon 
Ignatius  de  Loyola),  hepatic  artery,  kidney,  urinary  bladder  (200  gall- 
stones evacuated  in  the  urine  in  the  case  of  Barraud-Palletan) ,  pericar- 
dium, retroperitoneal  tissue,  vagina  or  even  the  pregnant  uterus. 

Diagnosis. — The  diagnosis  is  easily  made  when  colic,  vomiting,  tender- 
ness of  the  gall-bladder  and  icterus  are  present.  The  a:-rays  are  positive 
in  50  per  cent.  (Case). 

1.  The  Colic. — This  is  most  apt  to  be  confused  with  (a)  gastralgia 
or  hepatic  neuralgia;  due  regard  for  other  symptoms  of  gall-stones  and 
reserve  in  the  diagnosis  of  gastralgia  save  many  mistakes.  (6)  Gastric 
or  duodenal  ulcer,  hyperchlorhydria  and  hypersecretion  {q.  v.)  are  easily 
distinguished,  (c)  Lead  colic  has  the  characteristic  gingival  lead  line, 
obstinate  constipation  and  often  neuritic  manifestations,  (d)  Tabetic 
crisis  is  attended  by  the  Argyll-Robertson  pupil,  absent  knee-jerk  and 
ataxia,  (e)  Renal  colic  is  distinguished  by  pain  reflected  down  the  ureter, 
hematuria  and  pyuria;  and  Dietl's  crisis  in  floating  kidney,  by  bimanual 
examination  of  the  abdomen,  (/)  Mucous  colic  is  differentiated  by  the 
characteristic  stools,  (g)  Appendicitis  is  characterized  by  its  cardinal 
symptoms  (g.  v.);  Ochsner  finds  10  per  cent,  of  his  appendicitis  cases 
complicated  by  gall-stones  and  33  per  cent,  of  his  gall-stone  cases  by 
appendicitis,  (h)  Acute  pancreatitis  (g.  v.)  which  may  complicate  gall- 
stones, causes  greater  collapse  and  more  frequent  intestinal  obstruction, 
(i)  Febrile  syphilis  may  simulate  gall-stones  as  may  also  the  abdominal 
crises  observed  in  angioneurotic  edema. 

2.  Other  Biliary  Affections  (see  pages  594  and  595). 
Prognosis. — The  prognosis  is  difficult  to  formulate.    Stones  may  pass 

without  recurrence  of  colic  and  the  passage  of  smooth  calculi  may  justify 
some  hope  that  they  are  the  only  ones.  The  first  attack  is  usually  the 
worst.  Fever,  infection,  cancer  and  obstruction  must  be  covered  in  fore- 
casts to  patients  refusing  operation.  Riedel  held  that  10  per  cent,  recover 
spontaneously,  while  90  per  cent,  require  surgical  intervention. 


CHOLECYSTITIS  597 

Treatment. — 1.  Prevention. — Exercise,  deep  breathing  and  plenty  of 
water  aid  the  flow  of  bile.  Lacing  is  a  factor  to  be  regarded.  Digestive 
derangements  should  be  corrected.  Alcohol  is  contra-indicated.  The 
predisposing  gall-bladder  inflammation  seldom  comes  under  the  physi- 
cian's care,  but  in  suspicious  cases,  sodium  salicylate,  gr.  x-xv  t.  i.  d., 
given  alternate  weeks,  acts  as  a  cholagogue  and  antiseptic.  Hexamethyl- 
enamine,  5j  per  diem,  is  excreted  by  the  bile.  Potassium  iodide,  and 
sodium  phosphate,  3ss-j  are  beneficial. 

2.  Colic. — Hypodermics  of  morpliine  must  be  given,  gr.  |  being  com- 
bined with  nitroglycerin  gr.  j^y-  and  (for  the  first  injection)  atropine 
gr.  YToJ  repeated  doses  of  morphine  and  nitroglycerin  are  often  necessary. 
Inhalation  of  chloroform  is  indicated  in  severe  cases  until  the  morphine 
acts,  but  none  of  these  drugs  should  be  left  in  the  possession  of  any 
patient.  A  full  hot  bath  and  hot  fomentations  over  the  liver  are  valuable 
accessories.  Drinking  warm  water  facilitates  vomiting,  which  relieves 
the  pain. 

3.  Medical  Treatment. — This  in  no  way  influences  the  solution 
of  gall-stones.  Durande's  solvent  (oil  of  turpentine  1  part  to  ether  4 
parts)  is  useless  and,  like  chloroform,  is  only  antispasmodic.  Olive 
oil  only  facilitates  their  final  passage.  Salicylates,  calomel,  salines 
{v.  s.)  and  various  "cures,"  as  at  Carlsbad,  Vichy,  Kissingen,  Las  Vegas 
or  Bedford  Springs,  are  useful  in  quieting  concomitant  or  causative 
inflammation.     Local  massage  is  obviously  injurious. 

4.  Surgical  Treatment. — The  author  believes  that  gall-stones 
should  be  operated  on  when  recognized,  thus  saving  time,  suffering 
and  danger.  Riedel's  argument  for  early  operation — the  removal  of 
the  calculi  while  they  remain  in  the  gall-bladder — holds  good,  as  it  is 
the  only  salvation  against  perforation,  cholemia  and  carcinoma;  it  is 
refused,  however,  in  general  practice.  Hydrops,  empyema  of  the  gall- 
bladder and  pericholecystitic  abscesses,  cholangitis,  incapacitation, 
jaundice,  impaction,  and  frequent  resort  to  morphine  are  strong  indi- 
cations. Corpulent  men  do  not  bear  the  operation  well.  Women  who 
have  borne  children  lend  themselves  well  to  surgical  procedure.  If 
possible  one  should  refrain  from  operating  in  cases  of  diabetes,  arterio- 
sclerosis, chronic  nephritis  and  diseases  of  the  lungs  and  heart. 

In  Mayo's  4000  operated  cases  the  mortality  was  L8  per  cent,  in 
uncomplicated  cases,  while  those  complicated  by  suppuration  or  cancer 
brought  the  average  mortality  to  2.75  per  cent.;  the  death-rate  in  opera- 
tions on  the  common  duct  was  8  per  cent.  These  figvires  appear  to  the 
writer  as  the  best  possible  argument  for  early  operation.  Cholecys- 
totomy  is  often  inferior  to  cholecystectomy. 

CHOLECYSTITIS. 

Etiology. — Inflammation  of  the  gall-bladder  may  occur  before,  after, 
with  or  without  mflammation  of  the  bile  passages,  (a)  Predisposi77g 
factors  are  gall-stones  (especially  large  ones  which  cannot  pass,  which 
cause  65  to  90  per  cent,  of  cholecystitis  and.  cholangitis),  bile  stasis, 
foreign  bodies  or  previous  attacks,     (b)  The  exciting  cause  is  bacterial, 


598      DISEASES  OF   THE  GALL-BLADDER  AXD  BILE   VESSELS 

the  colon,  typhoid,  pyogenic,  pneiimococcus,  and  other  micrDorganisms. 
They  may  ascend  the  bile  channels  or  enter  with  the  blood  current. 
Inflammation  from  t^^hoid  infection  (Louis  and  Andralj  may  occur 
without  actual  typhoid  or  may  develop  twenty  years  later. 

Symptoms, — The  symptoms  vary  with  the  intensity  of  infection, 
which  is  almost  synonymous  with  the  type  (.simple,  membranous,  sup- 
purative, phlegmonous,  ulcerative  or  gangrenous).  In  light  forms 
the  symptoms  may  not  be  recognized;  this  corresponds  to  postmortem 
adhesions  in  cases  with  no  history  of  cholecystitis.  In  other,  perhaps 
more  severe  cases,  symptoms  are  obscm"ed  by  the  causative  typhoid  or 
by  gall-stones.  In  the  average  case  there  are:  (a)  fain  over  the  yart, 
which  may  be  severe  or  paroxysmal  and  may  radiate  toAvard  the  appendix 
or  back.  i'6i  Tenderness  as  in  gall-stones;  it  is  often  first  general  and 
then  local  and  the  right  rectus  is  tense;  it  is  clearly  elicited  by  a  thrust 
over  the  part  during  inspiration,  (c)  Fever,  increased  puhe-rate,  vomitijig 
or  nausea;  fever  is  absent  in  mild  infections;  in  tA'phoid,  cholecystitis 
may  be  confused  with  typhoid  relapse.  There  may  be  colic,  (d)  There 
may  be  a  palpable  gall-bladder.  Its  contents  may  be  purulent  (^empyema 
cystidis  fellete)  or  serous  (hydrops  cystidis  felletei.  Hydrops  may  enlarge 
the  gall-bladder  to  the  size  of  the  fist  or  in  extreme  cases  so  that  it  weighs 
50  to  60  pounds  and  fills  the  entire  abdomen,  simulating  ascites;  the 
fluid  is  alkaline  or  neutral,  serous  or  mucoid.  If  very  tense  the  gall- 
bladder may  not  fluctuate  or  if  very  lax  may  not  be  palpable  fsee  Float- 
IXG  KiDXEYK  There  may  be  pus  in  the  gall-bladder  without  enlarge- 
ment. In  chronic  cases  it  may  shrink,  ie)  Severe  sepsis  may  intervene  in 
diffuse  suppurative  cholangitis  or  pylephlebitis,  evidenced  by  septic  fever, 
chills,  leukocytosis,  bacteriemia,  swollen  liver  and  spleen,  nephritis  and 
ulcerative  endocarditis.  Icterus  occurs  in  33  per  cent.  (See  pages 
594  and  595.) 

Prognosis. — ]\Iany  cases  with  cholangitis  die  in  spite  of  operation. 
Mild  cases  may  subside,  but  recurrence  and  formation  of  gafl-stones 
are  frequent.  Under  expectant  therapy  the  outlook  is  serious  in  severe 
cases,  for  perforation,  peritonitis,  adhesions  'in  75  per  cent.)  or  pyloric 
obstruction  may  result. 

Treatment. — Rest,  milk  diet,  local  heat  and  morphine  may  suffice 
for  light  cases,  but  in  the  more  severe  infections  drainage  is  indicated. 

CHOLANGITIS.     CATARRHAL   ICTERUS.     CONGENITAL   OCCLUSION. 

Suppurative  Cholangitis. — It  usually  coexists  -^dth  suppurative  chole- 
cystitis and  infection  is  usually  hematogenous,  but  may  be  ascending — 
cholangitic  sepsis  (v.  pages  594  and  595.) 

Acute  Catarrhal  Jaundice. — Cholangitis  catarrhalis,  icterus  simplex, 
results  from  gastroduodenal  catarrh  which  causes  swelling  "^-ith  ob- 
struction of  the  papilla;  in  the  few  autopsied  cases  a  small  plug  of  mucus 
occludes  the  opening  of  the  common  duct;  Eppinger  found  swelling  of 
the  hmiphoid  follicles  where  the  duct  lies  in  the  waU  of  the  bowel.  Its 
usual  causes  are  practically  those  of  acute  gastritis  or  enteritis.  Favoring 
factors  include  passive  congestion,  acute  infections,  toxic  causes,  nephritis 


TUMORS  OF  THE  GALL-BLADDER  AND  BILE   VESSELS       599 

and  other  diseases  of  the  liver  or  bile  tracts.  Epidemic  forms  seem  to  be 
a  separate  type  of  infection  (v.  Weil's  Disease). 

Symptoms, —  G astro-intestinal  catarrh  occurs  first  in  half  the  cases 
and  after  a  few  days  icterus  appears,  with  its  usual  symptoms,  sudden 
decolorization  of  the  stools  and  bright  yellow  staining  of  the  skin  and 
urine;  in  the  other  half,  there  is  primary  infectious  catarrh  of  the  bile 
ducts.  The  liver  is  not  enlarged  at  first,  but  may  become  slightly 
swollen  later;  there  is  no  pain  or  emaciation,  the  spleen  and  gall-bladder 
are  seldom  enlarged  and  the  diagnosis  depends  on  the  mode  of  onset 
in  young,  healthy  subjects,  sequence  of  symptoms  and  exclusion  of 
other  causes  of  obstruction;  in  advanced  life  catarrhal  jaundice  is  less 
common  than  gall-stones  and  cancer.     (See  page  594.) 

Prognosis. — Cases  may  clear  in  a  week  or  last  five  months;  a  course 
of  over  the  average — ^four  to  eight  weeks — renders  the  diagnosis  uncer- 
tain. Cases  mth  fever  may  run  a  prolonged  course.  Death  rarely  occurs 
from  hemorrhage,  exhaustion  or  sudden  heart  failure. 

Treatment. — (a)  Causative  factors,  as  gastritis  or  stasis,  are  appro- 
priately treated;  dyspeptic  symptoms  yield  most  readily  to  gastric 
lavage  and  fractional  doses  of  calomel  at  night  followed  by  a  mild  saline 
in  the  morning;  active  catharsis  augments  or  initiates  catarrh. 

I^ — Acidi  hydrochlorici  diluti gj 

Tincturse  nucis  vomicae 3iv 

Tincturae  gentianse  co q.  s.  ad.  giv 

M.  et  S. — One  teaspoonful  after  meals  in  half  a  glass  of  water. 

The  green  "bilious  stools"  from  calomel  are  not  due  to  bile  but  to 
mercuric  sulphide.  (6)  In  the  diet  fats  are  particularly  to  be  avoided, 
as  neither  the  stomach  nor  intestine  can  digest  them;  tea,  coffee,  alcohol 
and  coarse  foods  should  be  interdicted;  skimmed  milk,  well-cooked 
carbohydrates,  toast,  eggs  and  mealy  soups  may  be  given;  meat  is 
often  poorly  tolerated,  seemingly  because  of  exclusion  of  the  pancreatic 
secretion,  (c)  As  long  as  acute  dyspepsia  exists,  rest  in  bed  is  indicated, 
in  order  to  maintain  nutrition  on  the  lowest  possible  diet,  (d)  The 
bowels  are  regulated  by  copious  injections  of  water,  to  incite  peristalsis 
and  dislodge  the  obstructing  mucus  plug,  (e)  The  itching  is  allayed 
by  1  per  cent,  carbolic  solution,  the  use  of  which  requires  care,  as  the 
urine  sometimes  becomes  cloudy;  acetanilide,  gr.  v,  q.  i.  d.;  potassium 
bromide,  5ss,  well  diluted,  by  rectum  once  or  twice  daily;  an  occasional 
hypodermic  of  pilocarpin  hydrochloride  gr,  |;  and  by  warm  baths. 

Chronic  Catarrhal  Cholangitis. — (v.  Gall-stones,  Pancreatic  Cancer  and 
Icterus.) 

Congenital  Occlusion  of  the  Bile  Ducts.  —  Seventy-six  cases  are 
recorded  (Howard  and  Wolbach),  due  perhaps  to  cholangitis  or  con- 
genital atresia.  Icterus  develops  within  a  month  after  birth  and  death 
results  in  weeks  or  months  from  cholemia  or  hemorrhages. 

TUMORS  OF  THE  GALL-BLADDER  AND  BILE  VESSELS. 

I.  Cancer  of  the  Gall-bladder. — ^Tumors  other  than  cancer  are  rare, 
as  sarcoma,  papilloma,  fibroma,  lipoma  or  adenoma. 


600       DISEASES  OF   THE  GALL-BLADDER  AXD  BILE   VESSELS 

Etiology. — The  most  striking  etiological  factor  is  gall-stones,  present 
in  70  to  91  per  cent.  (Courvoisier) ;  the  estimate  that  9  per  cent,  of  cases 
of  gall-stones  result  in  cancer  of  the  gall-bladder  seems  very  high;  80 
per  cent,  occur  in  women  over  fifty  years  of  age. 

Pathology. — The  tumor  may  be  scirrhus  or  medullary,  but  usually 
adenocarcinoma;  spheroidal  and  squamous  types  are  rare. 

Symptoms. — (a)  Gall-stones  which  irritate  the  mucosa  and  cause 
most  cases,  usually  produce  no  symptoms,  though  previous  colic  may 
be  noted  in  the  history,  (b)  A  tumor  of  the  gall-bladder  is  palpable  in 
over  66  per  cent.,  first  as  a  smooth  oval  and  later  as  a  larger  and  more 
nodular  swelling;  it  is  usually  due  to  the  growth,  for  the  gall-bladder 
itself  is  generally  shrunken.  The  fundus  is  the  usual  point  of  origin, 
being  most  irritated  by  calculi,  much  more  rarely  the  neck  of  the  gall- 
bladder or  least  frequently  the  cystic  duct.  The  tumor  appears  below 
the  edge  of  the  liver  with  which  it  moves.  There  may  be  local  discomfort 
and,  in  rare  cases,  severe  pain  like  that  of  gall-stones,  (c)  Cachexia 
appears  T\dth  all  its  attendant  symptoms. 

Complications. — Secondary  growths  in  the  liver  occur  in  58  per  cent, 
by  lymphogenous  routes  or  by  invasion  from  contiguity  and  sometimes 
cause  hepatic  enlargement;  from  the  liver  extension  by  the  hepatic 
veins  may  occasion  systemic  metastases.  Icterus  occurs  in  69  per  cent. ; 
cholemia  is  a  common  termination.  GroT\i:hs  in  the  peritoneum,  lungs 
or  pleura,  abdominal  lymph  glands  and  into  the  colon  occur  in  about 
10  per  cent.  each.  Warthin  records  adrenal  metastases  with  vitiligo 
and  pigmentation  like  that  of  Addison's  disease.  Pressure  on  the  pylorus 
may  cause  its  stenosis,  vomiting  or  dyspepsia.  Ascites  occurs  in  25  per 
cent,  and  is  due  to  compression  of  the  portal  vein  or  to  malignant  peri- 
tonitis. Suppurative  cholangitis  may  develop,  T^•ith  death  from  sepsis. 
The  differential  diagnosis  is  considered  under  gall-stones.  The  clinical 
course  averages  six  months.  Treatment  is  palliative,  unless  the  affection 
is  diagnosticated  early  or  is  accidentally  found  in  operating  for  other 
conditions. 

n.  Tumors  of  the  Extra-hepatic  Bile  Ducts. — RoUeston  collected  80 
cases,  and  Zezas  34  cancers  at  the  junction  of  the  three  great  bile  ducts. 
These  tumors  are  small,  seldom  infiltrate  and  are  of  the  columnar  type. 
The  common  duct  is  most  often  affected,  the  hepatic  duct  less  and  the 
cystic  duct  least  frequently.  The  salient  symptom  is  intense  icterus,  which 
develops  early,  increases  steadily,  occurs  in  nearly  all  cases,  causes 
icteric  necrosis  of  the  liver  cells  in  the  central  zone  and  precipitates 
early  cholemia  before  metastases  or  cholangitic  sepsis  have  time  to 
develop.  The  gall-bladder  is  almost  always  dilated  anatomically  in 
tumors  of  the  common  duct  and  is  felt  clinically  in  over  50  per  cent. 
Pain  is  not  common,  though  gall-stones  may  be  simulated.  Ascites, 
dyspepsia  and  gastro-intestinal  hemorrhages  from  cholemia  may  develop. 
Difi^erentiation  from  duodenal  or  pancreatic  tumors  (g.  v.)  is  usually 
impossible.  Treatment  consists  of  draining  the  gall-bladder  or  extirpa- 
ting the  tumor. 


ACUTE  PANCREATITIS— FAT  NECROSIS  601 

DISEASES  OF  THE  PANCREAS. 

ACUTE  PANCREATITIS;  FAT  NECROSIS. 

Etiology. — Infection  ascending  from  the  intestines  is  the  leading  cause. 
(a)  Calculus  obstructing  the  common  duct,  by  allowing  bile  to  regurgitate 
into  Wirsung's  duct,  may  cause  acute  pancreatitis  (Opie),  especially 
when  the  gall-bladder,  the  natural  reservoir  for  obstructed  bile,  is 
shrunken;  gall-stones  cause  42  per  cent,  of  cases  of  acute  fat  necrosis. 
Bile  salts  may  initiate  inflammation  and  fat  necrosis,  without  infection. 
The  accessory  duct  of  Santorini  may  carry  off  the  pancreatic  juice  when 
there  is  obstruction  of  Wirsung's  duct,  but  it  is  too  small  for  much 
compensation  in  66  per  cent,  of  cases;  (&)  metastatic  infection  is  an 
infrequent  cause;  the  author  observed  one  case  in  which  an  acute  ulcer 
of  the  leg  was  the  atrium;  (c)  suppuration  or  ulceration  in  contiguous 
tissues  may  be  causative. 

Predisposing  Factors. — (a)  Age  and  sex;  90  per  cent,  occur  in 
males  beyond  middle  life,  (b)  Obesity;  (c)  alcoholism;  (d)  trauma;  (e) 
gastro-intestinal  catarrh;  and  (/)  parturition  in  6.6  per  cent,  of  Peiser's 
128  cases. 

Symptoms. — ^The  clinical  picture  was  clearly  described  and  defined  by 
Fitz  (1889),  though  cases  were  reported  earlier  by  Oppolzer.  The  onset 
is  sudden  in  adult,  stout  males  who  have  enjoyed  previous  good  health 
or  who  have  a  history  of  alcoholism  or  of  gall-stones. 

1.  Epigastric  yain  is  the  initial  symptom;  it  is  very  sudden  and  agon- 
izing, constant  or  paroxysmal  and  may  be  confused  (or  coincident) 
with  gall-stone  colic,  though  it  is  even  more  intense;  it  is  diffusely  epi- 
gastric or  rarely  over  the  head  of  the  pancreas.  The  author  has  seen 
radiation  into  both  axillae.  The  intensity  of  the  pain  is  referable  to 
pressure  on  the  celiac  plexus  (neuralgia  or  neuritis  celiaca). 

2.  Epigastric  tenderness  is  usual,  often  over  the  head  or  sometimes 
more  over  the  tail  of  the  pancreas,  whence  the  inflammation  may  extend 
to  the  left  pleura  with  tenderness  and  friction.  The  recti  are  tense  and 
the  epigastrium  is  swollen. 

3.  Vomiting  is  early,  severe  and  sometimes  brings  up  blood. 

4.  Collapse  follows;  it  often  threatens  immediate  dissolution  and  too 
often  prevents  surgical  interference.  It  is  due  to  pressure  on,  or  actual 
inflammation  of,  the  closely  contiguous  celiac  plexus  and  semilunar 
ganglia.  In  one  of  the  author's  cases  there  were  relapsing  shock  with 
cyanosis,  dyspnea  and  a  pulse  of  140,  which  was  so  weak  that  no  surgeon 
would  operate  during  the  two  weeks  before  recovery.  Collapse  usually 
causes  death  in  2  to  4  days  in  unoperated  cases. 

5.  Fever  is  not  constant;  there  may  be  no  elevation  or  an  irregular 
rise  to  103°  or  104°.    Chills  are  most  common  in  late  suppuration. 

6.  The  pancreas  can  rarely  be  felt  becaus^e  of  its  deep  position  and 
the  tense  and  tympanitic  epigastrium. 

7.  The  boivels  are  constipated,  simulating  obstruction,  though  flatus  is 
passed.    Operation  or  autopsy  at  this  stage  shows  an  acute  pancreatitis 


602  DISEASES  OF  THE  PANCREAS 

with  swelling,  a  variegated  yellowish-red  or  black  color,  exudation  of  fibrin, 
pus  cells,  blood  (hemorrhagic  pancreatitis)  and  areas  of  acute  fat  necrosis 
(Balser,  1882).  Fat  necrosis  is  caused  by  the  fat-splitting  steapsin 
(Langerhans),  which  produces  glycerin  and  insoluble  fatty  acids  from 
the  pancreas  and  contiguous  adipose  tissues,  i.  e.,  omentum,  mesentery 
and  peritoneum;  the  glycerin  is  absorbed,  the  fatty  acids  are  pre- 
cipitated with  lime  as  opaque  white  areas  of  necrosis  and  some  of  the 
ferment  occasionally  escapes  into  the  blood,  producing  toxemic  symptoms 
or  necrosing  fatty  tissue  elsewhere,  as  in  the  pericardium  or  skin. 

8.  If  the  patient  lives  a  localized  peritonitis  develops  in  the  upper 
abdomen;  pus  may  fill  the  lesser  peritoneal  cavity;  the, pain  may  be- 
come general  from  diffuse  fat  necrosis  or  dyspnea  may  develop  from 
diaphragmatic  pleurisy. 

9.  Septicopyemic  symptoms  may  appear,  as  rigors,  hectic  fever,  pleurisy, 
icterus,  diarrhea  and  loss  of  weight  and  strength;  the  author  saw  splenic 
tumor,  nephritis  and  universal  lymph  adenitis. 

10.  Acute  glycosuria  was  present  in  one  of  the  author's  cases. 

In  the  third  week  rupture  into  the  colon  may  occur,  attended  by 
lancinating  pain  and  intestinal  hemorrhage. 

Suppurative  types,  of  which  Korte  collected  46  cases,  may  begin 
gradually,  without  acute  gangrene,  fat  necrosis  or  hemorrhage;  the 
symptoms  are  less  acute  and  severe.  The  suppuration  is  localized  or 
there  is  a  diffuse  purulent  infiltration;  it  may  cause  pylephlebitis,  liver 
abscess,  subphrenic  abscess,  burrowing  of  pus  into  the  peritoneum, 
loin  (which  Korte  considers  rather  characteristic),  peripheral  tissues  or 
alimentary  tract.  Protracted  suppuration  is  said  to  cause  glycosuria, 
skin  pigmentation  and  anasarca.  Korte  collected  40  cases  of  acute 
gangrenous  pancreatitis. 

Diagnosis. — The  cardinal  features  are  the  sudden  onset,  violent  epi- 
gastric pain,  distention  and  tenderness,  vomiting  and  collapse.  The 
absence  of  indican,  leucin  and  tyrosin  in  the  urine  is  suggestive.  Robson 
finds  calcium  oxalate  crystals  in  30  per  cent,  of  all  varieties  of  pan- 
creatic disease.    The  pancreatic  reaction  of  Cammidge  is  unreliable. 

Differentiation. — (a)  Acute  poisoning  is  eliminated  by  the  history 
and  gastric  contents.  (6)  Intestinal  obstruction  is  less  severe  in  onset; 
collapse  is  attended  by  distention,  intestinal  rigidity  or  peristalsis  above 
the  obstruction;  indicanuria  is  usual;  epigastric  distention  alone  is 
unusual;  in  one  pancreatic  case,  the  author  saw  obstruction  lasting  nine 
days.  Operation  may  be  necessary  for  diagnosis,  (c)  Gall-stone  colic 
is  rarely  as  severe  as  pancreatic  pain;  collapse  or  epigastric  distention  is 
infrequent,  {d)  Perforating  ulcer,  mesenteric  embolism  and  appendicitis 
must  be  considered. 

Prognosis. — The  malady  generally  evinces  a  severe  progressive  ten- 
dency. A  fatal  attack  may  follow  milder  seizures.  At  autopsy  fibrous 
tissue  and  crystals  or  granules  of  hematoidin  may  be  evidence  of  previous 
inflammation.  Death  may  occur  within  a  few  hours  to  three  days  from 
collapse,  in  two  or  three  months  from  sepsis  or  in  six  months  from  diabetes 
(Fitz).  The  pancreas  may  slough  into  the  intestine,  as  in  Traf oyer's 
and  Chiari's  cases,  with  recovery. 


PANCREATIC  APOPLEXY  603 

Treatment. — Rectal  feeding  and  stimulation,  morphine  hypodermically 
and  heat  are  indicated  during  the  initial  shock.  Though  early  opera- 
tion is  dangerous  because  of  shock  and  hemorrhage,  it  is  indicated 
lest  local  extension  or  general  toxemia  develop;  the  surgical  mortality 
is  60,  and  the  medical,  90  per  cent. 

CHRONIC  PANCREATITIS. 

Etiology  and  Pathology. — (a)  Gall-stones  in  the  common  duct  may 
induce  chronic  catarrh  of  Wirsung's  duct,  leading  to  chronic  pancreatitis 
(Robson).  (h)  Cancer,  gastroduodenal  catarrh  and  ulceration  (alcoholism, 
syphilis  and  pancreatic  calculi)  may  produce  the  same  results.  In  these 
instances  ascending  injection  appears  to  be  the  potent  factor,  causing 
interlobular  fibrosis  around  the  pancreatic  lobules  (Opie) ;  diabetes  is  a 
late  and  uncommon  sequence,  (c)  In  liver  cirrhosis  and  hemocliroinaiosis 
(see  pages  572  and  574)  an  interacinar  fibrosis  occurs,  developing  in 
the  lobules,  diffusely  invading  the  islands  of  Langerhans  and  causing 
glycosuria;  it  does  not  result  from  obstruction  of  the  common  duct. 

Symptoms. — Riedel,  who  first  described  the  affection,  holds  that  it 
is  found  more  frequently  with  increasing  thoroughness  of  operations  for 
gall-stones.  Symptoms  may  be  lacking.  They  vary  with  the  cause. 
In  catarrh  due  to  gall-stones  there  is  a  history  of  colic,  jaundice  and  some- 
times intermittent  fever.  Tenderness  in  the  epigastrium,  a  fulness  above 
the  umbilicus  and  loss  of  flesh  are  noted,  and  if  pancreatic  symptoms 
predominate  the  pain  passes  from  the  epigastrium  to  the  left  side,  to  the 
scapular  or  renal  region.  If  gall-stones  are  not  the  cause,  the  pain  may 
be  moderate  or  absent.  The  gall-bladder  may  enla^rge  from  obstruction 
of  the  common  duct,  when  the  liver  becomes  enlarged.  Marked  enlarge- 
ment of  the  spleen  is  frequent,  bile  is  found  in  the  urine  in  60  per  cent., 
calcium  oxalate  crystals  in  40  per  cent,  and  glycosuria  in  5.5  per  cent. 
(Robson).  Opie  found  glycosuria  but  once  in  22  cases.  A  tumor-like 
induration  of  the  head  of  the  pancreas  simulates  cancer  because  of  the 
emaciation  and  deep  icterus;  differentiation  may  be  impossible,  even 
during  laparotomy;  it  is  more  common  in  subacute  than  in  chronic 
cases.  As  in  tumor,  excessively  copious,  pale  stools,  laden  with  fat  and 
undigested  muscle  fibers,  are  noted.    Polyuria  is  reported. 

Prognosis. — ^Without  surgical  intervention  death  is  likely  to  occur 
from  emaciation,  cholemia,  diabetes  or  hemorrhagic  diathesis. 

Treatment. — Drainage  of  the  gall-bladder  or  anastomosis  is  indicated. 
Robson  operated  on  62  cases  and  Quenu  and  Duval  on  62  cases  with  13 
per  cent,  mortality.     Hemorrhage  is  a  dreaded  complication. 

PANCREATIC  APOPLEXY. 

Pancreatic  hemorrhage  has  been  described  by  Spiess  (1866),  Klebs 
(1870)  and  Zenker  (1876);  Anders  (1899)  collected  40  cases.  The 
anemias,  syphilis,  alcoholism,  acute  infections  and  local  lesions  of  the 
pancreas  seem  to  be  predisposing  causes;  66  per  cent,  occur  in  men. 
Doubtless  many   reported   cases   are   acute   hemorrhagic   pancreatitis. 


604  DISEASES  OF   THE  PANCREAS 

Sudden  onset,  collapse,  epigastric  pain,  ileus,  and  normal  or  subnormal 
temperature  mark  the  affection;  death  sometimes  occurs  within  a  few 
hours.  If  the  patient  survives  the  initial  stage  suppuration  may  develop 
in  the  pancreas  and  tissues  into  which  the  hemorrhage  burrows;  hemor- 
rhagic cysts  may  form.    The  treatment  is  surgical. 

LITHIASIS. 

About  100  cases  of  sialolithiasis  pancreatica  are  recorded.  The  etiology 
is  probably  infection  of  Wirsung's  duct;  stagnation  of  secretion  is  a  pre- 
disposing factor,  whence  the  occasional  association  with  gall-stones, 
pancreatic  inflammation  and  tumor. 

Symptoms  and  Diagnosis. — Confusion  with  gall-stones  is  often  in- 
evitable, for  colic  without  icterus  is  indicative  of  either  condition  and 
their  coexistence  is  not  uncommon.  The  pain  may  radiate  to  the  left 
side  and  shoulder.  In  some  cases  stones  were  found  in  the  feces  during 
life,  in  others  at  autopsy.  Salivation  is  reported.  In  Lichtheim's  case 
there  were  colic,  diarrhea  and  glycosuria  (found  in  45  per  cent,  of  cases). 
The  stones  are  single  or  multiple  (even  300),  whitish-gray,  round,  oval, 
irregularly  outlined  or  branching,  hard  or  friable  and  vary  from  almost 
impalpable  gravel  to  the  size  of  a  hazel-nut.  They  consist  largely  of 
calcium  carbonate  and  phosphate.  Shattuck  described  an  oxalate 
calculus.  The  a:-rays  may  detect  them.  Their  sequelae  are  obstruction 
and  inflammation  of  Wirsung's  duct  and  acute  suppurative  pancreatitis. 
The  treatment  in  fortunately  diagnosticated  cases  is  surgical. 

PANCREATIC  CYSTS. 

To  Nicholas  Senn  (1885)  belongs  the  credit  of  establishing  the  clinical 
picture.     Bessel-Hagen  (1900)  collected  149  cases. 

Etiology  and  Pathology. — (a)  Many  reported  cases  are  extra-pancreatic, 
especially  the  traumatic  cysts,  which  constitute  three-quarters  of  cysts. 
(6)  Duct  obstruction  (ranula  pancreatica,  Virchow)  by  calculi,  strictures, 
parasites,  tumors  or  inflammation  in  the  smaller  ducts  is  an  etiological 
factor,  (c)  Cystadenoma  is  the  cause  of  most  true  cysts  (Lazarus),  {d) 
Cysts  rarely  result  from  an  old  hemorrhage.  In  all  forms  the  cyst  causes 
parenchymatous  atrophy,  (e)  Sex:  Traumatic  and  inflammatory  forms 
are  most  frequent  in  men  and  the  cystadenomatous  type  in  women. 
(/)  Age:  Over  50  per  cent,  are  found  in  the  third  decade  of  life,  though 
there  is  a  congenital  form,  sometimes  with  cystic  liver  and  kidneys 
(Richardson) . 

Symptoms  and  Diagnosis. — 1.  As  to  the  cyst,  (a)  a  deep  retroperitoneal 
swelling  is  found,  (6)  which  is  more  or  less  central,  and  above  the  navel 
in  87  per  cent.,  where  other  cysts  are  most  uncommon;  it  lies  behind 
or  between  the  inflated  stomach  and  colon,  sometimes  below  the  colon 
but  rarely  above  the  stomach;  very  large  cysts  which  contain  10  to  20 
quarts  may  fill  the  abdomen.  Proliferative  cysts  developing  in  the  tail 
of  the  pancreas,  point  toward  the  spleen  or  left  kidney,  (c)  Its  form  is 
round  or  oval  and  smooth;  (d)  its  consistence  varies;  {e)  it  is  immobile  on 


TUMORS  OF  THE  PANCREAS  605 

palpation  and  on  inspiration.  (/)  The  fluid  is  alkaline,  1.010-25  sp.  gv., 
mucoid,  blood-stained  in  82  per  cent.  (Korte),  and  in  45  per  cent,  contains 
one  or  more  pancreatic  ferments  (diastatic,  saponifying  or  tryptic)  of 
which  the  latter  alone  is  characteristic,  for  the  other  ferments  occur 
in  various  exudates.  The  fluid  sometimes  contains  fat  and  cholesterin; 
aspiration  is  dangerous,  because  the  tension  of  the  cyst  is  great  and  fat 
necrosis  or  peritonitis  may  result  from  leaking  after  exploratory  puncture. 

2.  So-called  pancreatic  symptoms  are  rare,  as  emaciation,  salivation, 
glycosuria  or  stools  laden  with  undigested  fat  or  muscle  fibers. 

3.  Symptoms  of  peritonitis  or  intestinal  obstruction  may  occur  in 
traumatic  or  inflammatory  types  and  after  rupture.  The  author  saw 
a  case  in  which  the  picture  after  each  rupture  was  that  of  subacute 
tuberculous  peritonitis.  Rupture  into  the  bowel  is  followed  by  diarrhea 
and  disappearance  of  the  tumor. 

4.  Pain  like  that  of  cholelithiasis  may  be  present,  but  it  more  often 
radiates  to  the  left  side,  shoulder  and  neck.  Pressure  symptoms  include 
dyspnea,  vomiting,  icterus,  emaciation  and  polyuria. 

Differentiation  from  other  cysts  is  largely  a  topographical  question. 
Ovarian  cysts  have  their  pelvic  origin  and  connection,  but  hydronephrosis 
is  movable  and  originates  in  the  flank  to  which  pancreatic  cysts  seldom 
penetrate.  Fluid  in  the  lesser  peritoneal  sac  or  mesenteric,  omental 
and  retroperitoneal  cysts  are  difficult  to  distinguish.  Cysts  of  the  liver 
present  respiratory  excursion. 

Treatment. — Aspiration  is  never  permissible.  Enucleation  of  the  sac 
is  more  dangerous  than  simple  drainage.  Bessel-Hagen's  operative 
mortality  was  6.7  per  cent.    Diabetes  has  followed  operation. 

TUMORS  OF  THE  PANCREAS. 

Cancer  constitutes  67  per  cent,  of  all  pancreatic  diseases  but  con- 
fusion with  benign  induration  has  been  frequent  until  of  late  years. 
It  occurs  in  0.6  to  1  per  cent,  of  autopsies.  In  132  cases  of  pancreatic 
tumors  127  were  cancer,  2  sarcoma,  2  cysts  and  1  gumma  (Segre). 
Sarcoma  is  usually  secondary  from  contiguous  lymphosarcoma  in  the 
retroperitoneal  glands;  21  cases  are  reported. 

Cancer  is  usually  scirrhus,  less  often  medullary,  colloid  or  adenomatous. 
It  most  often  begins  in  the  head  of  the  organ.  In  some  cases  it  may  be 
secondary  to  pyloric  cancer. 

Symptoms. — (1)  Tumor  is  the  commonest  and  surest  symptom,  occur- 
ring in  25  to  50  per  cent. ;  it  lies  deep,  beside  the  spine  at  the  level  of  the 
navel  and  between  the  pylorus  and  colon.  It  is  tender  and  immobile; 
small  tumors  are  commonest;  in  some  instances  it  may  show  propagated 
pulsation  from  the  aorta  or  a  bruit  from  its  compression.  Palpation  should 
be  made  with  the  stomach  and  bowels  empty.  (2)  Icterus  occurs  in  72  per 
cent.,  increases  gradually  and  is  more  often  continuous  than  remittent. 
Occasionally,  just  before  death,  the  growing  anemia  seems  to  lessen  the 
jaundice.  Bard  arid  Pic  state  the  liver  is  usually  rather  small.  (3) 
The  gall-bladder  is  usually  enlarged  (perhaps  shrunken  when  the  hepatic 
or  cystic  duct  is  obstructed.)     (4)  Pain  and  early  vomiting  are  usual. 


606  DISEASES  OF   THE  PANCREAS 

The  pain  is  epigastric,  severe  and  sometimes  neuralgic  (neuritis  celiaca) 
or  radiating,  as  in  pancreatitis  or  lithiasis.  (5)  Cachexia  is  marked  and 
rapid;  great  prostration,  emaciation  and  a  syncopal  tendency  occur  as 
in  other  pancreatic  lesions.  The  temperature  is  subnormal.  (6)  The 
stools  may  contain  much  fat  (Kuntzmann,  1827,  and  Bright,  1833); 
in  steatorrhea  the  fatty  acids  and  neutral  fats  are  more  abundant  than 
the  fatty  soaps  (Miiller);  its  significance  grows  if  diarrhea  and  icterus 
are  not  present.  The  stools  also  contain  many  undigested  muscle  fibers 
(lientery)  and  sometimes  blood  is  present.  (7)  The  urine.  Mirallie 
encountered  glycosuria  in  26  per  cent.;  in  Robson's  15  cases  it  was 
absent.  It  is  said  to  be  an  early  symptom  and  to  disappear  with  the 
increasing  icterus.  Albuminuria  is  more  frequent.  The  indican  is 
decreased.  Peptone,  maltose  and  fat  have  been  found.  Polyuria  and 
bronzing  of  the, skin  are  rare  finding^.  Complications  include  compression 
of  the  aorta  or  cava;  retention  cysts  of  the  pancreas;  and  extension 
by  contiguity  to  the  portal  vein,  pylorUs,  bowel,  peritoneum,  ureter  or 
lungs. 

Differentiation. — 1.  Chronic  pancreatitis  with  icterus  and  tumor  may 
not  be  differentiated  even  by  laparotomy  (Riedel),  though  ascites 
indicates  neoplasm  and  recovery  means  inflammation. 

2.  Duodenal  cancer  above  the  papilla  causes  rather  the  picture  of 
pyloric  stenosis;  in  cancer  below  the  papilla  pancreatic  juice  may  be 
recovered  from  the  stomach. 

3.  Liver  disease,  with  the  frequent  icterus,  ascites  and  splenic  enlarge- 
ment, causes  little  difficulty  in  differentiation. 

4.  Calculus  in  the  Common  Duct. vs. — ■ — -Compression  of  Common  Duct  by 

Pancreatic  Tumor. 

1.  History  of  colic  usual.  Absent. 

2.  Tenderness  of  gall-bladder  usual.  Absent. 

3.  Icterus,  often  remittent.  Permanent. 

4.  Liver  less  large  than  in —  pancreatic  tumor. 

5.  Intermittent  fever,  and  rigors.  Subnormal  temperature. 

6.  Gall-bladder    (see   gall-stones)    shrunken  Dilated  in  92  per  cent.     (Courvoisier's  law). 

in  80  per  cent. 

7.  Slower  course.  Very  rapid  emaciation. 

According  to  Bard  and  Pic  the  icterus,  enlarged  gall-bladder,  rapid 
emaciation,  cachexia,  subnormal  temperature  and  normal  or  smaller 
liver  of  pancreatic  cancer  can  only  be  confused  with  some  few  cases 
of  gall-stones,  cancer  of  immediately  adjacent  parts,  primary  cancer 
of  the  liver  or  bile-passages  and  primary  duodenal  or  gastric  cancer 
with  early  diffuse  generalization  in  the  liver.  Kehr  states  that  chronic 
obstruction  of  the  common  duct  is  cancerous  in  70  per  cent.,  pancreatic 
in  20  per  cent,  and  calculous  in  10  per  cent. 

Treatment  is  largely  symptomatic;  morphine  should  be  given  for 
pain,  the  gall-bladder  should  be  drained  (cholecystotomy)  or  it  should  be 
sutured  to  the  intestine  (cholecystduodenostomy) .  Very  few  permanent 
recoveries  follow  extirpation. 


ACUTE  DIFFUSE  PERITONITIS  607 


DISEASES  OF  THE  PERITONEUM. 


ACUTE   DIFFUSE   PERITONITIS. 

Peritonitis  was  once  far  more  important  as  an  independent  affection 
than  at  present;  we  now  regard  it  as  chiefly  symptomatic  of  some  other 
disease,  e.  g.,  appendicitis,  salpingitis,  puerperal  sepsis,  etc. 

Etiology. — The  actual  cause  is  mycotic.  Some  writers  classify  peritonitis 
as  bacterial  (suppurative  forms),  chemical  (serous  and  serohemorrhagic 
forms)  and  mechanical  (adhesive  forms).  The  Streptococcus  pyogenes 
(puerperal  and  traumatic  forms)  and  Bacillus  coli  (forms  due  to  intestinal 
lesions)  are  the  two  most  frequent  organisms;  the  staphylococcus,  pneu- 
mococcus  and  tubercle  bacillus  are  frequent  and  less  often  the  Bacillus 
pyocyaneus,  proteus,  anthracis,  typhosus,  aerogenes  encapsulatus,  the 
ray  fungus,  gonococcus,  Ameba  coli,  etc.  Generally  speaking,  mono- 
infections are  less  common  than  mixed  infections. 

Factors  lessening  physiological  resistance  include  nephritis  (in  10  per 
cent.),  alcoholism,  cardiac  disease,  etc.;  in  other  words  peritonitis  may 
be  a  terminal  infection,  fatal  to  reduced  subjects. 

Atrium. — Compared  with  pleurisy  and  pericarditis,  peritonitis  is 
seldom  primary.  Though  it  may  follow  inflammation  of  every  abdominal 
viscus,  it  is  most  commonly  a  secondary  manifestation  of  intestinal 
disease  (e.  g.,  appendicitis)  or  of  pelvic  disease  in  women,  (a)  Infection 
through  the  alimentary  tract;  appendicitis,  bowel  ulceration  (typhoid, 
carcinomatous,  tuberculous),  bowel  obstruction,  perforation,  traumatism 
and  infarction  may  cause  it.  Gastric  are  less  frequent  than  intestinal 
lesions  and  ulcer  and  cancer  rank  first.  (6)  The  female  genitalia;  it  may 
result  from  gonorrhea  (Nogerrath),  extra-uterine  pregnancy,  puerperal 
infections  and  septic  abortion;  peritoneal  infection  from  diseases  of  the 
male  genitalia  is  rare,  (c)  Liver  and  bile  vessels;  local  or  general  peritonitis 
may  result;  peritonitis  is  more  common  as  a  result  of  hepatic  abscess 
and  syphilis  than  of  echinococcus,  cancer,  pylephlebitis  or  cholecystitis. 
(d)  Pancreas;  acute  pancreatitis,  (e)  Kidney  and  bladder;  pj'onephrosis, 
calculi  or  ulcerations  of  the  bladder.  (/)  Rarer  causes  are  splenic  affec- 
tions, retroperitoneal  adenopathies,  spinal  or  costal  caries,  lesions  of  the 
thoracic  duct  or  the  abdominal  parietes  or  extension  through  the  dia- 
phragm, (g)  Metastatic  peritonitis  is  not  common,  though  observed 
in  septicopyemia  and  acute  infections,  (h)  In  children  fetal  peritonitis 
has  been  observed  by  transplacental  infection;  in  the  newborn  the 
umbilical  vein  may  convey  infection,  though  peritonitis  occurs  in  but 
8  per  cent,  of  fatal  cord  infections.  It  occurs  more  commonly  through 
the  lymph  vessels  of  the  cord. 

Age  and  Sex. — Most  cases  occur  between  the  ages  of  fifteen  and 
forty  and  women  are  more  often  affected  than  men. 

Symptoms. — 1.  Local  or  Abdominal. — (a)  Pain,  the  usual  initial 
symptom,  is  almost  invariable,  is  continuous,  begins  near  the  navel  and 
remains  greatest  there;  a  causal  gastric  ulcer  may  produce  pain  in  the 
back,  salpingitis  is  attended  with  early  pelvic  pain  and  appendicitis 


608  DISEASES  OF   THE  PERITONEUM 

has  its  own  initial  localization,  but  the  pain  of  diffuse  peritonitis  is  felt 
at  or  below  the  navel,  (b)  Tenderness  accompanies  pain  and  is  deep 
rather  than  superficial;  they  are  very  rarely  absent  and  are  inflammatory; 
at  the  operation  or  autopsy  the  visceral  and  parietal  investments  are 
reddened,  lustreless,  covered  with  a  thin  film  of  fibrinous  exudate  which 
binds  the  intestinal  coils  together;  not  infrequently  the  peritoneum  is 
dotted  with  minute  petechise.  (c)  The  attitude  is  characteristic;  the  head 
is  lifted  and  the  knees  are  drawn  up  to  relieve  tension  or  to  keep  the 
bedclothes  from  contact  with  the  abdomen,  (d)  Vomiting  is  reflex;  it 
occurs  early  and  greatly  aggravates  the  pain;  the  vomitus  contains  food 
and  later  bile;  it  may  be  green  (vomitus  herbaceus),  rarely  dark  brown  or 
fecal.  It  is  accompanied  by  redness  and  dryness  of  the  tongue,  great 
thirst  and  singultus  which  is  a  sensory  phrenic  symptom ;  before  the  fatal 
issue  vomiting  and  singultus  cease,  (e)  The  abdomen  is  at  first  tense, 
retracted  and  scaphoid,  but  later  becomes  tympanitic  from  paresis  of  the 
inflamed  intestinal  coils  (Stokes)  and  decomposition  of  their  contents; 
the  diaphragm  stands  high  and  its  movement  is  restricted;  in  some, 
especially  muscular  subjects,  the  abdomen  may  be  retracted  throughout 
the  course.  Percussion  may  elicit  dulness,  usually  due  to  serous,  sero- 
purulent  or  perhaps  serohemorrhagic  exudation,  which  may  be  effused 
in  small  pockets  between  fresh  adhesions  or  may  fill  the  entire  cavity, 
amounting  to  even  30  or  40  quarts  and  sometimes  fluctuating  to  the  hand ; 
as  a  rule  a  tympanitic  note  prevails;  in  some  cases  dulness  suggests  the 
presence  of  fluid  which,  however,  is  not  found  on  exploration;  because 
of  adhesions,  the  fluid  changes  little  on  change  of  posture.  On  ausculta- 
tion a  friction-rub  is  sometimes  heard  (Beatty  and  Bright),  chiefly  over 
the  liver.  (/)  Constipation  results  from  inflammatory  infiltration  of  the 
intestine  (Stokes);  in  the  puerperal  streptococcic  and  in  pneumococcic 
peritonitides,  diarrhea  is  common. 

2.  General  Symptoms. — (a)  Shock  is  a  conspicuous  symptom.  Col- 
lapse may  occur  early  and  directly  from  perforation  or  later  from  toxemia. 
The  pidse  is  frequent,  hard,  wiry  and  about  120;  later  it  becomes  thready 
and  runs  to  140  or  170.  The  fades  Hippocratica  is  pronounced,  with 
its  anxious  expression,  wrinkled,  clammy,  cyanotic,  lead-colored  skin, 
pointed  nose,  hollowed  temples  and  sunken  eyes.  The  voice  whispers 
{vox  cholerica)  to  avoid  movement  of  the  diaphragm  and  the  breathing 
is  costal,  shallow,  difficult  and  rapid.  (6)  Fever  is  usually  present.  It 
may  rise  abruptly  with  a  chill  at  the  onset  but  follows  no  set  type;  it 
may  be  continuous  or  remittent  and  is  usually  found  by  rectum,  even 
during  collapse.  The  fever  and  pulse  curves  may  run  parallel  in  peritonitis 
with  a  slow  course.  (<?)  The  lungs  and  heart  are  crowded  upward  by  the 
abdominal  distention.  The  apex-beat  is  high  and  further  to  the  left  as 
the  heart  lies  more  horizontally,  (d)  The  urine  is  scant  from  lessened 
absorption  and  from  cardiac  weakness;  albuminuria  is  frequent;  indican- 
uria  is  constant  from  increased  putrefaction  in  the  paretic  bowel ;  dysuria 
is  usual;  tenesmus  is  less  common  than  retention. 

Course. — The  issue  is  fatal  within  two  days  in  the  rapidly  fatal  toxemic 
form  in  which  there  is  only  roughening  of  the  peritoneum  without  exuda- 
tion; the  slower  cases  rarely  last  more  than  five  days.     Consciousness 


ACUTE  DIFFUSE   PERITONITIS  609 

is  usually  preserved  to  the  end,  though  stupor  or  delirium  occasionally 
intervenes;  the  pulse  becomes  thready,  the  breathing  shallow  and  sighing, 
the  superficial  temperature  is  low  and  the  patient  succumbs  to  toxemic 
cardiac  failure.  In  exceptional  cases  death  occurs  within  a  few  hours 
or  relative  recovery  results  with  encapsulation  of  pus.  Treves  found 
inhalation  pneumonia  in  17  per  cent,  of  his  cases  and  Tilger  found  serous 
pleurisy  in  25  per  cent.;  of  the  latter,  63.3  per  cent,  were  right-sided, 
3.3  per  cent,  left-sided  and  33.3  per  cent,  bilateral. 

Types. — (a)  Peritonitis  serosa  usually  follows  the  fibrinous  form; 
the  fluid  is  yellow  or  light  green,  its  specific  gravity  is  1.015  or  more, 
it  contains  2  or  3  per  cent,  of  albumin  and  flocculi  of  fibrin,  epithelial 
cells,  red  cells  and  leukocytes.  (6)  P.  imndenta  may  occur  in  pockets 
or  as  a  massive  pyoperitoneum,  amounting  to  30  or  40  quarts,  (c) 
P.  putrida  occurs  in  septicopyemia  and  puerperal  fever,  but  especially 
in  perforating  carcinoma;  fetid  peritonitis  may  occur  without  perfora- 
tion, (d)  P.  perforatim  is  characterized  by  two  groups  of  symptoms, 
(i)  those  of  peritonitis  and  (ii)  those  of  gas  in  the  peritoneal  sac  (pneumo- 
peritoneum, pneumatosis  peritonei);  there  is  often  the  initial  subjective 
sense  of  perforation,  sudden  pain,  collapse  and  retracted  abdomen;  in 
four  to  twelve  hours  diffuse  peritonitis  sets  in;  free  gas  may  obliterate 
the  dulness  of  the  liver  and  spleen,  though  this  also  results  from  great 
tympanites  without  perforation;  the  liver  dulness  may  be  found  only 
in  the  posterior  axilla,  but  when  the  patient  is  turned  on  his  left  side  the 
free  gas  entirely  obscures  it;  the  abdominal  contents  may  be  putrid  or 
fecal;  when  due  to  perforating  gastric  ulcer  there  is  seldom  any  odor. 
The  diaphragm  is  pushed  to  its  highest  possible  level;  a  succusion  splash 
may  be  elicited  and  the  intestines  may  be  compressed  against  the  spine. 
Gas  may  develop  through  the  action  of  the  Bacillus  pyogenes  fetidus 
and  B.  aerogenes  encapsulatus,  but  pneumoperitonitis  without  perfora- 
tion is  rare,  (e)  P.  puerperalis,  usually  streptococcic,  is  described  on 
page  22;  it  is  characterized  by  moderate  pain,  enormous  tympanites, 
diarrhea  and  the  usual  septic  manifestations.  (/)  P.  pneumococcica; 
Barling  (1912)  collected  234  cases;  73  per  cent,  occur  in  young  girls. 
There  are  three  types :  (i)  the  very  acute  form,  in  which  the  lower  abdomen 
is  especially  involved,  often  simulating  appendicitis,  with  abrupt  onset, 
severe  pain,  high  fever,  vomiting  and  early,  continuous,  fetid  diarrhea; 
one-half  of  the  cases  die.  (ii)  With  the  above  symptoms  or  perhaps 
pneumococcic  involvement  of  the  joints,  ear,  meninges,  etc.,  there  are 
signs  of  pneumonia  and  peritonitis;  most  patients  die.  (iii)  The  last  type 
is  more  subacute,  uniting  symptoms  of  sepsis  with  those  of  pneumonia 
and  peritonitis;  nearly  all  of  this  form  die.  The  mortality  of  all  types 
is  80  per  cent.  The  process  is  diffuse  and  fibrinopurulent;  operation  is 
indicated  later.  It  often  points  at  the  navel,  through  which  a  creamy, 
greenish  pus  may  rupture.  Sometimes  it  ends  by  crisis;  an  encysted 
pus  sac  often  remains.  The  pneumococcus  may  be  found  in  the  blood. 
{g)  The  streptococcic,  colon  and  staphylococcic  peritonitides  are  described 
under  Appendicitis. 

Diagnosis. — Peritonitis  is  usually  diagnosticated  with  ease  from  the 
cause  (appendicular,  salpingitic,  gastric  ulcer,  septic  abortion),  by  the 
39 


610  DISEASES  OF   THE  PERITONEUM 

febrile  onset,  pain,  tenderness,  vomiting,  distention,  effusion  and  collapse. 
Aspiration  is  dangerous.  In  certain  cases  only  the  fact  of  peritonitis 
can  be  established,  perhaps  even  at  operation. 

Differentiation  is  necessary  from  (a)  intestinal  obstruction  {q.  v.); 
(b)  biliary  or  renal  colic;  (c)  acute  pancreatitis  {q.  v.);  (d)  ruptured  tubal 
pregnancy,  in  which  the  menstrual  history,  pelvic  localization,  acute 
anemia  and  shock  are  present;  (e)  ruptured  abdominal  aneurysm;  or 
infarction  of  the  superior  mesenteric  artery  in  which  a  cause  for  embolism, 
acute  obstruction  and  bloody  vomiting  or  diarrhea  with  later  peritonitis 
are  often  distinctive;  (/)  acute  enterocolitis,  which  is  attended  by  less 
pain  and  tenderness  and  by  more  diarrheal  colic,  tenesmus  and  collapse; 
(gf)  hysteria  (g.  v.),  which  may  simulate  peritonitis,  as  it  may  resemble 
every  other  disease;  if  its  presence  is  once  suspected  the  other  stigmata 
are  usually  definitive.  Qi)  The  referred  abdominal  pain  of  thoracic 
disease  (pleurisy  and  pneumonia)  is  very  seldom  accompanied  by  tender- 
ness, and  is  distinguished  by  examination  of  the  chest,  especially  of  its 
posterior  parts,  {i)  Mild  infections  with  much  exudation  may  simulate 
ascites  (q.  v.). 

Treatment. — Surgical  treatment  alone  is  efficacious.  In  older  statistics 
the  percentage  of  recoveries  was  small  (Krogius,  680  cases,  28  per  cent.). 
At  present,  90  per  cent,  recover  under  drainage,  semi-erect  posture  and 
continuous  enemata  of  normal  salt  solution  at  low  pressure. 

Palliative  treatment  is  of  little  value,  (a)  Opium  controls  pain;  the 
doses  recommended  by  Alonzo  Clark  (over  1000  grains  in  one  week!)  are 
now  only  of  historical  interest.  Morphine,  given  hypodermically,  pro- 
duces the  best  results,  (b)  The  patient  should  have  absolute  rest,  (c)  Tait's 
saline  purgation  to  increase  osmosis  is  productive  of  more  harm  than  good. 
(d)  Vomiting  is  treated  as  in  acute  gastritis;  the  stomach  should  be 
washed  out;  all  medication,  food  and  water  by  mouth  should  be  withheld 
and  given  only  by  rectum,  (e)  Tympanites  should  be  treated  by  the 
turpentine  stupe  and  by  enemata  containing  emulsum  asafetidse  5iij, 
spts.  chloroformi  5j  and  ol.  terebinthinse  5ss. 

CHRONIC   DIFFUSE   PERITONITIS. 

Aside  from  tuberculous  peritonitis,  chronic  diffuse  peritonitis  is  uncom- 
mon, (a)  The  serous  or  serohemorrhagic  form  will  be  considered  under 
ascites;  (6)  the  diffuse  adhesive  form  results  from  acute  and  tuberculous 
peritonitis;  the  peritoneal  sac  is  obliterated  and  at  operation  or  necropsy 
the  knife  cuts  directly  into  the  intestine,  (c)  Chronic  proliferative 
peritonitis  may  occur  in  peritoneal  cancer  or  tuberculosis,  chronic  alco- 
holism, cirrhosis  of  the  liver  or  cardiac  disease.  It  may  develop  with  or 
without  adhesions,  as  a  diffuse  sclerosis  of  the  peritoneum  and  as  a  sub- 
peritoneal proliferation.  Its  extreme  form  was  described  by  Virchow 
(1885)  as  peritonitis  deformans.  The  peritoneum  is  white,  lustreless  and 
diffusely  thickened,  though  in  some  places  more  than  in  others.  The 
omentum  is  retracted  upward,  so  that  it  lies  as  a  hard,  transverse  roll 
above  the  navel;  the  mesentery  is  indurated  (mesenteritis  retrahens), 
as  described  under  Tuberculous  Peritonitis  and  as  it  retracts  it  may 


LOCALIZED  PERITONITIS  611 

gather  the  intestinal  coils  into  a  ball  the  size  of  a  child's  head,  lying  cen- 
trally or  to  the  right  of  the  median  line.  Here  and  there  may  be  found 
multilocular  serous  encapsulations  or  palpable  tumor-like  thickenings. 
The  spleen,  liver,  stomach,  cecum  or  colon  may  be  particularly  indurated. 
In  some  cases  it  is  but  part  of  a  multiple  serositis  (polyserositis,  polyor- 
rhomenitis),  invading  also  the  pleura  and  pericardium.  Miliary  fibromata 
resembling  miliary  carcinosis  or  miliary  tuberculosis,  may  sometimes  form 
around  parasitic  ova  or  cholesterin  crystals. 


LOCAUZED  PERITONITIS. 

I.  Suppurative  Forms. — 1.  Subphrenic  Abscess  and  Pyopneumothorax 
Subphrenicus." — First  diagnosticated  by  Barlow  (1845)  and  especially 
described  by  Leyden  (1879),  Piquand  collected  890  cases  (1909),  upon 
which  the  following  figures  are  based: 

Etiology.- — (a)  Gastric  ulcer  and  cancer  accounted  for  251  cases,  (b) 
Afyendicitis  caused  191  cases;  (c)  trauma;  (d)  intestinal  idceration  (duo- 
denum 36  cases  and  the  rest  of  the  intestine  20  cases);  (e)  cholangitis 
and  cholecystitis  (66  cases);  liver  disease  (echinococcus,  abscess)  70  cases; 
(/)  splenic  disease  (40  cases);  (g)  renal  disease  (28  cases);  (h)  thoracic 
disease  (32  cases);  (i)  pancreatic  disease  (27  cases),  tuberculosis  (23  cases), 
female  genitalia  (17  cases),  trauma  (20  cases)  and  unknown  causes 
(69  cases). 

Symptoms. — Pus  is  ensacculated  beneath  the  diaphragm  (pyothorax 
subphrenicus),  associated  in  over  25  per  cent,  with  gas  formation  (pyo- 
pneumothorax subphrenicus).  The  subphrenic  abscess  is  right-sided  in 
59  per  cent.,  left-sided  in  38  and  bilateral  in  3  per  cent.,  is  limited  by 
the  suspensory  ligament  of  the  liver  and  may  be  intra-  or  extraperitoneal; 
in  the  latter  instance  the  abscess  is  most  often  appendicular  or  peri- 
nephric and  lies  well  back  in  the  abdomen.  Simple  pus  formation  is  often 
difficult  to  localize;  the  symptoms  are  those  of  sepsis,  with  pain,  tenderness 
or  dulness  on  the  liver  convexity,  which  suggest  liver  abscess.  The 
retroperitoneal  forms  give  most  dulness  posteriorly,  and  intraperitoneal 
forms  chiefly  anteriorly;  edema  of  the  chest  wall  may  occur  without 
suppuration;  the  a;-rays  may  produce  a  subphrenic  shadow. 

In  pyopneumothorax  subphrenicus  there  are  signs  "  of  a  cavity  beneath 
the  diaphragm,  filled  with  gas  and  pus,  pushing  the  diaphragm  upward 
and  simulating  pyopneumothorax"  (Leyden).  (a)  Tympany  and  absence 
of  vesicular  murmur  and  of  vocal  fremitus  are  found  from  the  third  rib 
downward,  above  which  is  the  compressed  lung  and  below  which  is  {b) 
the  dulness  of  the  liver  whose  exposed  surface  and  edge,  dislocated  down- 
ward, are  easily  percussed  and  palpated.  Sometimes  the  tympany 
entirely  covers  the  liver  dulness.  As  in  pneumothorax  (c)  succussion 
and,  on  change  of  posture,  the  clearly  shifting  line  of  dulness  may  be 
elicited,  (d)  Puncture  evacuates  gas  and  putrid  pus;  sometimes  on  a 
higher  puncture  serum  is  found  in  the  pleura,  for  pleurisy  develops  in 
66  per  cent,  of  the  cases.  The  needle  ascends  during  inspiration  and 
descends  during  expiration,  which  is  the  converse  of  the  findings  in  pleural 


612  DISEASES  OF   THE  PERITONEUM 

exudation  (Fiirbringer) .  If  a  manometer  is  attached  to  the  exploring 
needle,  a  rise  in  the  indicating  column  during  inspiration  and  a  fall  during 
expiration  denote  a  subphrenic  lesion  (Pfuhl).  (e)  The  x-rays  may 
show  a  shadow  between  the  diaphragm  and  the  liver  and  no  respiratory 
excursion.  (/)  Perforation  into  the  lungs  occurs  in  16  per  cent,  (more 
often  in  extra-  than  in  intraperitoneal  forms),  into  the  pleura  in  19  per 
cent,  and  into  the  pericardium  in  1  per  cent.  At  the  beginning  and  until 
perforation  there  is  generally  an  entire  absence  of  thoracic  symptoms, 
as  cough  or  sputum;  this  is  of  value  in  differentiation  from  true  pyo- 
pneumothorax, (g)  The  history  of  the  subphrenic  pyopneumothorax  is 
usually  that  of  some  abdominal  lesion  (v.  Etiology). 

Treatment  is  surgical.  Without  operation  the  mortality  is  over  90 
per  cent.;  with  operation  30  per  cent. 

2.  Suppuration  in  the  Lesser  Peritoneum. — This  may  result  from  gastric 
or  duodenal  ulceration,  acute  pancreatitis,  etc.  Closure  of  the  foramen 
of  Winslow  confines  the  pus;  a  tumor  appears  in  the  epigastric,  umbilical 
or  left  hypochondriac  region,  with  relations  like  those  of  pancreatic 
cyst;  variability  in  size  occurs  when  the  stomach  is  filled  with  gas  and 
fluid.  When  gas  and  pus  coexist  the  diaphragm  and  liver  are  pushed 
upward.    Treatment  is  surgical. 

3.  Other  Forms. — The  appendicular  abscess  has  been  described.  The 
pelvic  abscess  occurs  especially  from  tubal,  but  also  from  uterine  and 
ovarian  inflammation;  it  follows  abortion,  puerperal  fever,  gonorrhea, 
tuberculous  and  pneumococcic  peritonitis  in  young  girls.  Other  types 
are  suppuration  around  the  gall-bladder,  colon  and  sigmoid  and  in  other 
rare  localizations. 

II.  Adhesive  or  Indurative  Forms. — Local  thickening  or  adhesions 
may  occur  over  any  viscus,  especially  over  the  spleen,  next  the  liver  and 
less  commonly  the  intestines,  which  may  become  strangulated. 

Perisplenitis  is  most  common  over  chronic  malarial,  leukemic  and 
pseudoleukemic  enlargements  of  the  spleen. 

Perihepatitis  may  cover  small  areas  of  the  liver  like  soldier's  spots 
in  the  pericardium  or  may  engross  its  entire  surface,  as  described  by  Budd 
(1852)  and  Curschmann  (1884),  who  caUed  it  the  "icing  liver"  {Zucker- 
gussleber).  It  is  frequently  associated  with  deforming  proliferative 
peritonitis.  Nichols  describes  it  as  a  hyaline  degeneration,  hyaloserositis. 
There  are  three  groups  of  cases:  (a)  multiple  serositis  (polyorrhomenitis, 
Concato's  disease);  this  borders  closely  on  Pick's  " pseudocirrhosis  peri- 
carditica."  (b)  Arteriosclerosis  and  interstitial  nephritis  occurred  in  86 
per  cent,  in  Hale  White's  series,  (c)  Rarer  factors  are  syphilis,  tuber- 
culosis, malignancy  and  alcoholism  (page  616). 

in.  Chronic  Hemorrhagic  Peritonitis. — This  rare  disease  was  de- 
scribed first  by  Virchow,  who  likened  it  to  pachymeningitis  hemor- 
rhagica. It  occurs  chiefly  in  the  pelvis  and  is  most  often  circumscribed. 
Pachyperitonitis  is  characterized  by  hemorrhagic  inflammation;  from 
the  laminse  of  the  resulting  fresh  connective  tissue,  deposited  layer  by 
layer,  repeated  fresh  hemorrhages  arise. 


ASCITES  613 


CARCINOMA    OF    THE    PERITONEUM. 

Primary  endotheliomata  are  very  rare. 

Cancer  is  most  frequently  secondary  to  cancer  of  the  stomach,  ovaries, 
intestines,  pancreas  and  Hver.  Histologically  it  is  that  of  the  primary 
growth.  Its  gross  forms  are  (a)  miliary  carcinosis,  resembling  miliary 
tubercles;  (6)  vegetative;  (c)  ulcerative;  (d)  cystic  and  (e)  infiltrative.  The 
primary  tiunor  may  be  latent  clinically,  so  that  the  peritoneal  compli- 
cation is  apparently  primary.  The  secondary  growths  spread  by  contact, 
the  lymphatics  and  implantation  of  free  particles.  They  may  be  felt 
in  the  omentum,  mesentery  and  Douglas's  cul-de-sac.  The  diagnosis  is 
reached  by  the  symptoms  and  signs  of  the  initial  growth  or  by  those  of 
an  ascites,  which  is  serous,  hemorrhagic,  pseudochylous  or  adipose; 
its  progress  is  rapid  and  attended  by  cachexia.  Groups  of  cancer  cells 
may  be  found  in  the  aspirated  fluid  and  secondary  cancer  may  develop 
at  the  point  of  puncture  (page  616).  In  Hodenpyl's  remarkable  case, 
which  recovered,  the  ascitic  fluid  exerted  a  curative  action  when  injected 
into  animals  with  cancer. 

ASCITES. 

Hydroperitoneum  is  a  symptom  of  A'arious  diseases. 

Etiology.- — (a)  Stasis  explains  most  of  the  cases;  the  chief  varieties  are 
cardiac  lesions  (40  per  cent.),  pulmonary,  mediastinal  or  pleural  disease 
and  jjortal  stasis  (10  per  cent.),  due  to  disease  of  the  liver  or  portal  vein. 
Stasis  causes  increased  pressure  in  the  portal  system,  fohowed  by  mal- 
nutrition of  the  vessels  and  pouring  out  of  serum,  (b)  Hydremia  or 
cachexia  causes  malnutrition  and  increased  permeability  of  the  vessel 
walls;  it  occurs  in  amyloidosis,  chronic  nephritis  (10  per  cent.);  marantic 
conditions,  profound  anemias  and  occasionally  in  acute  infections,  (c) 
Inflammation,  as  simple,  tuberculous  (10  per  cent.),  suppurative  or  can- 
cerous peritonitis  (20  per  cent.),  (d)  Abdominal  tumors,  leukemic  spleen, 
etc.  INIore  than  one  factor  may  operate;  tuberculous  peritonitis  may 
complicate  liver  cirrhosis  or  ascites  may  be  due  to  the  hydremia  of 
nephritis,  accentuated  by  weakness  of  the  heart  {v.  i.  Etiological 
Diagnosis). 

Symptoms. — 1.  Ixspectiox. — A  symmetrical  enlargement  of  the  abdo- 
men in  the  average  case  presents  rather  more  lateral  than  anterior 
bulging.  The  abdomen  resembles  that  of  a  batrachian  {ventre  de  batracien) . 
The  skin  is  pale,  tense,  striated,  edematous;  the  pouting  navel  and  dias- 
tasis of  the  recti  muscles  are  noted.  A  caput  Medusce  may  be  noted  in 
cirrhosis  cases.  Dilated  veins  over  the  ribs  and  upper  abdomen  indicate 
compression  of  the  cava  inferior.  Sometimes  the  heart  imparts  systolic 
waves  to  the  fluid. 

2.  Palpation. — Fluctuation  {ballottement) ,  due  to  the  transmission 
of  a  fluid  wave  from  side  to  side,  is  usually  present  but  may  be  absent 
])ecause  of  tense  abdominal  walls  or  great  accumulation  of  fluid.    Pseudo- 


614  DISEASES  OF  THE  PERITONEUM 

fluctuation  may  be  caused  by  accumulation  of  fluid  other  than  ascitic, 
as  intestinal  contents,  or  by  lax,  obese  abdominal  walls;  in  the  latter 
condition  a  third  hand  placed  in  the  median  line  of  the  abdomen  will 
break  the  deceptive  wave,  due  to  parietal  vibration.  In  women  the  water- 
pillow  fluctuation  of  Landau  may  be  elicited  by  vaginal  examination  and 
the  uterus  seems  remarkably  movable.  Thrusting  palpation  may  disclose 
the  outline  of  the  liver,  spleen  or  possibly  some  neoplasm  even  through 
the  abundant  fluid  (placing  the  fingers  vertically  on  the  abdomen  and 
suddenly  thrusting  them  inward,  thus  anticipating  any  muscular  rigidity 
and  pushing  aside  the  ascitic  fluid). 

3.  Percussion. — A  pint  to  a  quart  of  fluid  must  be  present  for  clinical 
detection.  With  small  effusions  the  patient  should  be  examined  in  the 
genupectoral  position.  Elevation  of  the  buttocks  directs  the  scanty  fluid 
to  the  flanks  where  it  is  more  easily  demonstrable.  Classically,  the  fluid 
in  dependent  parts  gives  dulness  and  the  supernatant  intestines  are  located 
by  tympany  in  the  highest  parts  of  the  abdomen.  These  areas  vary  with 
change  of  position.  This  rule  is  void  when  the  mesentery  is  retracted 
and  does  not  allow  the  gut  to  float;  adhesions  between  the  intestinal 
loops  prevent  shifting  of  the  fluid;  when  the  gut  is  adherent  there  is  per- 
manent tympany  in  that  location.  Light  percussion  is  employed,  because 
heavy  tapping  elicits  tympany  from  the  more  deeply  situated  intestine. 
The  author  withdrew  two  gallons  of  ascitic  fluid  from  a  patient  in  whom 
no  dulness  could  be  elicited  in  any  position. 

Diagnosis. — Fecal  accumulations  cause  dulness  in  either  flank,  simu- 
lating fluid,  but  its  immobility  and  the  use  of  enemata  preclude  error. 
Kiissner  published  a  case  in  which  fluid  in  the  intestines  was  mistaken 
for  ascites.  Leube  confused  ascites  with  an  enormously  dilated  stomach 
and  John  Hunter  thrust  a  trocar  into  a  dilated  bladder.  Hydronephrosis, 
hydatid  cyst,  pregnancy  and  tympanites  are  frequently  sources  of  error. 
Rostan  (1837)  noted  that  tympany  might  be  absent  in  ascites  when 
the  intestines  contained  little  or  no  gas,  a  point  sometimes  forgotten 
in  differentiation  between  ascites  and  ovarian  cyst;  the  latter  may  thrust 
itself  in  between  the  coils  of  gut  and  simulate  ascites;  ovarian  cyst  usually 
produces  a  central  flatness  with  tympany  in  the  flanks,  and  neither  the 
dulness  nor  tympany  shifts  with  change  of  posture.  Adami  collected 
42  cases  of  fibrolipoma  and  myxolipoma  in  which  ascites  was  closely 
simulated. 

Etiological  Diagnosis. — 1.  Stasis. — In  cardiac  disease  the  dyspnea 
develops  early;  dyspnea  caused  by  ascites  pressing  upward  on  the  dia- 
phragm is  a  late  symptom.  Swelling  of  the  feet  usually  antedates  the 
ascites,  though  pericarditis  and  valvular  disease  may  produce  ascites 
without  anasarca.  The  liver  is  peculiarly  an  etiological  factor  in  ascites 
(see  page  587).  Portal  ascites  commences  in  the  peritoneum;  the  legs 
swell  secondarily  from  pressure  on  the  cava  inferior  or  from  cardiac 
weakness  due  to  great  ascites  (see  page  616). 

2.  Hydremia.  (Cachexia,  Increased  Vascular  Permeability.) — In 
renal  disease  the  eyelids  often  become  edematous  before  other  symptoms 
develop  and  the  nephritic  ascites  is  seldom  great  unless  the  liver  and 
heart  are  involved.     Cachectic  ascites  is  not  uncommon  in  leukemia 


ASCITES  615 

and  kindred  affections  and  in  acute  infectious  diseases  in  children;  the 
author  has  seen  three  instances  of  ascites  in  typhoid  convalescence. 

3.  Peritonitis. — ^The  specific  gravity  and  the  percentage  of  albumin 
in  the  fluid  are  important  factors  in  differentiating  between  exudate 
and  transudate.  Three  divisions  are  distinguished :  (a)  A  specific  gravity 
of  1.010  or  lower  indicates  a  cachectic  transudate,  e.  g.,  in  nephritis,  with 
less  than  1  per  cent,  albumin.  A  very  low  specific  gravity  and  percentage 
of  albumin  occur  in  amyloidosis,  (b)  A  hypostatic  transudate  has  a  specific 
gravity  which  ranges  between  1,010  and  1.014  and  has  between  1  and  3 
per  cent,  of  albumin,  (c)  An  exudate  has  a  specific  gravity  of  more  than 
1.015  (or  1.018)  and  the  albumin  reaches  4  to  6  per  cent.  The  lower 
strata  are  heavier  and  the  specific  gravity  should  be  measured  several 
times  during  the  paracentesis.  Less  than  1  per  cent,  of  albumin  excludes 
disease  of  the  peritoneum  or  portal  vein.  Reuss's  formula  computes 
the  albumin  percentage  from  the  specific  gravity — the  percentage  of 
albumin  =  f  (specific  gravity  minus  1000)  minus  2.8.  Ascites  due  to 
a  carcinoma  in  the  liver  substance  has  a  low  specific  gravity  and  albumin 
is  present  to  1  or  2  per  cent.;  if  carcinomatous  peritonitis  develops,  the 
specific  gravity  and  percentage  of  albumin  increase.  An  ascites  due  to 
nephritis  has  a  low  specific  gravity  but  the  figures  rise  when  stasis  due 
to  weak  heart  or  intercurrent  inflammation  develops.  In  simple  transu- 
dation (ascites  and  hydrothorax),  the  characters  of  an  exudate  may 
develop,  due  to  the  long-continued  irritation  of  the  serosa. 

Ascitic  fluid  contains  the  constituents  of  the  blood — albumin,  globulin, 
urea,  uric  acid,  sugar,  etc.  (a)  Ascitic  fluid  due  to  stasis  is  clear  yellow 
or  yellowish-green,  opalescent  and  alkaline  and  microscopically  contains 
some  lymph  cells,  erythrocytes  and  peritoneal  endothelium.  (6)  Exudates 
show  a  microscopic  picture  varying  with  the  cause;  fibrin  threads,  pus, 
blood,  adipose,  chylous  or  chyliform  fiuid,  intestinal  contents,  cancer 
cells,  tubercle  bacilli,  diplococci  or  pyogenic  organisms,  may  be  found. 
In  exudates  are  found  the  polymorphonuclear  leukocytes  and  some 
erythrocytes;  lymphocytes  and  red  cells  are  detected  in  tuberculous 
exudates  (see  page  460);  the  fluid  must  be  examined  at  once.  Rieder 
and  Dock  describe  cells  in  carcinomatous  peritonitis  in  which  asym- 
metrical karyokinetic  figures  appeared.  Quincke  states  that  red  disks, 
lymph  cells  and  peritoneal  endothelium  are  found  in  every  ascites. 
'  Primavera  found  that  a  drop  of  glacial  acetic  acid  will  leave  a  white 
cloud  as  it  falls  to  the  bottom  of  a  vessel  containing  an  exudate,  while 
its  addition  to  transudates  gives  no  reaction. 

"Essential"  ascites  is  usually  tuberculous  peritonitis. 

4.  Tumors. — Tumors,  as  uterine  fibromata  may  produce  hydro- 
peritoneum.  Very  small  uterine  myofibromata  may  excite  considerable 
peritoneal  effusion.  There  is  a  direct  relation  between  the  malignancy  of 
the  tumor  and  the  amount  of  the  fluid  found.  Ascites  is  infrequent  in 
uterine  tumors  but  when  observed  is  most  common  in  adenomyoma 
(Freund).  It  is  more  often  seen  in  papillomatous  cysts,  whose  walls 
rupture  by  fatty  degeneration  and  pour  out  their  contents  into  the 
abdominal  cavity;  serum  is  secreted  by  the  peritoneal  surface  because 
of  the  irritation,  even  though  the  ruptured  cyst  be  very  small  (Quenu). 


616 


DISEASES  OF  THE  PERITONEUM 


The  fluid  in  cysts  contains  more  solids  (50  to  60  pro  mille)  than  does 
the  ascites  of  renal  disease  (25  pro  mille,  Mehu).  Ascites  is  most  often 
observed  in  solid  ovarian  tumors. 


' '  Zuckergussleber ; ' ' 

Atrophic     cirrhosis  Chronic     tuberculous 

Carcinoma  of 

chronic   perihepatitis. 

of  liver. 

peritonitis. 

peritoneum. 

Age. 

Occurs    about    mid- 

Oftenest       about 

Between  ages  of  20 

Late  in  life. 

dle  life  or  later. 

middle  life. 

and  40. 

Sex. 

Both    sexes    equally 

More  frequent  in 

In  females. 

More      fl-equent      in 

liable. 

males. 

females. 

Previous 

Often    a    history    of 

History    of    alco-  \  Often     a     chronic 

In  some  cases  a  his- 

History. 

acute     pericarditis 

hoHsm,    syphilis  ,     cough,  diarrhea,  or 

tory    of    cancer    of 

or    perihepatitis. 

or  digestive  dis-  <     genital    tuberculo- 

stomach,      ovaries. 

turbances.              1     sis.       Often     with 

etc. 

j     pleurisy  (polysero- 

1     sitis). 

Alcoholism. 

No  influence. 

Frequent.                  !  None. 

None. 

Syphilis. 

No  influence. 

Occasionally.              None. 

None. 

Heredity. 

No  influence. 

Unimportant.             May  be  famiUal. 

Unimportant. 

Incidence. 

Acute     becoming 

Insidious.                    Onset  may  be  acute 

Insidious. 

chronic     or    insid- 

or insidious. 

ious  from  first. 

Chhonicity. 

Cases  last  for  2-20 

May  last  for  years  1  Prolonged. 

Rapid  course. 

Fever. 

years. 
Generally  absent  ex- 

May  be   afebrile; 

Usually  slight;  often 

Rarely    absent;    due 

cept  during  exacer- 

when present  is 

absent. 

to   cornplication   or 

bation      or      some 

slight. 

cachexia. 

compUcation. 

Pain. 

Indefinite    and    tri-. 
fling. 

Slight. 

Often  marked. 

Variable;  often 
marked. 

Digestive 

Slight  or  none. 

Constant;  dyspep- 

Fairly  common. 

Often     marked;    ali- 

Disturbance. 

sia,     nausea, 
vomiting,  gastric 
hemorrh  age, 
melena. 

•mentary  origin  or 
pressure. 

Ascites. 

Constant     and     ex- 

Constant.       Low 

Never  extreme,  may 

Moderate  grade;  may 

treme;       nutrition 

specific   gravity. 

be      absent,     may 

be   hemorrhagic   or 

long      maintained: 

Low  albumin. 

be       hemorrhagic. 

pseudochylous. 

may      be      tapped 

Often     sacculated. 

over     800     times; 

Tubercle       baciUi; 

may  resemble  peri- 

lymphocytic     for- 

tonitis; albumin   3 

mula.    Higher  spe- 

per cent.;  fibrin. 

cific  graWty. 

Anasarca. 

Constant  but  slight. 

Slight. 

None. 

Frequent. 

Jaundice. 

Absent. 

Occurs  in    15  per 
cent,  of  cases. 

Rare. 

Common  when  liver 
is  enlarged. 

Liver. 

Not  cirrhotic;  at  first 

Cirrhotic;  at  first 

Seldom     enlarged. 

May     be     enlarged, 

enlarged,     then 

enlarged,     then 

Matting  of  omen- 

with nodules. 

small;  smooth. 

small  and  warty. 
Hepatargia. 

tum  may  simulate 
hepatic       enlarge- 
ment.    May     be 
nodes     lower; 
doughy  feel. 

Spleen. 

Gradual     enlarge- 
ment. 

Gradual    enlarge- 
ment;    often 
marked. 

No  enlargement. 

None. 

Omentum. 

Thickened  and  con- 

Normal. 

Often     matted     up. 

Often      matted     up. 

tracted. 

Mesenteritis       re- 
trahens. 

Mesenteritis. 

Treatment. — The  treatment  of  ascites  varies  with  its  cause,  for  which 
reference  should  be  made  to  valvular  heart  disease,  atrophic  cirrhosis, 
tuberculous  peritonitis  and  nephritis. 

Paracentesis  in  peritoneal  carcinoma  and  chylous  ascites  (v.  i.)  hastens 
the  fatal  issue.  Hale  White  asserts  that  cases  of  cirrhosis  survive  but 
few  punctures,  while  cases  of  perihepatitis  may  be  punctured  more  than 
200  times.  Lecanu  reports  a  case  of  ascites  in  which  886  tappings  were 
performed  in  fifteen  years.  In  puncture,  surgical  antisepsis  is  most 
necessary,  for  reduced  subjects  are  easily  infected.  The  bladder  should 
be  emptied  by  catheterization.  The  trocar  should  be  introduced  in 
the  linea  alba  to  avoid  injury  to  the  bloodvessels.    It  should  be  pushed 


ASCITES  617 

carefully  and  is  felt  to  penetrate  the  parietal  peritoneum  by  the  sense 
of  something  giving  way.  A  dull-pointed  probe  should  be  sterilized, 
with  which  to  push  back  the  omentum  if  it  should  prolapse  against  the 
canula.  The  fluid  should  be  evacuated  slowly  to  obviate  collapse  which 
may  result  from  dilatation  of  the  abdominal  veins,  if  they  are  suddenly 
relieved  of  the  pressure  of  the  effusion.  A  cat-o'-nine-tails  bandage  may 
be  applied  as  the  tapping  progresses,  to  compress  the  abdominal  contents. 

Chylous  and  Adipose  Ascites. — The  peritoneal  cavity,  more  fre- 
quently than  any  other  serous  sac,  is  the  seat  of  those  unusual  exudates 
known  as  chylous,  chyliform,  lactiform  or  adipose  ascites.  The  first 
authentic  case  is  Poncy's  (1699).  The  literature  gives  about  200  cases. 
Seven  have  come  under  the  author's  observation. 

Chylous  ascites  properly  designates  an  effusion  of  chyle.  Adipose  ascites 
contains  a  large  percentage  of  fat,  with  no  chylous  admixture.  Some 
authors  use  the  terms  "adipose,"  and  "chyliform"  interchangeably. 
Chyliform  ascites  is  a  chyle-like  fluid  in  which  lymph  or  chyle  is  mixed 
with  exudate  or  transudate. 

1.  Chylous  Ascites. — Straus's  case  is  the  clearest  example,  in  which 
typical  chyle  was  extra vasated  through  two  fistulse.  Ingested  butter  or 
olive  oil  is  recognized  in  the  fluid  withdrawn  by  paracentesis.  Chylous 
ascites  contains  sugar,  which  is  said  to  be  diagnostic  when  diabetes  is  ex- 
cluded. Sugar  when  primarily  present  may  disappear  later.  Its  presence 
is  very  suggestive;  it  has  been  detected  not  more  than  two  dozen  times. 
Many  clinicians  discount  the  importance  of  the  presence  of  sugar  as  a 
diagnostic  test;  Bock  found  sugar  (0.04  to  0.07  per  cent.)  in  all  cases 
of  hydrops,  and  Eichhorst  in  10  out  of  17  cases  of  pleural  exudate.  A 
small  amount  of  fat  (0.9  per  cent.)  indicates  chyle.  Chylous  ascites 
is  rich  in  solids,  mineral  salts  and  albumin.  Albumin  and  fat  occur  in 
small  punctiform  granules,  susceptible  of  chemical  differentiation.  The 
escape  of  chyle  may  occur  through  a  visible  rupture  or  by  transudation 
through  the  altered  walls  of  the  chyle  vessels;  among  the  most  frequent 
causes  of  lymph  or  chyle  obstruction  are  compression  of  the  thoracic 
duct  or  lymph  system  by  glands,  neoplasms,  peritonitis,  occlusion  of 
left  subclavian  vein^  lifting  or  coughing,  filarial  disease  or  occlusion  of 
the  thoracic  duct.  Rupture  may  occur  in  any  part  of  the  lymphatic 
system,  in  the  thoracic  duct,  receptaculum,  lacteal  vessels,  lymph  glands 
and  chylous  cysts. 

2.  Adipose  or  Chyliform  Ascites, — Adipose  ascites  is  characterized 
by  the  absence  of  sugar  and  a  higher  percentage  of  fat.  The  opacity 
may  be  due  to  emulsionized  albumin.  Fat  is  found  in  most  cases;  its 
highest  figure  was  in  one  of  the  author's  cases,  6.5  per  cent.  The  granules 
of  albumin  and  fat  are  much  coarser  in  adipose  than  in  chylous  ascites. 
Hydropic  and  fatty  carcinoma  cells  may,  if  numerous,  cause  a  creamy 
layer.  Red  blood  disks  may  occur,  also  fibrin,  casein,  mucin,  sodium 
alkali  albuminate,  peptone,  lecithin,  cholesterin,  fibrinogen,  etc.  Among 
the  numerous  etiological  conditions  are  tuberculosis  of  the  peritoneum 
and  glands;  carcinoma  of  the  glands,  peritoneum  and  l3^mph  vessels; 
chronic  peritonitis;  liver  cirrhosis,  heart  disease  and  sarcoma  of  the 
omentum  or  mesenterv. 


618  DISEASES  OF   THE  PERITOXEVM 

Diagnosis. — A  diagnosis  has  been  made  prior  to  puncture  only  in 
^Morton's  early  case.  The  local  signs  and  symptoms  do  not  difJer  from 
those  of  serous  ascites.  Some  cases  diagnosed  as  the  vulgar  ascites, 
healing  without  treatment,  are  probably  chylous  hydrops.  It  is  not 
easy  to  differentiate  between  chylous  and  adipose  effusions,  even  at 
necropsy. 

Prognosis. — About  90  per  cent,  of  both  t^'pes  die.  Continuous  chylous 
fistulse  are  always  fatal.  The  immediate  prognosis  is  seemingly  more 
favorable  in  the  adipose  form. 

Treatment.- — Surgical  interference  is  chiefly  indicated  in  tuberculous 
peritonitis.  Paracentesis  should  be  avoided  as  much  as  possible  for  it 
is  weakening  and  precipitates  the  fatal  issue. 


SECTION  V. 

DISEASES  OF  THE  KIDNEYS. 


ACUTE    NEPHRITIS. 

Etiology. — (a)  Resulting  from  infectio7is,  the  scarlatinal  nephritis  (g.  v.) 
is  the  most  frequent  type  and  develops  after  desquamation.  Acute 
nephritis  occurs  in  diphtheria,  at  the  height  of  the  disease;  it  is  found 
in  a  large  percentage  of  cases  of  acute  enterocolitis  in  children;  it  may 
result  from  malaria,  variola,  sepsis,  ulcerative  endocarditis,  pneumonia, 
tuberculosis  and  syphilis,  or  occasionally  in  typhoid,  typhus,  measles,  ton- 
sillitis or  epidemic  meningitis;  it  is  rare  in  German  measles,  varicella  or 
purpura.  Infections  operate  (i)  more  often  by  their  toxins  than  (ii)  by  the 
causal  microbe,  though  the  typhoid  bacillus,  piieumococcus,  streptococcus 
and  others  are  found  in  the  kidneys  and  urine ;  (iii)  in  some  instances  hemo- 
lysins apparently  cause  nephritis  (nephritis  hemoglobinurica) .  (b)  Toxic 
substances,  taken  internally  or  applied  to  the  skin,  may  induce  acute 
nephritis,  as  turpentine,  salicylic  compounds,  phenol,  potassium  chlorate, 
cantharides,  etc.  (c)  Exposure  to  cold  and  dampness  (with  alcoholism) 
lessens  the  tissue  resistance  or  acts  as  a  hemolysin,  (d)  Skin  diseases, 
burns,  eczema  and  psoriasis,  may  impair  the  skin  functions  or  produce 
hemolysins,  (e)  Pregnancy  {v.  i.),  chronic  Bright's  disease,  cardiac 
affections  and  the  dyscrasise  predispose  to  acute  nephritis.  (/)  Acute 
nephritis  may  occur  independently  of  any  known  cause,  and  sometimes 
epidemically. 

Pathology. —  Gross  changes  may  not  be  apparent  in  mild  cases,  though 
in  some  the  kidneys  are  swollen  from  marked  interstitial  exudation  and 
are  dark  and  heavy.  In  other  cases  the  kidney  is  yellowish- white  and 
perhaps  mottled  from  small  hemorrhages.  The  edematous  capsule 
strips  readily  and  the  cut  section  drips  blood.  On  section  the  cortex 
is  swollen  and  granular,  and  its  striations  are  blurred  and  pale  in  con- 
trast with  the  dusky  medulla;  the  glomeruli  are  frequently  visible  as 
red  or  later  as  yellow  dots.  Without  the  microscope,  lesser  degrees  of 
acute  nephritis  may  be  confused  with  fatty  or  parenchymatous  degenera- 
tion. Microscopic  changes  are  usually  diffuse,  (a)  Glomerular  changes. 
Glomerulonephritis,  best  exemplified  by  the  scarlatinal  form  (q.  v.), 
is  caused  by  toxins  reaching  the  tufts  through  the  blood  current.  The 
glomerular  capillaries  show  infiltration  with  leukocytes,  an  albuminous 
or  cellular  exudate  escapes  into  the  capsule  and  the  epithelium  of 
Bowman's   capsule   degenerates,    desquamates    and    later    proliferates. 


620  DISEASES  OF   THE  KIDNEYS 

(6)  Tubular  changes.  Cloudy  swelling,  hyaline  and  fatty  degeneration 
occurring  especially  in  the  cortex  may  be  difficult  to  differentiate  from 
febrile  and  other  degenerations,  but  interstitial  exudation  occurs  in 
every  case  of  nephritis.  In  severe  or  diphtheritic  cases  some  cells  necrose 
entirely  and  desquamate.  The  swelling  around  the  convoluted  tubules 
is  one  cause  of  the  kidney  enlargement,  (c)  Vascular  and  interstitial 
changes  are  essential  to  the  pathological  diagnosis  and  are  more  focal 
than  diffuse.  Serum  exudes  into  the  connective  tissue,  tufts  and  tubules 
and  coagulates  in  them;  leukocytes  escape  into  the  parenchyma  and 
interstitium  and  in  some  cases  red  cells  also  (hemorrhagic  nephritis). 
Councilman  thinks  that  Unna's  plasma  cells  are  conveyed  to  the  kidney 
from  the  spleen  and  bone-marrow. 

Symptoms. — The  onset  may  be  sudden,  especially  following  exposure. 
Again  it  develops  gradually  in  the  course  or  convalescence  of  a  causal 
scarlatina,  diphtheria,  etc.  Many  cases  may  be  unrecognized  without 
frequent  analyses  of  the  urine  or  until  uremia  develops. 

1.  Urinary  Findings. — (a)  The  urine  is  decreased  to  ten  or  twelve 
ounces  or  in  severe  cases  is  suppressed;  this  is  due  to  glomerulitis,  stop- 
page of  the  tubules  by  coagulated  albumin  and  desquamated  epithelium 
or  swelling  of  the  capillaries;  the  decrease  usually  runs  parallel  with  the 
intensity  of  inflammation  and  hydrops.  During  convalescence  the 
urine  becomes  abundant  and  clear,  (b)  Its  color  ranges  from  that  of 
febrile  urine  to  a  dark,  smoky  tinge ;  it  is  seldom  red  or  actually  bloody ; 
in  the  hemoglobinuric  form  it  is  chocolate-colored,  (c)  The  specific 
gravity  averages  1.025  to  1.030  and  (d)  the  reaction  is  acid,  (e)  Albu- 
minuria amounts  to  i  to  1  per  cent,  and  5  to  8  gm.  daily.  There  is  serum 
albumin,  considerable  globuKn  and  if  there  are  many  cells,  as  in  tubular 
nephritis,  nucleo-albumin.  The  author  has  seen  6  fatal  cases  of  acute 
diffuse  nephritis,  confirmed  by  autopsy,  in  which  there  was  no  albumin- 
uria. (/)  Urea  is  decreased  even  to  ^  its  normal  quantity,  as  are  also 
the  chlorides  and  phosphates;  the  uric  acid  remains  normal  and  the 
xanthin  (alloxur)  bases  may  be  increased.  (g)  The  sediment  in 
mild  acute  tubular  nephritis  consists  of  many  epithelial  cells,  some 
red  and  white  corpuscles  and  hyaline  casts  with  crystals  of  oxalate 
of  lime  and  uric  acid  and  sometimes  hemoglobin  granules,  which 
also  may  be  found  as  free  granules.  In  diffuse  glomerular  nephritis 
there  are  almost  always  red  cells,  leukocytes,  epithelium,  fatty,  hyaline 
and  granular  casts  and  granules  of  fat.  Senator  maintains  that  the 
leukocytes  from  the  kidney  are  mononuclear.  Waxy  and  epithelial  casts 
are  found  only  in  the  severest  types.  Blood  and  casts  may  appear  before 
and  may  also  outlast  the  albuminuria.  For  the  significance  of  cylindruria 
see  page  625. 

2.  Anasarca. — This  is  often  the  first  symptom  to  attract  attention. 
(a)  It  occurs  about  the  eyes  early  in  the  morning  and  later  in  the  day  in 
other  parts,  as  the  limbs  and  external  genitalia.  As  the  process  advances 
it  may  become  general,  (b)  It  changes  its  location  readily  and  with 
anemia  gives  a  rather  characteristic  fades,  (c)  Anasarca  occurs  most 
commonly  in  cases  due  to  scarlatina  and  exposure,  less  commonly  in 
pregnancy,  malaria,  alcoholism  and  skin  diseases  and  seldom  in  sepsis, 


ACUTE  NEPHRITIS 


621 


pneumonia,  typhoid  or  diphtheria,  (d)  It  is  caused  by  inflammation  of 
the  skin  vessels,  which  is  identical  and  associated  with  the  inflammation 
in  the  glomerular  vessels,  (e)  Identical  changes  may  occur  in  the  serous 
sacs  (pleura,  pericardium  or,  far  less  often,  peritoneum,  meninges  and 
joints),  mucous  membranes  (glottis  or  intestinal  tract)  or  viscera  (pul- 


FiG.  46. — Casts.    1-4,  amyloid;  5,  cast,  epithelial  in  its  upper,  and  granular  in  its  lower,  part. 

monary  or  cerebral  edema) .   (/)  It  parallels  the  intensity  of  the  nephritis 
and  the  decrease  of  urine. 

3.  Anemia. — ^The  red  cells  and  hemoglobin  are  reduced,  often  early 
and  with  the  dropsy  is  suggestive  of  acute  nephritis. 

4.  Cardiovascular  Symptoms. — Hypertrophy  of  the  left  ventricle  is 
uncommon,  though  observed  within  ten  days  of  the  onset.     The  pulse 


fT^-) 


km 


WoOfOfJ 


Fig.  47. — Urinary  casts.    1,  hyaline,  with  fat  droplets  and  cells;  2,  hyaline,  with  leukocytes; 

3,  cast  with  fat  droplets. 


is  usually  slow  and  tense;  the  sphygmogram  shows  increase  of  the  tidal 
and  decrease  of  the  dicrotic  wave  and  the  sphygmomanometer  shows  the 
blood  tension  increased  even  to  180  or  200  mm.;  these  phenomena  are 
probably  due  to  vascular  contraction  induced  by  metabolic  products 
retained  in  the  blood  or  by  glomerulitis.    The  second  aortic  tone  may 


622  DISEASES  OF   THE  KIDXEYS 

become  accentuated  and,  if  heart  fatigue  develops,  the  gallop-rhythm 
is  heard. 

5.  Temperature. — Fever  is  exceptional.  There  may  be  pain  and 
tenderness  in  the  back,  frequent  and  painful  urination,  emaciation  and 
epistaxis.    Constipation  is  the  rule.    The  skin  is  generally  dry. 

Diagnosis. — ^The  urinary  findings  are  characteristic;  alhuminuria  (q.  v.) 
may  result  from  other  causes,  as  fever,  amyloidosis  or  stasis;  casts, 
leukocytes,  epithelia  and  even  red  cells  also  occur  in  chronic  nephritis, 
but  the  history  and  evolution  determine  the  diagnosis  (v.  page  640); 
cases  without  urinary  findings  are  extremely  rare.  The  greatest  danger 
lies  in  confusing  acute  nephritis  v*ith  an  acute  exacerhation  of  a  chronic 
process;  fully  half  of  the  author's  acute  cases  belonged  to  this  category. 
In  renal  hematuria  the  urine  contains  no  casts  (save  perhaps  red  cell 
casts),  few  leukocytes  and  practically  no  epithelia;  there  is  no  anasarca; 
the  urine  is  clear  at  one  time  and  is  laden  with  blood  at  another.  Ana- 
sarca (v.  s.)  occurs  in  certain  t\"pes  only  and  also  in  various  cachectic 
states. 

Dlignosis  of  Type. — (a)  The  kidney  of  pregnancy  usually  develops 
in  the  last  half  of  gestation  and  infrequently  before  the  third  month. 
Its  pathogenesis  is  disputed,  though  toxemia  due  to  the  double  task 
imposed  upon  the  maternal  kidneys  seems  the  most  probable  cause. 
It  has  been  suggested  that  anaphylaxis  or  decreased  antitoxic  activity  of 
the  thyroid  gland  is  a  causal  factor  or  that  the  placenta  elaborates  toxins 
(syncytiolysins) .  The  urine  is  decreased,  pale  and  of  low  specific  gravity; 
it  contains  much  albumin  and  not  much  sediment,  though  red  and  white 
cells,  lymphocytes,  fatty  epithelia  and  sometimes  casts  are  found.  The 
attendant  anasarca,  like  that  of  stasis,  develops  from  below  upward. 
^^^len  retinitis  develops  its  prognosis  is  more  favorable  than  in  other 
nephritides.  The  convulsive  seizures  Teclampsia)  are  often  uremic, 
though  Ingersley  collected  106  cases  in  which  there  was  neither  clinical 
albuminuria  nor  renal  alteration  at  necropsy;  Fehling  remarks  on  the 
slight  anatomical  changes  in  the  kidney  and  on  the  fact  that  but  5 
per  cent,  of  pregnant  patients  having  an  old  nephritis  develop  eclampsia. 
The  embolism  of  placental  cells  in  the  brain  or  lungs  (Schmorlj  is  probably 
rather  a  result  than  a  cause  of  eclampsia.  Zweifel  maintains  that  the 
oxidation  of  the  albumins  is  decreased,  the  nitrogen  output  decreased, 
the  ammonia  increased  and  that  acidosis  occurs.  The  maternal  mortality 
is  30  per  cent,  and  that  of  the  child  over  50  per  cent.  Very  few  cases 
develop  chronic  nephritis,  (h)  The  cholera  nephritis  is  parenchymatous 
and  chiefly  tubular  and  by  some  is  considered  renal  ischemia  rather  than 
nephritis,  (c)  In  hemoglobimiric  nephritis  hemolysins  disorganize  the 
blood  and  irritate  the  kidneys  by  the  hemoglobin  set  free.  It  is  found 
in  burns,  acute  infections  (typhoid,  pernicious  malaria,  scarlatina, 
yellow  fever,  Winckel's  disease  of  the  newborn),  exposure,  hemoglobin- 
emia  and  drug  poisoning,  notably  that  of  chlorate  of  potash,  (d)  Acute 
recurrent  hemorrhagic  nephritis  is  uncommon. 

Prognosis. — In  general  there  are  more  recoveries  than  deaths.  The 
follo^^-ing  factors  are  important:  (a)  R.ecovery  is  usual  in  atypical  or 
light  forms  not  involving  the  glomeruli.     (6)  The  causal  affection;  the 


ACUTE  NEPHRITIS  623 

scarlatinal  type  has  a  mortality  of  33  per  cent.;  the  virulence  of  the 
epidemic  is  an  important  factor,  as  are  also  heart  complications,  (c) 
Complications,  as  (i)  intercurrent  inflavimations ,  such  as  pneumonia, 
pleuritis,  pericarditis  or  erysipelas;  (ii)  edema  of  the  pharynx,  larynx, 
lungs  or  serous  sacs;  and  (iii)  ureviia,  which  will  be  fully  covered  under 
chronic  interstitial  nephritis;  uremia  is  more  often  an  adult  than  an 
infantile  and  a  late  rather  than  an  early  complication ;  headache,  delirium, 
dyspnea,  convulsions,  coma  and  vomiting  are  among  its  salient  signs. 

The  average  duration  is  less  than  two  weeks,  though  one  or  two  years 
may  elapse  before  recovery,  and  gradual  transition  into  chronic  nephritis 
sometimes  results. 

Treatment. — Most  of  the  points  mentioned  will  be  considered  more 
fully  in  the  treatment  of  chronic  nephritis,  (a)  Prophylaxis  is  of  limited 
value.  Drugs  which  irritate  the  kidneys  should  be  withheld  in  acute 
infections  or  pregnancy.  In  fevers  water  should  be  given  freely  by 
mouth  or  by  enema;  hydrotherapy  is  prophylactic,  save  in  scarlatina 
when  cold  baths  are  contra-indicated.  Induction  of  labor  is  indicated 
in  severe  cases.  (6)  Diet.  Milk  is  diuretic,  non-irritant  and  contains 
little  or  no  extractives  or  salt.  It  should  be  given  as  in  typhoid  (g.  v.). 
Thoroughly  cooked  carbohydrates,  as  gruels,  are  well  combined  with 
it.  Alcohol,  broths,  meats  and  beef-tea  are  contra-indicated,  (c) 
Absolute  rest  in  bed  is  imperative  to  protect  the  skin  and  spare 
the  kidneys  from  the  products  of  the  tissue  waste;  the  patient  should 
lie  between  flannel  blankets  and  should  be  dressed  in  flannel  nightgowns. 
{d)  No  drug  modifies  the  nephritis;  tannin  and  ergotin  (of  each  5 
grains  three  times  daily)  seem  to  restrict  renal  hemorrhage.  Salt  should 
be  withheld  (see  p.  635).  {e)  The  best  diuretics  are  water  and  milk,  which 
flush  out  detritus  from  the  kidneys;  excessive  quantities  are  often  given; 
potassium  citrate  is  given  in  doses  of  half  a  dram  with  sweetened,  weak 
lemonade.  Sweet  spirits  of  nitre  oss-j,  q.  i.  d.,  is  diuretic  and  also 
dilates  the  bloodvessels.  All  stronger  diuretics  are  to  be  avoided.  (/) 
Skin.  Warm  baths  are  diuretic  and  stimulate  some  vicarious  elimina- 
tion through  the  skin.  Careful  covering  and  rest  in  bed  relax  the  skin, 
materially  aid  its  functions  and  relieve  renal  hyperemia,  {g)  Saline 
catharsis  lowers  arterial  tension  and  aids  compensatory  elimination. 
As  salts  often  derange  the  stomach,  an  ounce  should  be  given  by  rectum 
with  two  ounces  of  glycerin  and  one  of  water.  One-half  to  one  dram  of 
compound  jalap  powder  or  ^^  grain  of  elaterin  is  indicated  when  uremia 
impends,  (li)  Treatment  of  uremia.  For  suppression  of  urine  a  full 
warm  bath  lasting  fifteen  to  twenty  minutes  should  be  given;  a  hot  pack 
should  be  applied,  followed  by  wrapping  in  blankets  and  covering  heavily 
with  a  rubber  sheet;  or  the  alcohol  sweat  or  hot-air  sweat  may  be  given. 
Cups  applied  to  the  back  may  divert  blood  away  from  the  kidneys, 
because  the  vessels  of  the  loin  anastomose  with  those  of  the  kidney. 
Pilocarpin,  catharsis,  incision  of  the  legs,  venesection,  saline  infusions, 
stimulation,  etc.,  are  considered  fully  under  Chronic  Nephritis,  (i)  In 
convalesce7ice,  iron  and  other  mild  tonics  should  be  given,  irritating  foods 
and  beverages  interdicted,  exercise  carefully  restricted  and  cold  and 
exposure  avoided  by  sending  the  patient,  if  possible,  to  a  warm  climate. 


624  DISEASES  OF   THE  KIDNEYS 


CHRONIC   NEPHRITIS. 

Aetius,  Avicenna,  Cotugno  (1770)  and  other  writers  mentioned  the 
association  of  hydrops  and  albuminuria,  but  to  Richard  Bright  (1827) 
is  due  the  credit  of  correlating  renal  disease,  albuminuria  and  dropsy; 
he  also  noted  the  etiological  importance  of  alcohol  and  cold,  as  well  as 
the  cardiac  hypertrophy,  uremia,  brain  hemorrhage,  coma,  convulsions, 
blindness  and  the  tendency  to  serositis. 

The  following  classification  of  nephritis  covers  typical  cases,  though 
combined  or  mixed  types  are  equally  frequent.  As  a  cause  of  death 
chronic  nephritis  ranks  sixth,  after  pneumonia,  tuberculosis,  heart 
disease,  endocarditis  and  unknown  causes. 

I.  Chronic  Parenchymatous  Nephritis. — Definition. — Chronic  Bright's 
disease,  with  special  involvement  of  the  parenchyma,  much  albuminuria 
and  abundant  formed  elements  in  the  urinary  sediment.  The  affection 
constitutes  3  per  cent,  of  all  diseases. 

Etiology. — -It  may  result  from  (a)  infections,  as  tuberculosis  (which 
causes  25  per  cent.),  malaria  and  syphilis;  (b)  from  exposure  to  cold 
and  dampness;  (c)  from  toxic  factors,  as  alcohol,  lead,  less  frequently 
mercury  or  arsenic;  {d)  from  cardiac  disease,  which  accounts  for  14  per 
cent,  of  nephritis;  {e)  exhausting  discharges,  suppuration  and  ulcera- 
tion; (/)  acute  nephritis  is  a  somewhat  predisposing  factor,  {g)  Most 
cases  occur  between  twenty  and  fifty  years  of  age;  it  is  rare  in  children. 
Males  are  affected  more  often  than  females. 

Pathology. — There  are  three  types  besides  the  mixed  forms. 

1.  The  "Large  White  Kidney,"  or  "Inflaaied  Fatty  Kidney." — 
This  is  never  decreased  in  size  and  may  weigh  10  to  12  ounces  and 
measure  two  or  three  times  the  normal  size. 

Gross  Characters. — ^The  capsule  is  non-adherent;  the  surface  is  smooth, 
yellowish-gray,  with  prominent  stellate  veins  and  sometimes  dots  of  hem- 
orrhage. On  section  the  cortex  is  broader,  the  striations  are  poorly 
marked  and  when  cut  streaks  of  fat  may  show;  the  glomeruli  and  con- 
voluted tubules  are  yellow  and  contrast  with  the  gray  bands  of  newly 
formed  connective  tissue.  The  medulla  shows  fewer  changes  and  is  red, 
in  sharp  contrast  with  the  light  cortex. 

Microscopic  Characters. — The  most  essential  changes  are  hyaline  and 
fatty  degeneration  and  atrophy,  chiefly  in  the  convoluted  tubules,  in 
w^hich  lie  desquamated  epithelia  and  coagulated  albumin.  The  glom- 
eruli are  always  diseased,  but  to  a  varying  degree;  they  are  enlarged, 
their  vessels  show  hyaline  and  fatty  degeneration  and  nuclear  multipli- 
cation; albumin  is  found  in  their  capsules  and  the  epithelium  is  swollen, 
fatty  or  even  necrotic.  The  connective  tissue  is  always  increased,  which 
histologically  separates  chronic  nephritis  from  acute  nephritis  and  mere 
degeneration. 

2.  The  "Large  Red"  or  "Variegated  Kidney." — Gross  Characters. 
— It  is  also  large,  but  is  firmer  than  the  kidney  just  described  or  that 
of  acute  inflammation,  for  it  has  more  connective  tissue,  which  may 
cause  some  tearing  and  loss  of  the  cortex  when  the  capsule  is  stripped  off. 
The  surface  may  be  perfectly  smooth.    The  cortex  is  swollen,  indistinctly 


CHRONIC  NEPHRITIS  625 

striated,  dotted  yellow  from  fatty  glomerular  change  or  red  from  minute 
ecchymoses  and  sometimes  streaked  yellow  and  red  from  similar  tubular 
changes. 

Minute  Characters. — These  are  essentially  those  of  the  large  white 
kidney,  except  that  fatty  degeneration  is  less  marked  and  connective 
tissue  alteration  and  hemorrhages  are  more  conspicuous. 

3.  The  Secondary  Contracted  Kidney. — This  form  may  develop 
after  a  year  or  two  from  the  above  forms. 

Gross  Characters. — It  may  be  as  large  as  the  "large  white"  or  "large 
red  kidney"  and  the  name  refers  rather  to  its  connective  tissue  than  to 
any  visible  renal  shrinkage.  The  capsule  is  adherent  in  places  and,  when 
stripped,  tears  off  small  areas  of  the  renal  substance.  The  surface  is 
rough  and  shows  in  some  places  reddish,  depressed  areas  (fibrous  contrac- 
tion or  granulations  and  parenchymatous  atrophy)  and  in  others  yellow 
areas  (which  are  more  normal,  though  fatty).  Section  shows  decrease 
in  the  cortex  corresponding  to  the  reddish  foci.  It  differs  from  the 
genuine  contracted  kidney  (primary  interstitial  nephritis)  in  the  follow- 
ing respects:  it  is  secondary,  much  more  rapid  in  development,  contains 
fewer  cysts,  is  more  yellow  and  its  red  granulations  and  yellow  promi- 
nences are  larger. 

Minute  Characters. — Epithelial  changes  resemble  those  of  the  two  forms 
described.  The  membrana  propria  of  the  tubules  thickens,  adheres  and 
obliterates  many  tubules.  The  glomeruli  collapse,  thicken  and  shrink 
to  small,  dark  gray  granular  bodies,  which  sometimes  calcify.  The 
retracted  areas,  capsular  adhesions  and  cortex  shrinkage  correspond 
to  connective-tissue  contraction. 

Symptoms. — The  onset  is  in  most  cases  gradual  and  insidious,  the 
earliest  symptoms  being  loss  of  strength,  pallor,  emaciation,  simple 
decline  of  health,  indigestion,  anorexia,  headache,  shortness  of  breath 
on  exertion  or  chronic  bronchitis. 

1.  Urinary  Findings. — Except  in  the  secondary  contracted  kidney 
{a)  the  urine  is  decreased  to  1000-200  c.c;  (6)  the  color  is  dark  yellowish- 
red,  opaque  or  rarely  smoky;  the  urates  are  held  in  suspension  by  the 
albumin;  sometimes  its  surface  is  shimmering  from  fatty  cells  and  casts; 
(c)  the  specific  gravity  is  1.020  to  1.040  and  {d)  the  reaction  is  acid; 
(e)  albumin  is  more  abundant  in  the  day  time  than  at  night  and  amounts 
to  1  to  3  per  cent,  and  15  to  30  gm.  daily;  it  coats  the  bubbles  formed 
by  agitation  of  the  specimen  and  preserves  them  for  a  long  time.  (/) 
The  absolute  amount  of  solids  is  generally  decreased;  for  example,  the 
urea  (which  normally  constitutes  90  per  cent,  of  the  nitrogen  output  and 
amounts  to  about  35  gms.  daily),  kreatin  and  sodium  chloride  are 
decreased  and  the  freezing-point  of  the  urine  is  lowered  (v.  i.).  (g)  The 
sediment  is  abundant  and  hyaline,  granular,  fatty  and  epithelial  casts 
abound  (first  noted  by  Simon  and  Nasse);  coarsely  granular  and  waxy 
casts  appear  late  in  the  disease;  the  granular  type  is  due  chiefly  to  fat 
particles,  which  may  darken  the  casts.  They  have  been  long  regarded 
as  significant  of  nephritis.  Key,  Nothnagel,  Rosenstein  and  others 
afterward  observed  their  occurrence  in  the  urine  of  normal  individuals 
and  of  late  there  has  been  a  tendency  to  underestimate  their  impor- 
40 


626  DISEASES  OF   THE  KIDNEYS 

tance.  According  to  Senator,  casts  originate  in  the  kidney  chiefly  from 
epithehal  ceUs  and  always  indicate  some  renal  disease.  They  may  be 
dissolved  in  the  bladder  by  the  pepsin  contained  in  the  urine.  Leuko- 
cytes and  fatty  epithelia  and,  in  some  forms  of  nephritis,  red  cells  occur 
in  considerable  amounts.  In  Ackermann's  case  no  casts  were  found  in 
the  urine,  but  were  found  in  masses  in  the  renal  pelvis  at  necropsy. 

In  the  secondary  contracted  kidney  the  urine  amounts  to  1500  to  2000 
c.c,  is  clearer,  is  somewhat  lower  in  specific  gravity  and  contains  some- 
what less  albumin  and  casts. 

2.  Edema. — Edema  is  very  frequent.  Its  absence  argues  for  little 
glomerular  involvement.  It  commences  about  the  eyes,  changes  its  loca- 
tion readily  and  is  at  first  evanescent,  but  soon  becomes  general,  obstinate 
and  ominous.  It  is  more  pronounced  in  the  "large  white  kidney"  than  in 
other  types  and  increases  as  the  urine  decreases.  The  puffy  and  promi- 
nent eyes,  pale,  swollen  cheeks,  dull  expression  and  distended  abdomen 
and  shapeless  wrists  and  ankles  often  suggest  the  diagnosis.  The  serous 
and  mucous  membranes  are  similarly  involved,  though  to  a  lesser  degree, 
and  also  as  possible  terminal  events,  pulmonary  or  cerebral  edema  may 
develop.  Edema  is  caused  (a)  by  hypalbuminosis  and  hydremia  of  the 
blood  (Bright's  theory),  especially  in  hemorrhagic  types,  (6)  by  abnor- 
mal permeability  of  the  vessel  walls,  a  theory  advanced  by  Cohnheim 
and  Lichtheim,  or  (c)  glomerular  changes,  causing  chloride  and  water 
retention. 

3.  Anemia. — Anemia  distinguishes  chronic  parenchymatous  nephritis 
from  the  genuine  interstitial  type.  There  is  usually  retention  of  urea, 
uric  acid  and  chlorides;  sometimes  the  blood  is  cloudy. 

4.  Cardiovascular  Findings. — The  pulse  is  more  often  small,  soft, 
rapid  and  associated  with  a  weak  apex,  indicating  dilatation,  than 
tense  and  associated  with  a  loud  second  aortic  tone  and  strong  apex, 
indicating  hypertrophy.  Secondary  contraction  and  mixed  nephritis 
are  likely  to  develop  findings  similar  to  those  of  the  genuine  interstitial 
nephritis;  Senator  finds  eccentric  hypertrophy  in  parenchymatous  and 
simple  or  concentric  hypertrophy  in  interstitial  nephritis.  Myocardial 
degeneration  is  common. 

Complications  and  Causes  of  Death. — (a)  Marasmus  results  from  the 
anemia,  indigestion,  diarrhea,  edema  of  the  alimentary  mucosa  or  its 
irritation  by  decomposed  urea.  (6)  Intercurrent  infections  may  result, 
as  inflammation  of  the  pleurse  or  pericardium,  cellulitis  and  especially 
pneumonia;  many  pneumonia  deaths  really  result  from  nephritis;  in 
one  instance  the  writer  saw  acute  necrosis  and  sloughing  of  the  scrotum. 
Other  complications  are  (c)  edema  of  the  lungs,  larynx,  serous  sacs  and 
extremities,  impeding  respiration  and  obstructing  the  peripheral  arterial 
flow;  (d)  hemorrhages  (8  per  cent.)  in  the  brain  or  other  organs;  (e) 
retinitis  (18  per  cent.);  (/)  uremia,  with  its  numerous  nervous,  circula- 
tory and  digestive  symptoms  (v.  page  630) ;  (g)  acute  exacerbations,  par- 
ticularly in  the  chronic  hemorrhagic  type;  and  (h)  cardiac  insufficiency. 

Diagnosis. — The  diagnosis  rests  upon  three  cardinal  symptoms:  (a) 
the  urinary,  which  are  characteristic  when  twenty-four-hour  specimens 
are  carefully  and  repeatedly  examined  in  every  patient;  (6)  the  anasarca, 


CHRONIC  NEPHRITIS  627 

which  is  sometimes  absent  in  secondary  contracted  kidney  and  in  Wag- 
ner's hemorrhagic  type;  and  (c)  the  anemia.    (See  pages  640  and  641.) 

Prognosis. — Though  some  cases  suggesting  an  arrest  of  the  process  are 
found  at  autopsy,  the  cUnical  course  is  usually  progressive  and  fatal. 
Dropsy  usually  causes  death  in  a  few  months  to  a  year,  though  the 
author  saw  5  typical  cases  recover  after  two  and  a  half  years;  they 
did  not  result  from  acute  infections  like  the  recoveries  reported  by 
Senator  and  Rosenstein.  The  outlook  is  better  in  children  than  in  adults. 
The  large,  white  kidney  causes  death  in  one-half  to  one  year,  the  large, 
variegated  kidney  and  the  secondary,  contracted  kidney  in  one  and  a 
half  to  three  years.     The  treatment  is  considered  on  page  633. 

II.  Chronic  Interstitial  Nephritis. — Definition. — A  primary,  interstitial, 
contracting  sclerosis  of  the  kidney,  characterized  clinically  by  abundant 
urine  of  low  specific  gravity,  with  small  amounts  of  albumin  and  few 
cellular  elements;  and  by  marked  cardiac  hypertrophy,  arteriosclerosis, 
hypertension,  retinitis  and  uremia. 

This  genuine  contracted  kidney  must  not  be  confused  with  secondary 
contracted  kidney,  arteriosclerotic  contraction,  embolic  contraction  or 
the  contraction  resulting  from  ascending  infection. 

Frequency. — In  ten  years  Eichhorst  treated  31,562  cases,  of  which  1.4 
per  cent,  had  contracted  kidneys  (six  and  a  half  times  as  frequent  as  the 
parenchymatous  form). 

Etiology. — ^The  etiology  is  that  of  arteriosclerosis,  with  which  contracted 
kidney  has  a  threefold  relation:  arteriosclerosis  may  cause  the  arterio- 
sclerotic kidney;  contracted  kidney  may  cause  arteriosclerosis;  or 
both  may  result  from  a  common  cause.  The  often  unknown  toxin  reaches 
the  kidney  through  the  blood  stream. 

The  disease  may  result  from  (a)  chronic  alcoholism  combined  with 
exposure  or  overeating;  (b)  chronic  lead  yoisoning;  (c)  gout,  caused 
by  the  alloxur  bodies;  {d)  syphilis;  (e)  diabetes,  caused  by  sugar  or 
acidosis;  the  diabetes  lessens  or  ceases  when  induration  develops;  (/) 
age;  it  begins  between  the  years  of  thirty  and  fifty  and  is  clinically  mani- 
fest after  fifty  years  of  age.  Sawyer  collected  24  cases  in  children,  (g) 
Sex.  The  disease  is  three  times  as  frequent  in  men  as  in  women.  In  the 
infantile  form  most  cases  occur  in  girls,  (h)  Infrequent  causes  are 
acute  nephritis,  the  kidney  of  pregnancy,  hereditary  tendency,  as  in 
Dickinson's  series  through  four  generations,  and  endocarditis. 

Pathology. — It  is  undecided  whether  the  process  is  inflammatory  or 
atrophic;  probably  induration  follows  cellular  degeneration. 

Gross  Pathology. — (a)  The  kidneys  are  contracted  even  to  one-third 
their  original  size  and  may  weigh  but  21  gm.;  contraction  is  rarely  sym- 
metrical in  both.  (&)  Their  consistence  is  increased,  (c)  The  capsule 
is  thick,  tendinous  and  adherent  and  strips  off  particles  of  cortex  when 
removed,  (d)  The  surface  is  uneven;  the  small  reddish  or  sometimes 
paler  prominences,  measuring  0.5  to  5  mm.  represent  the  more  normal 
tissue;  the  paler  retracted  areas  are  fibrous,  (e)  Small  cysts  are  fre- 
quently found,  usually  with  clear  contents;  their  size  ranges  from  that 
of  a  pin-point  to  a  cherry ;  they  result  from  glomerular  and  tubular  con- 
striction by  connective  tissue  (retention  cysts).    (/)  On  section  the  cortex 


628  DISEASES  OF   THE  KIDNEYS 

is  shrunken;  even  to  1  mm.,  irregular  and  gray  from  fibrillar  connective 
tissue.  The  medulla  is  less  changed,  though  also  shrunken;  pale  fibrous 
lines  alternate  with  red,  dilated  vessels;  uric  acid  or  calcium  salts  are 
deposited. 

Minute  Pathology. — The  changes  are  largely  cortical,  focal,  asym- 
metrical and  interstitial,  (a)  The  glomeruli  early  exhibit  round  cells, 
nuclear  increase,  desquamated  cells  and  albumin;  later  they  atroj^hy 
from  degeneration  of  the  afi^erent  artery;  in  the  extreme  stage  the 
glomeruli  become  hyaline  and  fibrous;  some  tufts  may  visibly  hyper- 
trophy, Sabourin's  compensatory  adenomata.  (6)  The  epithelium  is 
always  changed,  though  much  less  than  in  parenchymatous  forms;  in 
the  sunken  areas  many  tubules  disappear  and  degenerated  cells  are 
seen  in  the  prominent  surface  granulations;  in  the  medulla  the  collecting 
tubules  are  larger,  even  cystic,  and  are  filled  with  colloid  material,  (c) 
The  connective  tissue  is  increased  everywhere,  but  more  in  the  cortex 
than  in  the  medulla;  round-cell  infiltration  occurs  early  and  induration 
late;  the  vessels  are  sclerotic  in  all  their  coats,  but  especially  in  the 
intima,  which  some  consider  is  the  earliest  and  causative  alteration. 

Symptoms. — Long  latency  for  years,  insidious  onset  and  protracted 
compensation  by  heart  hypertrophy  are  characteristic  of  this  type.  Many 
cases  are  first  discovered  during  an  acute  infection,  as  pneumonia,  on 
examination  for  life  insurance  or  at  the  coroner's  autopsy  after  accidents. 
It  may  appear  for  years,  to  be  a  physiological  or  c^'^clic  albuminuria. 
Polyuria,  cardiac  symptoms,  retinitis,  indigestion  or  depreciation  of 
health  may  be  the  first  symptom.  The  edema,  pronounced  urinary  find- 
ings in  a  single  specimen  and  anemia  of  chronic  parenchymatous  nephritis 
are  seldom  conspicuous  and  almost  never  early  symptoms  in  this  type. 
The  condition  may  be  first  declared  by  heart  incompetence,  uremic 
coma  or  convulsions. 

1.  Urinary  Findings. — Urinary  findings  are  generally  the  earliest 
signs.  Twenty-four-hour  specimens  should  be  examined  repeatedly  in 
doubtful  cases,  with  a  fresh  specimen  for  microscopic  examination.  As 
a  general  statement,  the  urine  is  increased,  pale  and  voided  frequently; 
it  is  low  in  specific  gravity  and  contains  small  amounts  of  albumin 
and  solids;  and  the  scanty  sediment  contains  few  casts.  In  detail:  (a) 
The  amount  is  gradually  increased  (polyuria)  as  the  kidneys  lose  their 
power  to  condense  the  urine;  this  is  a  frequent  cause  for  consulting  the 
physician.  Nagel  found  polyuria  in  only  47  per  cent.  The  urine  is  also 
passed  frequently  (pollakiuria) ,  especially  at  night,  always  suspicious 
when  the  prostate  is  normal,  In  well-developed  cases  it  totals  2000  to  3000 
c.c,  rarely  8000  to  12,000.  (b)  It  is  pale  and  weakly  acid,  (c)  The  specific 
gravity  averages  1.010  (1.005  to  1.012).  (d)  Albumin  is  present  in  most 
cases,  but  is  not  abundant;  the  merest  traces  are  found  up  to  a  daily 
total  of  2  to  5,  rarely  10  gm.  It  is  often  absent  in  single  specimens, 
especially  in  the  morning,  whence  a  twenty-four-hour  specimen  should 
always  be  examined.  Delicate  tests  are  often  necessary  {v.  Albumin- 
uria). It  may  appear  only  after  eating,  exercise  or  fatigue,  whence  its 
greater  frequency  toward  night;  it  may  increase  after  dyspepsia  or 
bronchitis.     Senator's  statement  that  its  alleged  absence  is  due  to  an 


CHRONIC  NEPHRITIS  629 

arteriosclerotic  kidney  and  not  to  interstitial  nephritis  is  not'  invariably 
correct.  Albuminuria  may  be  absent  for  weeks  or  months.  A  permanent 
foam  due  to  the  albumin  is  frequent,  (e)  Solids  are  decreased,  i.  e.,  the 
urea,  uric  acid,  ammonium,  chlorides  and  phosphates.  The  determination 
of  the  freezing-point,  cryoscopy,  employed  by  Koranyi  to  estimate  the 
amount  of  soluble  molecules  in  the  blood  and  urine,  is  not  of  prac- 
tical value  in  medical  cases.  (/)  Tests  of  renal  function  show  decreased 
activity  {v.  i.  Therapy.)  (g)  The  sediment  is  scant,  absent  or  obtained 
only  by  the  centrifuge.  Hyaline,  granular  and  epithelial  casts  are  found 
in  small  numbers  when  the  light  is  moderated  by  the  diaphragm,  some- 
times only  after  repeated  search;  the  granular  casts  are  often  wide, 
originating  in  the  dilated  tubules  of  the  medulla.  A  few  epithelia,  leuko- 
cytes and  crystals  of  uric  acid  and  oxalate  of  lime  are  found.  Red  cells 
are  infrequent. 

The  urinary  findings  are  modified  by  intercurrent  uremia,  fever  and 
heart  failure,  all  of  which  concentrate  the  urine. 

2.  Cardiovascular  Symptoms. — Cardiovascular  symptoms  were  noted 
by  Bright,  but  their  significance  was  first  established  by  Traube.  They 
appear  in  75  per  cent,  of  cases.  Briefiy  stated,  they  are  the  signs 
of  cardiac  hypertrophy  and  arterial  hypertension — a  heaving  apex,  a 
metallic,  second  aortic  tone,  hard  vessels  and  raised  blood-pressure. 
Cardiac  hypertrophy  is  more  quickly  detected  clinically  than  patho- 
logically, especially  in  the  young,  because  the  urine  is  increased  before 
the  signs  of  hypertrophy  prevail  and  concentric  hypertrophy  is  present 
long  before  dilatation  appears.  Emphysema  may  obscure  the  precordial 
evidences  of  hypertrophy,  such  as  the  heaving  apex-beat  and  double 
impulse  at  the  apex,  and  one  must  therefore  depend  on  the  evidences 
presented  by  the  tense  pidse,  the  hardness  of  the  arteries,  the  sphygmo- 
graphic  tracings  with  a  square  apex,  the  loud,  ringing,  second  aortic  tone 
or  other  manifestations  of  increased  arterial  tension,  as  epistaxis,  vertigo, 
headache,  tinnitus,  palpitation  or  cardiac  asthma.  The  systolic  blood- 
pressure  in  interstitial  nephritis  may  exceed  200  mm.,  and  is  one  of  the 
most  constant  and  early  symptoms.  (See  pages  395  and  396.)  The  cause 
of  the  hypertrophy  or  hypertension  is  not  definitely  known — mechanical 
obstruction  to  the  blood  fiow  by  renal  contraction  (glomerular  changes) 
and  vasomotor  constriction  excited  by  retained  waste  substances  are  prob- 
able causes.  Though  hypertrophy  occurs  in  interstitial  rather  than  in 
parenchymatous  nephritis,  the  two  types  often  mingle,  with  the  urinary 
findings  of  the  "large  white  kidney"  and  the  cardiovascular  findings  of 
a  renal  contraction.  In  the  last  stage  of  contracted  kidney  the  hyper- 
trophied  heart  weakens,  the  hypertension  falls,  the  apex  becomes  weaker, 
a  systolic  murmur  appears  from  myocardial  insufficiency  and  Potain's 
gallop-rhythm,  a  sign  of  heart  fatigue,  is  heard. 

3.  Retinitis. — Retinitis  albuminurica  may  be  the  first  declaration  of 
the  disease  and  thus  come  under  the  observation  of  the  ophthalmologist. 
It  occurs  more  frequently  than  in  other  renal  lesions,  25  per  cent.  Its 
forms  are  stellate,  white  areas  of  fatty  and  fibrous  tissue,  a  white  zone 
surrounding  the  disk,  degeneration  of  the  disk  or  retina,  "flame-like" 
hemorrhages  and  choked  disk  whose  large  veins  are  compressed  where 


630  DISEASES  OP  THE  KIDNEYS 

the  arteries  cross  them.  Identical  findin2:s  occur  in  other  conditions. 
(See  Plate  VI,  Fig.  8.) 

4.  Uremia. — Uremia  is  the  most  dreaded  and  frequent  complication; 
its  nature  and  immediate  cause  are  unknown;  it  can  only  be  stated  that 
it  is  an  auto-intoxication,  due  to  disturbance  of  renal  function,  probably 
with  retention  within  the  blood  of  nitrogenous  substances.  Further 
explanations  are  theoretical,  such  as  acidosis;  failm-e  of  the  "internal 
secretion"  of  the  kidney;  the  toxic  action  of  abnormal  products  of 
metabolism  or  breaking  up  of  the  proteids  by  nephrolysins;  it  is  not 
due  to  retention  of  urea  alone  or  to  mechanical  conditions  alone,  as 
edema  or  anemia  of  the  brain.  It  occurs  most  often  in  chronic  inter- 
stitial, next  in  acute,  then  in  chronic  parenchymatous  nephritis  and  is  far 
less  common  in  other  diseases  of  the  urinary  tract,  as  pyelonephritis,  etc. 

Uremic  syinptovis  may  be  acute,  perhaps  developing  precipitately; 
more  frequently  it  is  chronic;  prodromal  headache  is  followed  by  chronic 
gastric  irritability,  vomiting  and  epigastric  oppression;  dyspnea  and 
high  arterial  tension,  alternate  with  restlessness,  anxiety,  insomnia  or 
disturbed  \'ision;  and  finally  psychic  disturbance,  poly  visceral  scleroses, 
myocardial  incompetency,  gallop-rhythm,  Cheyne-Stokes's  breathing  or 
angina  pectoris  terminates — rapidly  or  with  miserable  remissions — in 
uremic  convulsions,  uremic  coma  or  apoplexA'.  These  manifestations 
will  be  considered  as  nervous,  digestive,  respiratory  and  cardiac: 

Nervous  Symptoms. — (a)  Acute  coiuulsions  (eclampsia)  are  due  to 
irritation  of  the  cortex  by  toxins,  and  closely  resemble  the  epileptic 
attack.  There  are  usually  prodromes,  as  pain  or  pressure  in  the  head, 
neuralgia,  insomnia,  vertigo,  visual  disturbance,  tinnitus,  nausea,  vomit- 
ing or  dyspnea;  there  is  usually  no  "epileptic  cry."  Then  clonic  or 
tonic  convulsions  appear,  usually  generalized  and  invohdng  especially 
the  flexor  or  extensor  muscles  of  the  arms  and  legs;  the  abdomen  is 
retracted;  there  are  dyspnea,  cyanosis  and  involuntary  evacuations;  the 
reflexes,  especially  the  patellars,  are  increased,  and  even  ankle-clonus 
and  Babinski's  sign  may  develop,  sometimes  unilaterally  and  thus  simu- 
lating apoplexy;  the  pupils  are  wide  and  reactionless;  the  pulse  is  full 
and  slow  before  the  attack  but  becomes  rapid  during  the  convulsions. 
The  skin  is  covered  with  sweat  and  the  temperature  is  usually  elevated. 
The  convulsions  cease  after  fifteen  to  thirty  minutes  and  coma  intervenes, 
during  which  the  convulsions  may  recur.  Death  is  the  usual  outcome, 
but  recovery  is  possible,  as  in  one  of  the  author's  cases,  in  which  the 
anterior  third  of  the  tongue  was  bitten  off.  (h)  Other  motor  manifesta- 
tions. Landois's  general  statement  is  as  follows:  Paralysis  affects  espe- 
cially the  sensorium,  to  a  lesser  degree  the  special  senses  and  rarely 
motility;  irritation  seldom  affects  the  sensorium  (e.  g.,  delirium),  it  acts 
principally  upon  the  motor  paths  (com'ulsions)  and  seldom  upon  the 
special  senses.  Uremic  convulsions  may  resemble  focal  sjTnptoms,  such 
as  con^Tilsions  of  only  half  the  body  or  rarely  as  convergent  strabismus, 
facial  spasm,  Jacksonian  epilepsy,  nystagmus,  localized  trembling  and 
twitchings,  muscular  cramps,  grinding  of  the  teeth,  tetanic  convulsions, 
trismus,  convulsions  on  one  side  and  contractures  on  the  other,  rigidity 
of  the  neck  or  opisthotonos.     In  7  cases  seen  b}'  the  author  the  symptoms 


dHRONiC  NEPHRITIS  63l 

were  those  of   an   acute   focal   brain  lesion;   in  2,  treated   by  lumbar 
puncture,  relief  was  immediate. 

Paralyses  in  uremia  are  infrequent,  are  chiefly  transitory  hemiplegias 
and  are  due  to  cerebral  edema,  capillary  hemorrhage,  softening,  apoplexy 
or  cortical  overstimulation  by  toxins.  Hemiplegia  may  occur  with 
aphasia,  amnesia,  deafness,  crossed  oculomotor  paralysis,  glossoplegia 
or  conjugate  deviation  of  the  eyes.  The  author  reported  5  cases  in 
which  uremia  very  closely  resembled  meningitis.  Other  cases  have  been 
suggestive  of  brain  tumor,  (e)  Acute  coma  often  occurs  without  ante- 
cedent eclampsia,  being  preceded  by  headache,  stupor  or  apathy;  coma 
may  last  for  days  or  even  months,  (d)  Psychic  symptoms.  The  most 
common  is  a  characteristic  restlessness  and  anxiety.  Obstinate  headache, 
of  a  dull,  throbbing  nature  is  common;  it  often  begins  in  the  early 
morning;  it  may  be  occipital  or  hemicranic.  Insomnia  is  common, 
though  during  the  day  the  patient  is  often  sleepy.  Delirium  and  mania 
are  more  frequent  in  chronic  nephritis  in  adults  than  in  juvenile  cases; 
melancholia  and  delusional  insanity  occur;  these  mental  states  may 
assume  medicolegal  importance  as  to  the  testamentary  capacity  of  the 
patient,  (e)  Special  senses.  Sudden,  complete  and  bilateral  blindness 
is  cortical  in  origin;  this  amaurosis  may  be  an  initial  symptom;  there 
are  usually  no  retinal  findings  and  the  condition  lasts  but  a  few  hours, 
though  in  exceptional  cases  edema  or  choking  of  the  disk  is  found.  The 
pupils  are  wide  and  reactionless  in  acute  eclampsia,  but  are  small  and 
mobile  in  chronic  uremia.  There  may  be  sudden  or  gradual  uremic  deaf- 
ness and  tinnitus  aurium.  Barker  remarked  exophthalmos  in  half  his 
patients,  especially  those  with  a  suburemic  state,  retinitis  and  hyper- 
tension; most  of  these  cases  also  exhibited  the  signs  of  v.  Graefe,  Mobius 
and  Stellwag. 

Digestive  Symptoms. — These  rank  second  to  the  nervous  symptoms 
in  frequency.  The  breath  is  often  offensive  and  sometimes  has  an  odor 
of  urine,  which  Senator  considers  of  prognostic  value,  for  it  often  precedes 
eclampsia.  The  tongue  is  foul,  the  mouth  inflamed  and  the  saliva 
increased  (uremic  stomatitis).  Nausea  and  vomiting  are  partly  central 
and  partly  local  from  decomposed  urea,  eliminated  vicariously  into  the 
stomach;  the  same  may  be  said  of  hiccough  and  diarrhea;  the  HCl  is 
decreased.  All  these  symptoms  may  be  very  acute.  Diarrhea  may  be 
serous  or  dysenteric  from  the  B.  dysenterise.  Mathieu  and  Roux  in 
a  study  of  23  cases  of  "uremic  ulcers,"  described  by  Treitz  (1859), 
found  them  chiefly  in  cases  of  advanced  nephritis  in  subjects  under 
twenty  years  old;  they  rarely  occur  in  the  stomach;  diarrhea  is  common, 
but  bowel  hemorrhage  and  constipation  are  rare.  They  are  seemingly 
produced  by  necrosis  due  to  toxemia.  The  prognosis  is  almost  always 
unfavorable. 

Respiratory  and  Cardiac  Symptoms. —  Dyspnea  is  very  common.  It 
is  sometimes  toxic  and  central,  occurring  in  close  parallelism  with  cerebral 
manifestations.  In  other  cases  asthma  uremicum  is  cardiac.  Prodromal 
slowing  of  the  heart  to  60  to  40  beats  is  frequent  in  incipient  uremia. 
The  dyspnea  may  be  continuous  or  paroxysmal  ,and  is  often  nocturnal; 
Cheyne-Stokes's  breathing  is  an  unfavorable  sign,  though  recovery  is 


632  DISEASES  OF  THE  KIDNEYS 

possible.  Obstinate  hoarseness  and  a  rare  form  of  laryngeal  spasm  are 
recorded. 

5.  Other  Complications  a^'d  Symptoms. — (a)  Various  hemorrhages 
occur;  in  the  brain  in  12  per  cent,  of  cases;  also  in  the  diu^a,  nose,  bronchi, 
stomach,  bowels,  uterus,  conjunctiva  or  retina.  Purpura  occurs  espe- 
cially in  recurrent  hemorrhagic  nephritis.  The  author  observed  11  cases 
of  profuse  gastro-intestinal  hemorrhages  in  uremic  subjects,  (b)  Inflam- 
mations: Chronic  bronchitis  always  suggests  kidney  disease.  Pericar- 
ditis, pleuritis  and  pneimionia  especially,  may  develop  as  terminal 
infections.  ]Many  deaths  from  pneumonia  are  due  to  a  previously 
unnoticed  nephritis.  Laryngitis  and  acute  inflammatory  edema  glottidis 
may  occur,  (e)  Edema  is  a  late  symptom  and  results  not  from  the  neph- 
ritis, unless  it  is  of  the  mixed  type,  but  from  cardiac  failure.  Ascites  is 
nearly  always  cirrhotic  or  cardiac,  {d)  The  skin  is  usually  dry,  harsh 
and  sometimes  covered  with  urea  crystals — "urea  frost"  or  uridrosis. 
Itching,  erythema,  urticaria,  eczema  and  numbness  or  "dead  fingers," 
cramps  in  the  calves,  unusual  susceptibility  to  cold  (cryesthesia),  neuritis 
or  rheumatoid  pains  are  probably  toxemic. 

Diagnosis. — There  are  three  cardinal  findings,  cardiovascular,  urinary 
and  retinal;  as  Senator  says,  "He  who  examines  the  iu"ine  and  heart  ih 
every  case  rarely  fails  to  diagnosticate  nephritis." 

Cardiac  Sy:viptoms. — The  very  interdependence  of  cardiac  and  renal 
changes  may  prove  confusing;  thus  primary  cardiac  disease  may  cause 
renal  congestion,  embolism  or  even  acute  or  chronic  nephritis;  again 
alcohol,  syphilis,  etc.,  may  be  a  common  cause  of  arteriosclerosis,  myo- 
carditis, high  blood-pressure  and  nephritis;  and  finally,  the  heart  lesion 
may  be  secondary  to  renal  disease.  Gallop-rhythm  is  more  common 
in*  the  cor  renale  than  in  primary  cardiac  affections. 

Urixary  Fixdixgs. — In  diabetes  mellitiis  there  is  polyuria,  in  which  the 
high  specific  gravity  and  glycosuria  are  distinctive;  in  diabetes  insiindiis 
the  absence  of  albumin,  casts  and  cardiac  changes  are  characteristic; 
and  pyelitis  is  characterized  by  albumin  and  pyuria  but  not  by  casts 
or  cardiac  changes.  In  the  arteriosclerotic  kidney  arterial  and  cardiac 
antedate  the  urinary  changes  (the  converse  is  true  in  interstitial  neph- 
ritis), the  specific  gravity'  is  higher,  albumin  less  in  amount  and  in 
frequencv  of  occurrence  and  the  course  is  much  more  rapid  (see  page 
640). 

Uremia.- — ^Miliary  tuberculosis,  meningitis,  cerebral  abscess  and  sepsis 
may  be  diagnosticated  lu-emia,  because  nephritis  is  also  present  and 
there  is  danger  of  mistaking  uremic  symptoms,  as  hemicrania,  nervous 
s\Tnptoms,  dysentery,  etc.,  for  independent  disease.  Many  authors 
have  remarked  on  the  lack  of  correspondence  between  the  clinical  and 
pathological  findings  in  nephritis.  Uremia  is  assumed  to  be  the  cause 
of  nervous  symptoms  only  when  other  causes  may  be  excluded,  because 
in  the  course  of  renal  disease  organic  lesions,  as  cerebral  hemorrhage,  may 
simulate  uremia.  Though  the  urine  is  usually  decreased,  Liebermeister 
instances  a  case  in  which,  immediately  before  a  uremic  seizure,  both  urine 
and  urea  were  increased  twofold.  Biermer  reports  an  anuria  which  lasted 
two  hundred  and  twenty-two  hours  before  uremia  developed. 


CHRONIC  NEPHRITIS  633 

Apoplexy  is  probably  present  when  pressure  symptoms,  as  vomiting 
or  slow  tense  pulse,  complete  hemiplegia  or  conjugate  deviation  exist; 
it  is  rarely  completely  simulated  by  uremia.  Meningitis,  insolation  and 
alcohol  or  opium  coma  are  rarelv  simulated.  The  author  has  seen  a  few 
cases  in  which  uremia  simulated  typhoid  or  sepsis  by  the  constant  high 
temperature. 

Prognosis. — It  is  often  detected  only  w^hen  the  patient  suffers  from 
cardiac  insufhciencv,  beginning  uremia,  apoplexy  or  intercurrent  inflam- 
mation; for  this  reason  this  incurable  malady  is  seldom  treated  in  its 
early  stages.  The  clinical  course  usually  runs  five  to  ten  years  after 
albuminuria  is  found;  a  course  of  twenty  to  thirty  years  is  reported. 
Much  depends  on  the  docility  and  financial  ability  of  the  patient.  Marked 
arteriosclerosis  hastens  the  fatal  issue.  Retinitis  is  an  ominous  symptom 
and  increases  the  gravitv  of  the  outlook  fourfold;  in  Belt's  419  cases  72 
per  cent,  died  in  one  and  90  per  cent,  in  two  years.  Webstei,  Wert, 
Hare  and  the  author  report  cases  which  lived  from  four  to  ten  years 
after  retinitis  was  found.  Uremia,  pneumonia,  apoplexy  and  other 
complications  are  unfavorable. 

Treatment  of  Chronic  Nephritis,  Parenchymatous  and  Inter- 
stitial. —  Both  forms  are  considered  together,  because  they  often 
blend. 

1.  Prophylaxis. — Prevention  and  treatment  of  the  cause  have  a 
very  limited  practical  application.  Irritating  foods,  excessive  eating, 
all  forms  of  intemperance,  overwork,  neglect  of  infections  and  dyspepsia 
come  under  this  head,  but  are  usually  treated  too  late. 

2.  Rest,  Exercise. — The  kidneys  may  be  relieved  by  rest  in  the 
horizontal  posture,  as  recognized  by  Bright.  Rest  should  be  absolute 
as  long  as  the  heart  is  weak,  the  urine  scanty  or  hydrops  conspicuous. 
In  moderate  renal  involvement  or  in  intervals  of  improvement  moderate 
exercise  is  advisable.  Rest  in  bed  lessens  the  amount  of  waste  products 
to  be  eliminated  by  the  kidneys  and  so  protects  the  skin  and  dilates  its 
vessels  that  the  cutaneous  functions  become  more  active.  The  author 
treated  2  severe  cases  of  parenchymatous  nephritis  by  rest  in  bed  for 
a  year  and  permanent  recovery  resulted.  Fatigue,  dampness  and  cold 
must  be  avoided,  by  rest  in  bed  during  severe  symptoms  or  acute  exacer- 
bations and  by  relative  rest  and  w^arm  clothing  in  cases  of  moderate 
severity.  In  men  leading  a  strenuous  life,  moderate  nephritis  is  often 
improved  when  nervous  tension  is  relieved;  in  any  event  exercise  should 
supplant  work  and  not  be  taken  after  hard,  nervous  strain. 

3.  Springs,  Climate. — At  water  resorts  the  importance  of  diet  and 
hygiene  is  impressed  on  the  patient;  the  suggestive  element  is  also  im- 
portant. Diffuse  nephritis  (with  both  parenchymatous  and  interstitial 
changes)  is  most  benefited.  Only  patients  without  edema  or  serious  heart 
involvement  should  be  sent  to  such  places  as  Poland  Springs,  Bedford 
Springs,  Saratoga,  Vichy  or  Neuheim.  A  stay  in  California,  Mississippi 
or  Texas  during  the  winter,  at  least,  will  materially  benefit. 

4.  Diet. — The  diet  must  be  non-irritative,  must  not  especially  tax 
the  kidneys  in  its  elimination,  must  not  burden  the  circulation  and  must 
maintain  nutrition.    Disease  of  the  glomeruli  alone  may  be  compensated 


(334  biSMASES  OF   THE  KIDNEYS 

by  vicarious  excretion  of  water  through  the  huigs,  skin  and  intestines, 
but  disease  of  the  tubules  whose  function  is  ehmination  of  the  end- 
products  of  protein  metabohsm,  cannot  well  be  compensated  by  other 
structures,  whence  the  indication  for  limifaiion  of  albuminous  foods  and  • 
substitution  by  fats  and  carbohydrates.  It  is  less  important  what  pro- 
tein the  kidney  can  eliminate  than  to  determine  what  amount  of  protein 
must  be  ingested  to  spare  the  body  protein,  e.  g.,  the  myocardium  from 
fatty  change;  50  gm.  is  sufficient  for  a  short  time  and  85  gm.  over  a  longer 
period.  The  small  amount  of  albumin  lost  through  the  kidneys  can  be 
offset  by  a  glass  of  milk  daily;  in  this  respect  nephritis  differs  from  dia- 
betes in  which  the  system  is  irritated  by  unappropriated  sugar  and  loses 
a  vast  number  of  units  of  heat  and  energy.  It  is  a  mistake  to  gauge 
the  severity  of  a  nephritis  by  the  degree  of  albuminuria  or  to  estimate 
improvement  by  the  influence  of  diet  upon  the  albuminuria  alone.  Fats 
as  butter,  olive  oil  and  cream,  are  very  important  in  replacing  albumin. 
As  in  diabetes  the  restriction  of  diet  most  of  all  concerns  the  maintenance 
of  nutrition,  especially  when  the  patient  suffers  from  parench^Tuatous 
nephritis,  the  form  in  which  restriction  of  diet  is  theoretically  most 
needed,  but  in  which  anemia  and  malnutrition  distinguish  it  from  the 
interstitial  t\-pe.  The  patient  is  considered  more  than  the  disease  or  the 
type  of  the  disease. 

The  milk  diet  is  free  of  extractives  and  poor  in  salt,  and  influences 
the  albuminuria  more  favorably  than  other  proteins.  It  has  its  restric- 
tions; it  is  bulky,  3.5  quarts  being  required  to  maintain  nutrition  at 
rest  (2200  calories),  and  it  therefore  may  cause  dyspepsia,  containing 
an  excess  of  about  60  per  cent,  of  protein;  it  lacks  iron,  but  this  can  be 
easily  compensated;  it  contains  too  much  water,  thereby  overloading 
the  heart;  and  its  phosphates  tax  the  kidneys.  One  to  one  and  a  half 
quarts  of  milk  with  a  pint  of  cream,  fats  and  carbohydrates  (baby  foods, 
sago,  rice  or  potatoes)  meet  the  needs  of  metabolism;  over  half  of  the 
phosphates  can  be  precipitated  in  the  intestine  by  calcium  carbonate, 
gr.  X,  with  the  milk.  It  should  be  taken  in  sips,  as  it  is  a  food,  not  a 
beverage.  ]MiIk  was  a  favorite  article  of  diet  with  the  older  masters  of 
medicine;  a  short  time  ago  we  heard  that  it  contained  an  excess  of  water; 
now  it  is  exceUent  because  it  contains  little  salt  I 

The  present  reaction  in  favor  of  meat  is  extreme,  as  it  promotes  uremia. 
The  average  daily  amount  is  100  gm.  There  is  no  difference  between 
red  and  white  meats  as  to  extractives  or  purin  bodies.  Some  meat  is 
preferable  to  overloading  the  stomach  with  a  bulky  vegetable  diet,  save 
when  uremia  is  imminent.  Boiled  meats  contain  less  extractives.  Game 
is  interdicted. 

Raw  eggs  increase  (perhaps  induce)  albuminuria;  three  cooked  eggs 
are  allowed.  Substances  excreted  with  difficulty  include  the  following, 
according  to  von  Xoorden:  Urea  (in  meat),  creatinin  (in  meat  broths, 
extractives  and  to  a  less  extent  in  eggs),  urinary  pigments  (in  hemo- 
globin), hippuric  acid  (in  cranberries,  fruits  with  pits,  prunes,  plums  and 
gages),  phosphates  (in  milk)  and  inorganic  sulphates  (in  meats);  uric 
acid  and  alloxur  bodies  found  in  glandular  organs — the  thymus,  sweet- 
breads, liver  and  kidnev — in  broths  and  coffee  are  eliminated  readily. 


CHRONIC  NEPHRITIS  635 

The  chlorides  and  also  sod.  bicarb,  and  phosphate  are  especially  avoided 
in  parench\'matous  nephritis  with  edema.  As  pointed  out  by  Widal, 
Lemerre  and  Javal,  in  1902,  administration  of  salt  (which  is  retained  in 
the  body)  increases  the  body  weight,  induces  edema  and  aggravates 
albuminuria,  while  "  dechloruration"  of  the  food  reduces  weight,  edema 
and  albuminuria.  Salt  probably  raises  arterial  tension.  The  tissues 
ordinarily  demand  2-3  gm.,  but  most  people  take  10  gm.  or  more.  Milk 
contains  2  gm.  per  liter  and  meat  soups  6-8.  The  salt  in  bread  and 
butter  may  be  disregarded.  Rice,  potatoes,  sugar  and  eggs  may  be 
given.  In  acute  or  early  nephritis,  salt  is  excreted  in  excess  (polychlor- 
uria),  as  the  tubules  are  oversensitive;  later  they  are  less  sensitive  and 
there  is  achloruria;  the  pot.  iodide  and  phenolsulphonephthalein  tests 
concern  the  same  tissues.  Widal  differentiates  two  stages  of  edema, 
the  deep  or  invisible  and  the  obvious;  the  former  is  distinguished  only 
by  regularly  weighing  the  patient.  He  designates  the  retention  of  chlo- 
rides as  hydropic  uremia  and  nitrogen  retention  as  dry  uremia.  Irritants, 
as  cheese,  relishes,  horse-radish,  onions,  rhubarb,  garlic,  radishes,  aspara- 
gus, spices,  sauces,  broths,  beef-tea  and  alcohol,  should  be  absolutely 
avoided;  tea  and  coffee  because  they  may  aggravate  or  produce  nephritis 
and  tobacco  must  be  limited. 

5.  Water. — In  regard  to  water,  the  same  extremes  of  opinion  are 
noted;  fluids  were  once  excessively  restricted  and  later  undue  quantities 
were  recommended;  von  Noorden  states  that  flooding  the  vascular 
system  with  water  overtaxes  the  heart;  "water  can  only  be  excreted  by 
the  kidney  if  the  blood-pressure  is  increased;  many  patients  having  weak 
hearts  give  a  history  of  excessive  water  drinking;  in  such  cases  improve- 
ment is  frequent  if  the  ingestion  of  water  is  limited."  The  maximum 
elimination  of  waste  substances  occurs  on  about  1500  c.c.  of  fluids; 
500-1000  c.c.  are  given  when  there  is  edema.  We  consider  the  weight 
of  the  patient  and  the  in-  and  output  of  fluid  from  the  kidneys  and 
bowels.  The  urinary  output  is  70  per  cent,  of  the  water  ingested.  1500 
c.c.  of  water  ingested  (+  500  in  food)  =  1500  c.c.  of  urine  (+  500  c.c. 
excreted  by  the  lungs  and  skin).  In  early  or  acute  nephritis,  there  is 
polyuria,  due  to  increased  sensitiveness  of  the  bloodvessels,  and  loss  of 
power  to  concentrate  the  urine;  later  there  is  normaluria  and  eventually 
oliguria  or  anuria  (decreased  sensitiveness  of  the  glomeruli). 

The  folloiving  therapeutic  measures  are  hut  symptomatic: 

6.  Diuretics. — Diuretin  produces  no  renal  hyperemia  but  acts  directly 
on  the  epithelium  and  sometimes  reduces  the  albuminuria  {v.  page  377). 
The  use  of  diuretics  is  indicated  by  increase  of  hydrops,  scanty  urine  and 
imminent  uremia.  Theocin  is  more  efficacious,  given  well  diluted  to 
avoid  nausea.  Diuretics  first  increase,  and  then  decrease  the  urine 
(fatigue  of  the  kidneys);  they  are  injurious  when  the  organs  have  lost 
their  power  to  secrete.  The  refrigerants  (cream  of  tartar,  5j)  or  potas- 
sium citrate  (gr.  xx-xxx)  are  the  safest  diuretics;  they  are  thought 
to  abstract  water  from  the  tissues  and  facilitate  the  excretion  of  urea, 
uric  acid  and  similar  products.  Basham's  mixture  (liq.  ferri  et  ammonii 
acetatis)  as  a  tonic  and  diuretic  should  be  given  in  doses  of  1  or  2  drams. 
Digitalis  perhaps  is  a  renal  stimulant. 


636 


DISEASES  OF  THE  KIDNEYS 


7.  Hydrops. — Hydrops  necessitates  treatment  because  it  prevents 
movement,  threatens  suffocation  by  pulmonary  or  laryngeal  edema, 
increases  the  danger  of  secondary  infection,  as  erysipelas  or  cellulitis, 
embarrasses  the  circulation  by  pressure  on  the  afferent  capillaries  and 
efferent  lymphatics  and  venules,  interferes  with  digestion  and  increases 
the  danger  of  m-emia.  (a)  Though  cathartics  may  eliminate  fluids  as 
well  as  solids,  drastics  must  be  given  with  due  care  for  the  digestion 
and  nutrition;  vegetable  are  better  than  saline  cathartics.  Purging 
in  nephritics  may  increase  the  protein  in  the  movements  even  to  30  per 
cent,  (normally  10  per  cent.).  Watery  stools  are  produced  by  pulv. 
jalapse  co.,  5j>  or  elaterinum,  gr.  y&,  but  not  by  cascara,  rhubarb,  aloes, 
senna  or  phenolphthalein;  liq.  magnes.  citrat.  contains  an  excess  of  water 
and  Pluto,  etc.,  an  excess  of  chlorides;  concentrated  Epsom  salts  may  in- 


FiG.  48. — Sweat  bath  employed  in  nephritis. 


duce  fatal  results,  (b)  Siceats.  Though  the  functional  relation  between  the 
skin  and  kidneys  cannot  be  overestimated,  profuse  sweating  eliminates  fluid 
rather  than  solids  (about  2  gm.  each  of  CI  and  N  per  liter).  When  a 
patient  sweats  one  quart  (1000  c.c.)  7  to  15  grains  (0.5  to  1  gm.)  of  urea 
are  eliminated.  Sweats  do  not  concentrate  the  blood  and  predispose  to 
uremia,  but  lower  the  blood-pressure  10  to  20  mm.,  by  diverting  blood  from 
the  splanchnic  to  the  cutaneous  vessels.  The  author  has  seen  a  fatal  issue 
result  from  sweating  and  prefers  the  old-fashioned  full  warm  bath  of 
Osborne  and  Liebermeister,  to  the  more  active  methods;  an  ice-bag  is 
placed  on  the  head  to  prevent  brain  congestion.  Commencing  with 
water  at  body  temperature  this'  is  raised  five  or  six  degrees.  After 
twenty  or  thirty  minutes  the  patient  is  removed  and  wrapped — without 
drying — in  blankets.  A  hot-air  bath  may  be  given  by  placing  a  lamp 
under  one  end  of  a  stove-pipe  which  runs  by  an  elbow  into  a  tent  built 


CHRONIC  NEPHRITIS  637 

over  the  patient.  In  the  alcohol  sweat,  hot  bricks  protected  by  flannel 
are  placed  around  the  heavily  covered  patient;  equal  parts  of  alcohol 
and  water  are  poured  on  the  bricks  and  the  patient  is  covered  again; 
the  steam  vapor  is  well  tolerated  unless  the  heart  is  weak,  when  fatal 
collapse  may  ensue.  It  is  often  unsafe  to  give  pilocarpine,  gr.  3-  (page 
623),  because  it  may  produce  vomiting,  diarrhea,  syncope,  pulmonary 
edema  and  sudden  death,  even  when  the  heart  appears  strong,  (c) 
Mechanical  relief  by  means  of  incision  is  superior  to  all  other  measures 
which  must  first  bring  the  fluid  with  all  its  urea  and  extractives  into 
the  circulation,  with  the  danger  of  inducing  uremia.  The  author  makes 
deep  incisions,  three  inches  long,  over  the  lower  leg  (not  over  the  malleoli 
where  infection  from  the  feet  is  likely).  In  testing  the  fluid  evacuated 
there  has  frequently  been  0.1  per  cent,  urea,  a  measure  for  other  retained 
products  of  kindred  nature;  quarts  often  seep  out.  Free  incision  is 
obviously  less  dangerous  than  punctures  or  Southey's  capillary  tubes. 
8.  The  Circulation. — Treatment  often  resolves  itself  into  the  care 
of  the  heart.  Excitement,  nervous  strain,  physical  exertion,  constipa- 
tion, tobacco,  coffee,  alcohol  and  exposure  to  heat  must  be  avoided, 
as  cardiac  dilatation  is  the  inevitable  fate  of  hypertrophy.  In  the 
uremic  seizures,  with  the  same  symptoms  in  other  respects,  the  heart 
may  beat  strongly  or  weakly,  (a)  With  cardiac  over  action  observed 
early  in  uremia,  the  high  tension  must  be  corrected  by  vasodilators 
(see  pages  399  and  400) .  Iodides  are  beneficial  when  there  is  no  urgency, 
grs.  X,  t.  i.  d. ;  iodism,  especially  salivation,  may  result  from  renal  reten- 
tion. When  extreme  tension  and  imminent  uremia  exist,  tr.  veratri 
viridi,  TUv-x,  every  half-hour  for  three  doses  may  be  given;  the  author 
prefers  spiritus  glycerylis  nitratis,  TTlij,  until  results  are  produced;  vaso- 
dilators are  often  given  to  excess,  as  hypertrophy  and  increased  arterial 
tension  are  less  pathological  than  compensatory  conditions.  Chloral 
frequently  operates  better  than  any  other  remedy.  Lowering  the  tension 
30-40  points,  decreases  elimination  of  solids  and  fiuids.  Bleedi7ig  may 
relieve  the  intracranial  blood-pressure,  lessen-  the  molecular  concen- 
tration of  the  blood  (i.  e.,  its  toxicity),  relieve  the  laboring  heart, 
and  avert  for  awhile  the  uremia;  salines  may  be  given  afterward, 
either  subcutaneously  or  by  rectum;  they  "lavage  the  blood."  An 
excess  of  salt  may  be  given  in  the  infusions  («.  s.)  and  when  they 
are  repeated  the  salt  should  be  left  out,  for  it  may  induce  edema  of  the 
lungs.  Bouchard  states  that  the  abstraction  of  32  gm.  of  blood  removes 
more  toxins  than  280  gm.  of  fluid  feces  or  100  liters  of  sweat.  Increased 
intracranial  tension  may  be  relieved  by  lumbar  puncture;  the  normal 
pressure  of  120  mm.  is  increased,  sometimes  to  600  mm.;  the  author 
remarked  relief  of  the  headache,  vomiting,  convulsions  and  coma,  (b) 
When  the  heart  is  weak,  rapid,  irregular  or  galloping,  cardiac  stimula- 
tion by  digitalis  and  strychnine  is  indicated.  Infusion  of  digitalis  by 
mouth  may  cause  vomiting  and  ITlij-v  of  the  fluidextract  may  then  be 
given  hypodermically  or  by  rectum.  Its  combination  with  calomel 
may  cause  the  most  intense  salivation  and  in  one  instance  necrosis  of 
the  entire  tongue.  Cardiac  unrest,  palpitation  or  dyspnea  should  be 
relieved  by  a  hypodermic  of  morphine,  by  application  of  ice  to  the  heart 


638  DISEASES  OF   THE  KIDNEYS 

or  by  champagne,  nitroglycerin,  bromides  and  valerian.  Pilocarpine 
and  sweats  overtax  or  fatally  depress  the  heart.  \^on  Ziemssen  gave 
champagne  and  digitalis  by  mouth  as  long  as  the  patient  could  swallow 
and  then  digitalis  by  rectum  and  camphor  subcutaneouslv. 

9.  Vomiting. — Vomiting  and  diarrhea  are  as  often  vicarious  as  toxemic 
and  should  not  be  checked  at  once.  Gastric  lavage  and  colonic  flushings 
are  beneficial.  If  improvement  ensues,  a  starvation  diet  should  be  insti- 
tuted. 

10.  CoNTULSiONS. — Hypodermics  of  morphine  should  be  given  (though 
medical  opinion  is  generally  against  it),  with  chloral  (gr.  xv  every  hour 
for  iiot  more  than  four  doses). 

11.  Operation. — Many  cases  of  "  decapsulated"  kidney  are  not 
genuine  nephritis,  but  albuminuria  from  floating  kidney  or  ascending 
infection,  and  nephritis  is  more  than  merely  a  renal  disease,  perhaps  a 
result  of  a  general  blood  condition. 

PASSIVE    CONGESTION.     EMBOLISM. 

I.  Passive  Congestion. — Venous  hyperemia  is  an  important  lesion 
compared  with  arterial  h;s'peremia,  of  which  latter  little  is  definitely 
known,  though  it  occurs  in  renal  inflammation,  diabetes  and  after  the 
administration  of  diuretics. 

Etiology — (a)  Among  the  chief  causes  of  general  stasis  are  cardiac 
insufficiency  from  valvular  disease,  myocarditis  and  pulmonary  emphy- 
sema. (6)  Local  stasis  has  scarcely  any  part  in  the  renal  pathology. 
Berkmann  (1859)  described  renal  stasis  and  thrombosis  of  the  renal 
veins  occiu"ring  in  the  newborn  or  nurslings  after  severe  diarrhea;  when 
unilateral  there  is  renal  pain,  great  albuminuria,  some  hematuria,  swell- 
ing of  the  kidney  and  decreased  urine;  most  cases  of  bilateral  thrombosis 
die  from  uremia.  Thrombosis  of  the  cava  and  pressure  by  large  tumors 
may  cause  passive  congestion. 

Pathology. — The  slowing  of  the  arterial  flow  and  to  a  less  degree  venous 
hyperemia,  alter  the  integrity  of  the  secreting  renal  structures,  notably 
the  glomeruli.  In  experiments,  arterial  insufficiency  causes  initial  glome- 
rular alteration,  while  venous  obstruction  causes  primary  congestion 
in  the  medullary  portion. 

Early  Changes. — The  kidney  is  swollen,  dark  and  firm  and  the 
stellate  veins  are  prominent.  On  section  it  expands  beyond  its  close- 
fitting  capsule,  which  is  readily  stripped  off.  The  organ  is  very  vascular 
and  may  drip  blood.  The  glomeruli  are  seen  as  dark  red  points  and 
the  medullary  bloodvessels  are  clearly  defined.  ]\Iicroscopically  the 
conspicuous  changes  are  hyperemia,  occasionally  with  punctate  hemor- 
rhages, fatty  and  cloudy  degeneration  of  the  epithelium  of  the  tufts  and 
convoluted  tubules,  escape  of  albumin  into  them,  forming  hyaline  casts 
in  the  tubules,  and  finally  some  thickening  of  the  vessels. 

Late  Changes. — Prolonged  stasis  leads  to  greater  atrophy  of  the 
secreting  structures  and  to  increase  of  connective  tissue;  this  "cyanotic 
induration"  has  been  rather  overdrawn  in  clinical  descriptions,  but  may 
result  from  extreme  and  protracted  stasis.    The  kidney  becomes  pale  and 


AMYLOID  DEGENERATION  OF   THE  KIDNEY  639 

firm,  the  cortex  shrinks  and  connective  tissue  develops  in  the  medulla, 
^licroscopically,  fibrillar  connective  tissue,  thickening  of  Bowman's 
capsule  and  epithelial  degeneration  are  found. 

Symptoms. — The  urinary  findings  are  of  chief  interest.  The  urine  is 
decreased  and  its  amount  directly  follows  the  heart's  activity.  It  is 
acid,  dark,  concentrated  (specific  gravity  1.025  to  1.030)  and  it  has  a 
lateritious  sediment  of  urates  and  uric  acid.  Albumin  and  globulin  are 
present  in  moderate  amounts.  Microscopically  a  few  leukocytes,  epithe- 
lial cells  and  hyaline  casts  are  found;  granular  casts  are  seldom  found; 
red  cells  indicate  nephritis  or  infarction. 

Diagnosis. — The  urinary  findings  are  significant  in  association  with 
the  causal  lesion;  edema  begins  in  the  legs;  the  nutmeg  liver,  dyspnea, 
cyanosis  and  pulmonary  stasis  are  present.  The  percentage  of  albumin 
runs  parallel  with  the  strength  of  the  heart,  increasing  with  its  failure 
or  decreasing  if  digitalis  or  strychnine  improve  its  action.  If  cardiants 
increase  the  urine,  and  if  abundant  albumin  and  casts  still  remain,  there 
is  probably  coincident  nephritis.     (See  page  640.) 

II.  Embolism. — Valvular  disease  of  the  left  heart  is  its  predisposing 
cause.  Sixty-six  to  75  per  cent,  of  all  embolisms  are  renal.  Stoppage 
of  a  renal  terminal  artery  causes  the  well-known  wedge-shaped  anemic 
infarct  in  twenty-foiu-  to  thirty-six  hours;  the  local  ischemia  causes 
fatty  degeneration,  necrosis  and  a  finely  granular  transudation  into 
the  connective  tissue  and  glomeruli.  Fibrous  substitution  occurs  with 
ultimate  shrinkage  and  deformity.  Repeated  infarctions  produce  the 
irregular  "embolic  contracted  kidney."  The  process  may  be  innocent 
(mechanical)  or  less  commonly  suppurative. 

Symptoms. — In  most  cases  there  are  no  symptoms.  Exceptionally  a 
diagnosis  is  possible,  based  on  (1)  the  valvular  lesion;  (2)  sudden  onset 
with  fever,  chills  and  vomiting;  (3)  lumbar  pain  and  tenderness  and 
(4)  hematuria  and  albuminuria.    Treatment  is  symptomatic. 

AMYLOID   DEGENERATION   OF   THE   KIDNEY. 

Etiology. — The  etiology  of  amyloid  kidney  is  that  of  amyloid  liver 
(ry.  v.),  i.  e.,  ulcerative  tuberculosis,  protracted  siqjpuration  and  inveterate 
syphilis.  First  described  by  Rokitansky  (1842),  its  symptomatology 
was  developed  by  Wilkes,  Todd  and  Traube. 

Pathology. — Renal  amyloidosis  seldom  occurs  without  amyloid  of 
the  liver  and  spleen.  To  the  naked  eye  the  kidneys  generalh'  appear 
enlarged,  weighing  together  even  as  much  as  870  gm.;  when  amyloid 
infiltration  is  slight,  there  may  be  no  alteration  in  size  or  weight;  in 
some  cases  the  kidneys  are  large  from  coincident  chronic  parenchymatous 
or  small  from  interstitial  nephritis.  The  capsule  strips  readily,  showing 
a  pale,  smooth  surface.  On  section  the  cortex  is  enlarged,  waxy  and  pale 
and  its  edge  translucent;  the  glomeruli  stand  out  as  glistening  points  and 
become  brown  when  treated  with  Lugol's  solution.  IMicroscopically 
the  amyloid  substance  can  be  seen  clearly;  it  is  so  named  because  of 
its  starch-like  reaction,  though  chemically  it  is  an  albuminoid.  It  is 
either  deposited  from  the  blood  in  the  small  vessels  or  more  probably 


640 


DISEASES  OF   THE  KIDNEYS 


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642  DISEASES  OF  THE  KIDNEYS 

formed  in  situ,  especially  in  the  glomeruli,  then  in  their  afferent  vessels 
and  the  straight  vessels  of  the  medulla.  The  renal  interstitium  is  involved 
secondarily;  the  memhrana  j^ropria  may  be  affected  but  the  cells  may 
suffer  only  secondary  compression,  degeneration  and  atrophy. 

Symptoms. — (a)  Urinary  symptoms  are  exceptionally  absent.  The 
urine  is  generally  limpid  and  increased,  but  may  be  decreased  when 
amyloid  degeneration  is  associated  with  parenchymatous  or  greatly 
increased  when  associated  with  interstitial  nephritis;  some  writers  place 
undue  importance  upon  variability  in  its  amount.  The  specific  gravity 
is  1.010  to  1.015  or  higher  in  syphilitic  cases.  Albuminuria  is  u^ual, 
being  absent  only  in  exceptional  cases  which  invade  the  vasa  recta  and 
evade  the  glomerular  capillaries;  albuminuria  results  from  increased 
permeability  of  the  glomerular  vessels  and  may  ajnount  to  1  or  2  per 
cent.;  Senator  remarked  the  large  amount  of  globulin  in  the  urine. 
There  is  little  change  in  the  solids;  indicanuria  is  not  infrequent.  ^Nlicro- 
scopically  hyaline  casts  may  be  present  and  perhaps  a  few  leukocytes 
and  epithelia,  but  the  sediment  is  scanty  in  most  cases;  the  so-called 
waxy  or  amyloid  casts  found  in  severe  nephritides  have  no  relation  to 
amyloidosis  of  the  kidney,  (b)  Cardiac  hypertrophy,  uremia  and  retin- 
itis, do  not  occur  in  renal  amyloidosis,  except  when  it  is  associated  with 
nephritis,  (c)  Amyloid  degeneration  of  both  the  spleen  and  liver  and 
sometimes  the  alimentary  tract  is  associated  in  66  per  cent,  of  cases; 
these  and  the  causal  disease  are  necessary  for  diagnosis,  (d)  Edema 
and  anemia,  which  is  almost  cachexia,  are  usual  in  diffuse  amyloidosis. 
Hydrops  of  the  serous  sacs,  especially  ascites,  is  less  common  than  edema 
and  usually  occurs  as  a  late  or  terminal  event.     Differentiation  {v.  p.  640). 

Prognosis. — ^Amyloid  disease  is  incurable,  though  light  grades  may 
recede.  Amyloid  of  the  kidneys  in  most  cases  runs  its  course  in  a  year 
or  less,  particularly  when  associated  with  parenchymatous  nephritis. 
Cases  may  endure  for  several,  even  fifteen  years,  but  these  are  generally 
complicated  b}'  contracted  kidney. 

Treatment. — With  modern  surgical  methods  and  early  treatment  of 
tuberculosis  and  syphilis  amyloid  disease  is  less  common  than  formerly; 
for  the  developed  disease  there  is  no  treatment. 

MALFORMATIONS    OF    THE    KIDNEY. 

I.  Malforaiations  and  Structural  Anomalies  of  the  Kidney. — These 
are  of  little  clinical  importance.  Complete  absence  or  rudimentary 
development  of  both  kidneys  occurs  only  in  unviable  infants. 

One  kidney  may  be  absent  or  rudimentary,  whereon  the  normal  kidney 
vicariously  hypertrophies  and  may  be  mistaken  for  malignant  disease, 
whence  its  removal  is  fatal.  In  Ballowitz's  184  cases  61  per  cent,  occurred 
in  males  and  in  63  per  cent,  the  left  kidney  was  lacking.  Absence 
of  one  kidney  is  usually  associated  with  unilateral  malformation 
of  the  internal  genitalia,  but  this  is  not  true  in  unilateral  renal  atrophy 
or  in  horseshoe  kidney.  Before  operation  cystoscopy  is  imperative  in 
doubtful  cases  to  determine  the  presence  of  two  ureters,  Two  ureters 
may  come  from  one  kidney. 


MALFORMATIONS  OF   THE  KIDNEY  643 

Fifteen  cases  of  supernumerary  kidneys  are  recorded  (Graser)  and  in 
2  cases  there  were  four  kidneys. 

The  "  horseshoe"  kidney  (ren  arcuatus)  due  to  the  fusion  of  both  kid- 
neys, is  fairly  common ;  it  may  cause  pain.  Errors  in  diagnosis  are  com- 
mon, especially  if  the  kidney  is  dislocated  and  are  inevitable  if  the  renal 
pelvis  is  inflamed  or  dilated.  The  ren  arcuatus  has  been  mistaken  for  a 
tumor  and  extirpated. 

II.  Movable  Kidney. — Congenital  dislocation  occurs  twice  as  frequently 
in  males  as  in  females  and  is  usually  left-sided,  wherein  it  differs  from 
the  acquired  form,  and  frequently  coincides  with  congenital  anomalies 
of  the  genitalia  and  intestines.  The  kidneys  may  lie  one  upon  the  other 
(dystopia  renum  cruciata),  of  which  Chatelin  could  collect  but  15  cases. 

Acquired  dislocation,  described  by  Rayer  a  century  ago,  is  much  more 
common  and  important.  It  is  called  movable  or  floating  kidney,  ren 
mobilis  s.  migrans,  ectopia  renis  acquisita  or  nephroptosis. 

Etiology. — (a)  Sex;  88  per  cent,  occur  in  women,  (b)  Age;  most 
cases  occur  between  the  twentieth  and  fiftieth  years.  Comby  reports 
18  and  Abt  5  cases  in  children,  (c)  The  kidney  is  supported  by  the  fat 
around  it,  the  peritoneum  in  front  of  it  and  by  its  own  bloodvessels. 
Among  the  alleged  causes  are:  atrophy  of  the  perirenal  fat;  the  presence 
of  a  mesonephron  surrounding  the  kidney  to  a  variable  extent;  loeakening 
of  the  abdominal  walls  by  pregnancy  and  other  causes;  alterations  in 
the  intra-abdominal  pressure  by  malpositions  of  the  uterus;  pressure 
by  corsets;  congenital  laxness  of  the  supporting  structures,  in  connection 
with  which  Stiller  claims  that  the  tenth  rib  is  usually  "floating"  like 
the  eleventh  and  twelfth  ribs  (costa  fluctuans  decima);  tumors  of  the 
kidney,  which  drag  it  downward;  and  trauma  or  sudden  efforts.  Enterop- 
tosis  is  frequently  observed  with  floating  kidney. 

Symptoms. — Symptoms  are  absent,  probably  in  most  cases;  they 
may  date  from  the  time  when  the  physician  incautiously  remarks  upon 
the  presence  of  a  "floating  kidney." 

1.  Pain. — Pain  may  be  merely  a  dragging  sensation  or  severe  renal 
colic,  from  stretching  of  the  renal  nerves;  it  may  be  lumbar,  abdominal 
or  may  shoot  toward  the  chest,  thigh  or  sciatic  region ;  it  may  be  constant 
or  intermittent  like  a  crisis  {v.  i.). 

2.  Objective  Kidney  Findings. — On  bimanual  examination  with 
one  hand  over  the  kidney  in  front  and  the  other  pushing  it  up  from 
behind,  the  findings  vary;  (a)  frequently  the  kidney  is  not  painful  or 
tender,  but  palpable,  which  condition  has  no  significance,  especially  in 
women;  (6)  the  kidney  may  be  movable,  descending  on  deep  inspiration, 
maybe  to  the  navel,  where  it  can  be  retained  by  pressure  during  expira- 
tion; movable  kidney  is  found  in  20  per  cent,  of  women;  (c)  the  most 
extreme  type  is  floating  kidney,  which  may  wander  to  the  lower  abdomen 
or  pelvis,  even  into  a  hernial  sac.  In  76  per  cent,  of  cases  the  right  kidney 
is  involved,  in  11  per  cent,  the  left  and  in  13  per  cent,  both  kidneys 
(Kiittner) ;  the  right  kidney  has  longer  vessels,  but  the  left  renal  vein 
is  more  firmly  connected  with  the  suprarenal  vein  and  the  pancreas. 
When  the  kidney  is  grasped  a  sickening  sensation  sometimes  results,  as 
when  the  testicle  is  compressed.    The  smooth  tumor  is  recognized  by  its 


644  DISEASES  OF   THE  KIDNEYS 

shape.  In  rare  cases  the  pulsating  renal  vessels  are  felt.  It  may  be  felt 
only  in  the  standing  posture  or  in  the  left  decubitus.  Occasionally  tym- 
pany can  be  found  along  the  spine,  over  the  dull  area  normally  occupied 
by  the  kidney,  which  merges  with  the  liver  and  spleen  above  and  extends 
outward  2.5  inches  on  the  left  and  3.5  inches  on  the  right  side.  In  thin 
subjects  the  sinking-in  of  the  back  and  the  tumor  in  front  may  some- 
times be  clearly  seen. 

3.  Complications. — (a)  The  same  train  of  neurasthenic,  hysterical 
or  hjT^ochondriacal  symptoms  are  present  as  in  enteroptosis.  Nervous 
dyspepsia  is  particularly  common,  (b)  Dietl  (1864)  described  sudden 
severe  pain  and  collapse  known  as  "Dietl's  crises;"  they  are  marked  by 
fever,  chill,  vomiting,  collapse,  severe  pain,  sometimes  with  swelling  and 
tenderness  of  the  kidney,  scanty  urine  containing  blood,  pus,  uric  acid 
and  oxalates  and  in  some  instances  peritonitic  manifestations;  Dietl's 
theory  that  the  kidney  became  "incarcerated"  between  the  connective 
tissue  and  peritoneum  is  now  abandoned;  in  one  of  Sutton's  cases  the 
ureter  was  found  twisted  three  times,  causing  acute  renal  retention  and 
hydronephrosis.  Perhaps  the  renal  vessels  suffer  torsion  or  the  crises  are 
due  to  acute  nephritis  or  peritonitis,  (c)  Dilatation  of  the  stomach  is 
only  a  coordinate  and  not  at  all  a  common  coincidence,  (f/)  Bysvienor- 
rhea,  constipation  and  enteroptosis  are  common  complications.  Colitis 
mucosa,  compression  of  the  intestine,  icterus,  abdominal  aneurysm  by 
tugging  upon  the  aorta  and  compression  of  the  cava  inferior  are  rare 
and  questionable  sequences.  Albuminuria  may  occur  periodically,  on 
palpation  of  the  kidney  or  when  the  patient  stands  (orthostatic  type). 

Diagnosis. — The  finding  of  the  sensitive  kidney-shaped  movable  tumor 
is  most  important.  It  may  be  mistaken  for  movable  omental,  gastric, 
intestinal  and  gall-bladder  tumors  or  corset  liver.  Particular  reserve  is 
necessary  in  the  diagnosis  of  left-sided  floating  kidney.  Severe  pain  may 
be  confused  with  a  tabetic  crisis,  appendicitis  or  the  passage  of  gall-  or 
kidney-stones. 

Prognosis. — Death  is  an  extremely  rare  occurrence. 

Treatment. — The  patient  should  never  be  told  of  a  movable  kidney, 
because  neurasthenic  symptoms  may  date  from  the  diagnosis,  (a)  A 
rest  cure  may  develop  adipose  tissue  and  relieve  the  nervous  symptoms. 
(h)  A  well-fitted  bandage,  with  padding  to  prevent  renal  descent,  is 
excellent  in  many  cases,  (c)  In  obstinate  and  extreme  cases,  nephro- 
pexy  is  indicated.  Hahn's  results  are  75  per  cent,  complete  recovery, 
15  per  cent,  decidedly  improved  and  10  per  cent,  failures;  the  mortality 
is  under  1  per  cent.  Nephrectomy  is  seldom  indicated,  (d)  The  crises 
are  treated  by  morphine,  reposition  and  later  by  operation. 

ANOMALIES    OF   RENAL    SECRETION. 

I.  Albuminuria. — Albuminuria,  discovered  by  Cotugno,  in  1770, 
results  (a)  from  leakage  of  albumin  through  the  glomeruli  and  tubules 
{alhuminuria  vera,  renalis)  or  (6)  from  blood,  pus,  semen  or  fluid  of 
tumors  (albuminuria  spuria).  The  spurious  or  accidental  form  will  be 
considered  under  Pvuria  and  Hematuria. 


ANOMALIES  OF  RENAL  SECRETION  645 

The  most  common  albumin  is  serum  albmnin  (or  simply  albumin) 
with  which  serum  globulin  is  frequently  associated. 

Etiology. — (a)  Its  incidence  in  the  diffuse  renal  diseases,  the  nephritides, 
amyloidosis  and  passive  congestion  has  been  discussed.  (6)  Blood 
alterations  are  frequent  causes:  (i)  blood  diseases  proper,  as  anemia, 
leukemia,  pernicious  anemia,  etc.,  in  which  the  poverty  of  the  blood  or 
toxins  induce  renal  degeneration;  (ii)  toxemic  states,  as  acute  and 
chronic  infections,  in  which  "febrile  albumimiria"  evidences  the  renal 
degeneration;  this  condition  borders  very  closely  on  mild  acute  neph- 
ritis; (iii)  diabetes,  icterus  and  poisoning  by  lead,  mercury,  etc.  (c) 
Nervous  maladies  possibly  act  by  lowering  the  local  blood-pressure,  as 
epilepsy,  exophthalmic  goitre  or  migraine,  (d)  Affections  of  the  diges- 
tive tract,  as  intestinal  incarceration,  hepatic  disease  and  lead  colic  may 
produce  albuminuria,  (e)  In  the  neiohorn  it  was  first  noted  by  Virchow. 
It  is  almost  regular  in  the  first  week  of  life  and  occurs  wdth  hyaline  casts, 
urates  and  epithelium.  Ribbert  holds  that  it  is  due  to  imperfect  develop- 
ment of  the  glomeruli.  (/)  Pregnancy;  it  occurs  in  40  per  cent,  of  cases 
in  the  last  few  months  of  gestation  (from  increased  tax  on  the  kidneys 
and  from  pressure)  and  in  the  same  percentage  after  delivery  (from  effort 
and  strain).  (</)  Is  there  a  " 'physiological  alhuvrinuria'"^  Various  types 
are  described,  as  Pavey's  cyclical  albuminuria,  which  appears  and  dis- 
appears; intermittent  albuminuria;  adolescent  albuminuria,  in  young, 
anemic  subjects,  often  with  vasomotor  disturbances,  or  orthostatic  albu- 
minuria, also  termed  postm-al  or  lordotic,  which  appears  only  w^hen  the 
subject  stands;  the  latter  types  give  the  euglobulin  reaction,  show  a  lower 
blood-pressure  (by  10-20  mm.),  when  the  patient  sits  than  when  he  lies 
down  and  are  harmless.  Some  bring  under  this  caption  albiuninuria 
after  h,eavy  eating,  severe  exercise,  coitus,  mental  strain  or  cold  baths. 
Senator,  Bradford  and  Grainger  Stewart,  whose  names  alone  carry  weight, 
insist  that  there  is  a  physiological  albuminuria,  in  which  signs  of  neph- 
ritis, as  casts  or  cardiovascular  changes,  are  absent.  The  author  regards 
most  cases  of  albuminuria  as  pathological;  its  cause  may  be  an  insidi- 
ously developing  nephritis,  a  receding  nephritis,  stasis  or  may  be  "con- 
stitutional," as  Martins  calls  it,  but  it  is  always  a  sign  of  glomerular  or 
tubular  lesion  (see  Prognosis).  The  amount  of  albumin  in  this  type 
rarely  exceeds  0.5  per  mille  (Senator). 

Detection. — The  urine  must  be  clear  and  acid;  if  turbid  it  should  be 
filtered  and  if  it  then  remains  turbid  it  should  be  cleared  by  shaking  with 
magnesia;  it  must  be  acidulated,  if  necessary,  with  acetic  acid;  if  very 
concentrated,  dilution  with  distilled  water  is  advisable. 

1.  Boiling  Test. — ^A  test-tube,  two-thirds  filled  with  urine,  is  held  by 
its  lower  part  and  the  upper  layers  are  boiled.  Albumin  produces  cloud- 
ing, which  may  also  result  from  phosphates  and  carbonates  (dissolving 
when  nitric  acid  is  added),  balsams  (dissolving  in  alcohol)  and  urotropin. 
Nitric  acid  should  not  be  added  before  boiling,  for  a  soluble  acid-albumin 
may  result. 

2.  Nitric  Acid  or  Heller's  Test. — Urine,  somewhat  diluted,  is 
placed  in  a  test-tube  and  nitric  acid  is  run  under  it  by  a  pipette.  Albumin, 
globulin,  mucin  and  albumose  are  precipitated  at  once  or  after  a  few 


646  DISEASES  OF  THE  KIDNEYS 

minutes  at  the  contact  point;  albumose  dissolves  by  heating,  the  others 
do  not. 

3.  Ferrocyanide  Test. — To  a  test-tube  half-full  of  urine  10  drops 
of  acetic  acid  are  added,  which  may  precipitate  uric  acid,  urates,  oleo- 
resins  or  nucleo-albumin.  These  are  filtered  out  and  5  c.c.  of  10  per  cent, 
potassium  ferrocyanide  is  added.  A  precipitate  indicates  albumin, 
globulin  or  albumose;  the  latter  dissolves  on  heating. 

4.  Acetic  Acid  and  Salt  Test. — Adding  to  the  urine  acetic  acid  to 
an  acid  reaction  and  then  an  equal  volume  of  saturated  sodium  chloride 
solution  precipitates  albumin  and  albumose. 

5.  Spiegler's  Test. — Nucleo-albumin  is  removed  by  adding  15  drops 
of  dilute  acetic  acid  and  filtering.  To  the  urine  is  added  a  quantity  of 
Spiegler's  reagent  (bichloride  mercury  8,  tartaric  acid  4,  glycerin  20 
and  distilled  water  200)  when  albumin  or  albumose  develops  at  the 
contact  zone. 

Globulin  occurs  chiefly  in  renal  congestion,  acute  and  chronic  nephritis 
and  amyloid  degeneration.  It  dissolves  in  an  excess  of  acetic  acid.  It 
is  precipitated  by  boiling.  Flocculi  of  globulin  are  thrown  down,  when 
2  drops  of  dilute  acetic  acid  are  added  to  1.6  ounces  of  filtered  urine 
diluted  ten  times  with  distilled  water. 

Nucleo-albumin  (euglobulin,  mucin)  occurs  in  acute  desquamative 
nephritis,  icterus,  poisonings  causing  necrosis  of  the  renal  cells  and 
regularly  in  catarrh  of  the  urinary  passages.  It  is  precipitated  by  boiling 
and  by  acetic  acid  but  unlike  globulin,  does  not  dissolve  in  an  excess  of 
acetic  acid.  Shreds  of  mucus,  voided  with  colic,  have  been  observed  by 
von  Jaksch  and  Baumiiller;  the  condition  seems  analogous  to  colica 
mucosa  and  spasmodic  asthma. 

Albumose  is  albumin  which  does  not  coagulate  by  heat.  When  the 
urine  is  boiled  the  albumin  is  precipitated  and  filtered  out.  Albumose 
in  the  filtrate  causes  clouding  and  precipitation  on  cooling,  (a)  Bence- 
J ones' s  albumose  is  rather  a  peculiar  albumin  than  an  albumose ;  described 
by  him  in  1848,  albumosuria  has  also  been  called  Kahler's  disease.  De 
Castello,  in  1909,  collected  52  cases.  It  has  been  found  in  osteomalacia, 
multiple  myeloma,  leukemia  and  bone-marrow  tumors.  It  is  precipitated 
by  cold  nitric  acid,  dissolves  on  heating  and  reappears  on  cooling,  (b) 
Albumose  may  be  found  in  various  acute  infections,  septicemia,  peri- 
tonitis, empyema,  etc.  Albumin  in  the  kidney,  bladder  or  urinal  may  be 
converted  by  pepsin  into  albumose. 

Diagnosis. — Blood  or  pus  may  give  albumin  reactions  {v.  i.). 

Prognosis  and  Treatment. — These  are  etiological.  The  outlook  is  not 
favorable,  though  not  necessarily  bad.  In  seemingly  "physiological" 
cases,  the  condition  of  the  heart  must  be  watched  and  casts  carefully 
looked  for.  In  youth  and  adolescence  albuminuria  may  be  "physio- 
logical;" Senator  observed  such  a  case  develop  contracted  kidney  after 
twenty  years;  in  middle  and  later  life  it  is  usually  nephritic.  Shattuck 
and  Osier,  however,  hold  that  "albuminuria  is  more  common  apart 
from  Bright's  disease  than  is  commonly  supposed,  that  it  increases 
with  advancing  years  and  that  a  small  amount  of  albumin  with  finely 
granular  casts  of  small  diameter  in  those  over  fifty  years  of  age  is  of  small 


ANOMALIES  OF  RENAL  SECRETION  647 

importance."  Life-insurance  figures  show  that  it  entails  double  the 
average  death-rate.  Hawkins  reported  a  case  in  which  albuminuria 
lasted,  without  any  unhappy  symptoms,  for  forty-three  years  after 
Bright  had  given  a  fatal  prognosis. 

II.  Hematuria. — ^Etiology. — Like  albuminuria,  blood  in  the  urine  is 
only  a  symptom  of  many  diverse  conditions,  (a)  It  is  most  frequently 
renal,  (i)  General  conditions  may  cause  it,  as  intoxications  (by  quinine, 
carbolic  acid,  turpentine  or  salicylic  acid),  acute  infections  (malaria, 
exanthemata,  particularly  hemorrhagic  types,  appendicitis)  or  blood 
diseases  (hemophilia,  leukemia  and  the  anemias),  (ii)  Other  causes 
are  local  renal  conditions,  as  trauma,  vascular  maladies  (thrombosis  of 
the  renal  veins,  infarct,  aneurysm,  varicose  veins,  arteriosclerosis  and 
rarely  passive  congestion);  inflammation  (acute,  chronic,  hemorrhagic 
and  suppurative  ne'phritis) ;  tumors;  tuberculosis;  calculous  ulceration  and 
pyelitis;  rarely  amyloidosis  or  parasites  (distoma,  filaria,  nephrophages 
sanguinarius) ;  sometimes  floating  and  cystic  kidney,  especially  after 
bimanual  examination,  (iii)  Hematuria  may  be  "idiopathic"  or  "essen- 
tial," occurring  in  very  rare  cases  in  "apparently  healthy  kidneys," 
to  which  phrase  there  has  been  a  just  objection;  it  has  been  called  renal 
epistaxis,  angioneurotic  hematuria  and  renal  purpura.  Nephrotomy  may 
give  relief.  In  Eshner's  48  cases  of  unilateral  renal  hematuria  nothing 
was  found  at  operation  in  33  per  cent.,  floating  kidney  in  12.5,  renal 
pelvic  changes  in  19,  and  diffuse  renal  disease  in  24  per  cent,  (b)  Of 
lesions  in  the  lower  urinary  tract,  the  chief  types  are  stone  in  the  ureter 
or  bladder;  ruptured  varices  anywhere  in  the  urinary  tract;  stasis  from 
liver  cirrhosis  or  thrombosis  of  the  iliac  veins;  inflammation  (pyelitis, 
ureteritis,  cystitis,  prostatitis  or  urethritis,  sometimes  called  "Russian 
gonorrhea");  and  tuberculous,  malignant  or  other  ulcerations. 

Symptoms  and  Diagnosis. — Hemorrhage  may  be  macro-  or  microscopic. 
The  urine  ma}''  be  clear  or  turbid,  red  or  smoke-colored.  It  is  usually 
acid,  or  alkaline  from  copious  vesical  hemorrhage.  The  color  is  brighter 
when  the  urine  is  alkaline.  Confusion  is  possible  with  concentrated, 
icteric,  carbolic,  fuchsin,  hematoxylin  and  senna  urines.  The  presence 
of  blood  is  positively  determined  (a)  by  the  microscope;  the  red  cells 
remain  normal  for  a  long  time  in  acid  urine,  but  may  become  pale  in 
dilute  and  mulberry-form  in  concentrated  urine;  (6)  by  the  spectroscope; 
if  no  red  cells  are  present  with  positive  spectroscopic  findings  it  indicates 
hemoglobinuria  (v.  i.);  and  (c)  by  chemical  tests,  as  Heller's,  Almen's 
guaiac  or  Teichmann's  test. 

Diagnosis  of  the  origin  and  cause  of  hematuria  is  often  most  difficult. 
(a)  In  cases  of  renal  origin,  the  blood  is  intimately  mixed  with  the 
urine,  as  much  with  that  first  voided  as  with  the  last.  The  color  is  often 
that  of  water  in  which  raw  meat  has  soaked  ("beef-water"  color).  Clots 
are  infrequent  in  renal  hematuria,  save  from  trauma,  tumors,  aneurysm 
or  varicosities.  The  red  cells  are  seldom  seen  in  rouleaiix-form  and 
are  fragmented  from  action  of  the  renal  cells;  this  does  not -occur  in 
vesical  hemorrhage.  If  there  is  some  other  renal  lesion,  as  nephritis, 
there  is  more  albumin  than  the  red  cells  would  account  for,  and  albumin 
is  present  after  careful  filtering;  if  there  is  albumin  with  a  red  cell  count. 


64S  DISEASES  OF   THE  KIDXEYS 

by  the  hemocytometer,  of  less  than  3000  j>er  c.mm.,  the  albuminuria  is 
renal.  Blood  casts,  granular  casts  and  renal  epithelium  are  indicative  of 
renal  origin.  (6)  Hematuria  originating  in  the  pelvis  and  ureter  is  more 
often  marked  by  clots  and  possibly  by  caudate  epithelium,  (c)  Blood 
from  the  bladder  is  more  apt  to  clot  and  the  last  urine  voided  is  more 
bloody  than  the  first.  Tenesmus  and  alkaline  urine  often  indicate  a 
vesical  origin,  (d)  Urethral  hemorrhage  stains  most  deeply  the  first 
urine  Avoided.    Hematuria  may  be  accidental,  e.  g.,  menstrual. 

Treatment. — The  treatment  is  etiological.  Rest,  morphine  and  aside 
from  the  local  treatment  of  vesical  disease,  urethritis  and  calculous 
pyelitis,  tannic  acid,  thyroid  extract,  calcium  chloride  aa  gr.  v.,  t.  i.  d., 
normal  horse  serum  and  adrenalin  1  to  1000  (given  by  the  catheter)  may 
stop  hemorrhage.  In  idiopathic  renal  hematuria,  simple  incision  of  the 
kidney  is  frequently  efficacious. 

m.  Hemoglobinuria. — This  is  hemoglobin  in  the  urine  without 
hematm-ia.  Though  first  described  by  Dressier  (18o4j,  most  of  the 
early  accounts  are  English  (Pa Ay,  lS55j. 

Etiology. — The  toxic  form  may  follow  transfusion  of  blood,  poisons, 
organic  and  inorganic,  as  potassium  chlorate,  phosphorus,  mercury, 
quinine  (in  malarial  cases),  phenol;  burns,  icterus,  pernicious  anemia, 
scarlatina,  acute  nephritis,  Winckel's  disease  and  estivo-autumnal 
malaria.  The  jKiroxysmal  form,  of  which  Gilman  Thompson  collected 
206  cases,  occurs  largely  in  England,  France  and  Germany;  96  per  cent, 
are  males,  chiefly  between  thirty  and  forty  years  of  age.  (i)  After  some 
infection,  notably  lues,  (ii)  a  hemolysin  is  formed,  capable  of  dissolving 
the  red  disks  of  the  subject  or  of  other  individuals;  cold  is  important  in 
anchoring  the  hemolysin  to  the  red  cells  but  does  not  produce  this  toxin; 
besides  this  type  of  Donath  and  Landsteiner  (hemolysin  in  the  blood  and 
hemoglobinemia),  there  is  another,  characterized  by  abnormal  fragility 
of  the  red  cells;  exercise,  excesses  or  menstruation  may  precipitate  an 
attack.  It  is  observed  in  horses  after  cold  and  exertion,  with  hemoglobin- 
emia and  hemoglobinuria,  paresis  of  the  hindlegs  and  death  from  dis- 
turbed circulation  and  respiration.  In  cattle  and  sheep  epidemics. 
Babes  and  Krogius  found  a  hematococcus.  (iiij  There  is  some  renal 
disturbance  and  hemoglobin  is  excreted,  chiefly  by  the  convoluted  tubules; 
genuine  renal  hemoglobinuria  (without  hemoglobinemia)  seems  to  occur 
in  some  cases  of  nephritis  and  from  certain  intestinal  nematodes,  (iv) 
Hemolytic  icterus  and  splenomegaly  may  result. 

Symptoms. — Symptoms  occur  only  after  destruction  of  at  least  one- 
sixth  of  the  blood.  After  a  chill,  fever,  lumbar  pain  which  radiates 
to  the  legs,  cyanosis,  oppression  and  gastric  symptoms,  the  urinary 
findings  appear;  the  urine  is  dark  and  contains  clumps  of  blood  pigment, 
peculiar  granular  (iron)  casts  and  epithelium  stained  Avith  hemoglobin, 
and  albumin.  In  most  cases  the  hemoglobin  is  already  altered  to 
methemoglobin,  as  shown  by  the  spectroscope.  There  may  be  slight 
jaundice,  edema  or  urticaria.  The  blood  shows  increased  coagulability 
and  diminution  in  the  number  and  redness  of  the  red  cells,  Avhich  do  not 
form  in  rouleaux.  There  may  be  swelling  of  the  liA-er  and  spleen  from 
hemoglobin  deposits  in  them.     The  paroxysm  lasts  one-half  to  several 


ANOMALIES  OF  RENAL  SECRETION  649 

hours  and  in  the  interval  the  general  health  is  fairly  good.  The  course 
is  most  chronic.  No  death  is  known  from  the  paroxysm  itself  and  very 
rarely  from  the  disease. 

Treatment. — Prophylaxis  in  regard  to  cold  and  exertion  may  modify 
the  attacks.  Attacks  are  sometimes  aborted  by  nitrite  of  amyl  inhala- 
tions and  warmth  may  modify  the  seizure. 

rV.  Pyuria.  —  Etiology.  —  (a)  Pus  may  occur  intermittently,  as  in 
pyonephrosis  or  continuously,  as  in  calculous  or  tuberculous  yyelitis. 
The  urine  is  usually  acid  in  tubercle,  colon  and  proteus  infec- 
tions and  in  some  infections  ascending  from  the  bladder;  the  staphyl- 
ococcus may  render  the  urine  less  acid  than  normal  or  alkaline  {v.  i. 
Pyelitis).  (6)  In  cystitis  pyuria  the  urine  may  be  acid  or  alkaline  and 
contains  ropy  mucus  and  triple  phosphates.  Pus  is  seen  especiallj^  in 
the  last  urine  voided,  (c)  Urethral  pyuria,  usually  gonorrheal,  is  greatest 
in  the  urine  first  evacuated,  id)  Accidental  pyuria  from  leucorrheal 
contamination  is  excluded  by  catheterization.  In  pyuria  from  rupture 
into  the  urinary  tract  of  appendicular,  pelvic  or  jleoas  abscess,  much 
pus  is  voided  at  first,  but  it  gradually  lessens  and  d^appears. 

Symptoms. — The  urine  is  yellowish-white,  turbid,  with  a  ropy  sediment 
becoming  gelatinous  when  caustic  potash  is  added;  it  is  often  ammoniacal, 
from  decomposition  of  the  urea,  by  the  proteus  and  staphylococci.  Gas 
may  be  voided  with  the  urine  (pneumaturia),  particularly  in  entero vesical 
fistula  and  diabetic  cystitis.  Alkalinity  was  formerly  thought  character- 
istic of  cystitic,  and  acidity  of  pyelitic  pyuria,  but  this  distinction  has 
been  dropped.  Albumin  is  found,  corresponding  in  simple  pyuria  with 
the  number  of  pus  cells.  Albuminuria  may  be  absent  if  there  are  not 
over  600-800  pus  cells  to  the  c.mm.  It  is  less  or  may  disappear  when 
the  urine  is  filtered.  The  question  often  arises  whether  the  albuminuria 
is  simply  accidental  or  whether,  for  instance,  cystitis  is  combined  with 
contracted  kidney;  besides  consideration  of  the  amount  of  urine,  its 
specific  gravity,  cardiovascular  findings,  washing  out  the  bladder  and 
ureteral  catheterization — leukocytes  coming  from  the  renal  parenchyma 
in  nephritis  are  mononuclear  and  those  from  suppuration  are  poly- 
morphonuclear; DeLint  found  that  (a)  when  there  is  one  part  per 
mille  of  albumin  and  less  than  7000  pus  cells  the  albuminuria  is  renal; 
and  (6)  it  results  from  the  pus  alone  when  there  are  more  than  40,000 
pus  cells;  no  conclusion  can  be  drawn  if  the  pus  cells  number  between 
7000  and  40,000  per  c.mm. 

Treatment. — The  treatment  is  that  of  the  fundamental  tuberculosis, 
calculus,  pyelitis,  cystitis,  etc.  Phenylis  salicylas  and  hexamethylen- 
amina,  aa  gr.  x,  t.  i.  d.,  are  excellent  antiseptics  for  the  urinary  tract. 

V.  Chyluria.  —  The  tropical  form  plugs  the  lymph  vessels,  which 
dilate  and  rupture  in  the  kidneys,  as  proved  by  Mackenzie's  autopsy 
(see  page  314).  The  non-tropical  forms  are  not  understood  and  have 
rarely  occurred  in  Europeans  who  have  never  been  in  the  tropics; 
the  rare  autopsies  have  shown  no  marked  renal  alteration.  Probably 
there  is  some  communication  between  the  urinary  and  chylous  vessels. 

The  urine  resembles  chyle,  is  weakly  acid  or  neutral  in  reaction,  may 
present  a  fatty,  creamy  surface  and  contains  2  to  10  per  cent,  albumin 


650  DISEASES  OF  THE  KIDNEYS 

(serum  albumin,  globulin  or  albumose),  cholesterin,  lecithin,  fat  and 
stearic  and  palmitic  acids.  Sugar  is  seldom  found.  Microscopic  findings 
are  fat  globules,  leukocytes,  sometimes  red  disks  and  the  filaria  parasites, 
usually  in  the  fibrin  clots,  which  sometimes  occasion  dysuria.  Casts 
are  never  found.  Chyluria  is  often  intermittent;  it  occurs  especially 
at  night  and  in  66  per  cent,  of  cases,  it  disappears  in  the  recumbent  pos- 
ture. In  some  cases  there  is  free  fat  in  the  blood  (lipemia).  Its  course 
is  chronic.  Recovery  is  the  rule,  though  death  may  occur  from  anemia 
and  marasmus.  Treatment  is  unsatisfactory.  Potassium  picronitrate, 
gr.  I,  t.  i.  d.,  is  said  to  accelerate  recovery.  Prophylaxis  regarding 
drinking  water  must  be  considered  in  the  tropics, 

VI.  Lipuria. — Lipuria  or  adiposuria  is  symptomatic  of  (a)  lipemia  or 
fat  in  the  blood.  The  clearest  instances  follow  fractures,  contusions 
of  the  liver  or  delivery  (fat  from  the  pelvic  cellular  tissue).  Fatty  foods, 
acute  yellow  atrophy,  diabetes,  disease  of  the  pancreas  and  various 
poisonings  are  possible  causes.  (6)  It  is  symptomatic  of  7-enal  lesions 
(or  fatty  epithelial,  degenerated  tumor  or  pus  cells). 

Under  the  microscope  small  fat  globules  are  seen  which  stain  black 
with  osmic  acid  or  red  with  the  alcanna  test.  The  fat  may  be  saponi- 
fied by  alkalies,  emulsified  by  albumins  or  dissolved  by  alcohol,  ether, 
xylol  or  chloroform.  Lipuria  is  often  simulated  by  bacteria  or  phosphates 
or  by  oil  from  catheters,  suppositories  or  greasy  urinals. 

VII.  Phosphaturia. — Phosphoric  acid  is  chiefly  excreted  in  com- 
bination, two-thirds  with  sodium  and  potassium,  the  alkaline  phosphates, 
and  one-third  with  calcium  and  magnesium,  the  earthy  phosphates; 
it  is  chiefly  derived  from  the  food,  but  some  is  derived  from  decomposi- 
tion of  lecithin,  nuclein  and  protagon.  It  averages  two  to  three 
grams  daily.  Amounts  over  4  gm.  or  alteration  of  the  normal  relation 
of  the  phosphorus  to  the  nitrogen  (17  or  20  to  100)  are  pathological. 
An  excessive  deposit  which  occurs  in  dyspepsia  is  not  synonymous  with 
an  actual  increase.  Phosphaturia  may  be  observed  in  neurasthenia, 
pulmonary  tuberculosis,  diabetes  (largely  from  the  diet),  acute  yellow 
atrophy,  leukemia  and  anemia;  8  gm.  daily  were  reported  by  Teissier 
and  Ralfe,  who  termed  the  condition  diabetes  phosphaticus.  Earthy 
phosphates  may  cloud  the  last  part  of  the  urine,  which  is  mistaken  by 
the  laity  for  "spermatorrhea."  The  addition  of  an  acid  rapidly  clears 
the  urine.  The  diet,  recommended  for  this  condition,  consists  of  meat, 
fish,  bread,  potatoes  and  apples.  Coffee,  nux  vomica,  arsenic,  cod-liver 
oil  and  ammonium  benzoate  (gr.  x-xxx,  t.  i.  d.)  are  also  given. 

VIII.  Lithuria. — No  subject  has  occasioned  more  clinical  absurdities 
than  uric  acid.  It  normally  bears  to  urea  a  ratio  of  1  to  70.  Futcher 
has  found  a  ratio  of  1  to  300  or  500  {v.  Gout).  It  is  deposited  in  larger 
amounts  than  normal  when  the  urine  is  very  acid  and  the  mineral  salts 
or  pigments  are  decreased.  An  increased  precipitation  as  red  granules 
resembling  red  pepper  is  far  more  common  than  an  increased  excretion 
of  uric  acid.  Uric  acid  combines  chiefly  with  ammonium  and  sodium, 
which  form  urates  of  the  "brick-dust"  color  so  frequently  seen  in  febrile 
urine  and  urine  of  high  specific  gravity  or  excessive  acidity  {sedimentum 
lateritium).    They  are  soluble  when  heated. 


ANOMALIES  OF  RENAL  SECRETION  651 

IX.  Oxaluria. — Oxalates  first  detected  by  Donne  (1838)  in  the  normal 
urine  amount  to  less  than  10  mg.  daily.  Larger  daily  quantities  are 
pathological.  Helen  Baldwin  decided  that  they  are  not  formed  during 
normal  metabolism  and  are  taken  in  with  the  food.  Oxaluria  is  observed 
in  gout,  hyperacidity,  increased  intestinal  putrefaction,  neurasthenia, 
icterus  and  diabetes.  Oxalates  occur  as  octahedral  and  dumb-bell 
crystals,  which,  according  to  Klemperer,  occur  in  50  per  cent,  of  renal 
calculi.  Cantani  maintains  that  oxaluria  is  associated  with  nervous 
depression,  irritability,  lumbar  pain,  sweats  and  nervous  dyspepsia, 
though  the  consensus  of  opinion  is  against  any  definite  clinical  picture 
or  diathesis.  Klemperer  advised  a  diet  of  meat,  fat  and  vegetables 
(except  spinach  and  cabbage);  he  excludes  milk  and  eggs  and  adminis- 
ters magnesium  sulphate  5ss.  Nitromuriatic  acid  TTlij,  with  tincture  of 
nux  vomica  TTlx,  is  excellent. 

X.  Indicanuria. — Potassium  indoxylsulphate  is  present  in  small  amounts 
in  normal  urine.  It  is  colorless  as  a  rule,  but  may  be  voided  blue  or  violet 
in  alkaline  urine.  When  acid  or  some  oxidizing  substance  is  added  it 
decomposes  and  frees  indigo.  The  action  of  the  pancreatic  juice  on  albu- 
mins produces  indol,  which  is  absorbed,  oxidized  in  the  tissues  to  indoxyl 
and  unites  with  potassium  sulphate  to  form  potassium  indoxylsulphate. 
Its  absence  in  some  pancreatic  diseases  has  been  discussed.  It  is  rarely 
found  in  urinary  calculi.  It  is  increased  in  cachexise  in  which  albu- 
minous substances  are  decomposed,  in  intestinal  obstruction,  carcinoma, 
suppuration  and  peritonitis.  Boiling  the  urine  and  adding  nitric  acid, 
as  in  the  ring  test  for  albumin,  gives  a  blue  ring;  adding  chloroform  and 
shaking  brings  down  the  violet-  or  blue-stained  chloroform. 

XI.  Other  Anomalies. — Alkaptonuria  was  discovered  by  Badecker.  It 
is  a  crystalline,  aromatic  body,  probably  derived  from  proteid  decom- 
position, whose  chief  clinical  significance  is  that  (a)  it  reduces  Fehling's 
solution,  thereby  simulating  glycosuria,  though  negative  to  polarization 
and  fermentation  tests;  and  {b)  it  imparts  to  the  urine  a  dark  brown 
color,  usually  apparent  only  after  it  has  stood  or  after  caustic  potash  is 
added  (by  derivation,  urine  which  "absorbs"  an  "alkali"  freely).  Add- 
ing a  drop  of  a  very  dilute  solution  of  ferric  chloride  causes  a  dull  green 
color  which  at  once  disappears.  It  is  said  to  be  homogentisic  or  uroleu- 
cinic  acid.  Garrod  collected  47  cases,  73  per  cent,  of  which  were 
males;  in  32  congenital  cases,  19  occurred  •  in  7  families.  Virchow 
(1866)  described  a  case  of  ochronosis,  a  discoloration  of  the  cartilages  and 
ligaments;  Osier  described  2  cases  associated  with  alkaptonuria,  making 
11  in  the  literature;  it  may  occur  with  pigmentation  of  the  face,  chronic 
arthritis  and  deformation  of  the  lumbar  vertebrae.  Chronic  phenol 
poisoning  is  a  possible  cause. 

Hydrochinon,  from  phenol  poisoning,  causes  similar  discoloration. 

Hematoporphyrinuria,  discovered  by  Hoppe-Seyler,  imparts  a  dark 
color  to  the  urine.  It  occurs  in  tuberculosis,  intestinal  hemorrhage, 
sulphonal  and  lead  poisoning,  etc.  Hematoporphyrin  resembles  hematin, 
save  that  it  contains  no  iron.  Barker  reports  a  fatal  familial  form,  with 
gastric  dilatation,  fits  and  polyneuritis. 


652  DISEASES  OF   THE  KIDXEYS 


PYELITIS.     PYELONEPHRITIS.     SUPPURATIVE  NEPHRITIS. 

I.  Pyelitis. — Pyeliti-  and  pyelonephritis  are  inflammation  of  the  pehis, 
and  pelvis  and  kidney,  respectively.  They  were  first  fully  described 
by  Rayer,  though  recognized  by  Hippocrates  and  Galen. 

Etiology. — Pyelitis  is  mycotic.  The  kidneys  usualh'  eliminate  bacteria 
without  injury  to  their  structure,  but  when  the  general  vitality  or  the 
local  resistance  of  the  kidneys  is  lowered,  inflammation  of  the  pelvis 
or  kidney  may  result.  A'arious  bacteria  may  be  found,  including  the 
tubercle  bacillus,  (a;  Foreign  bodies,  as  calculi,  less  often  cancer  or 
tubercle,  and  rarely  parasites,  promote  infection.  (6j  Goodhart  has 
shown  that  .50  per  cent,  of  cases  with  obstruction  ffrom  urethral  stricture 
or  prostatic  hypertrophy;  to  the  flow  of  urine  die  of  renal  suppuration 
— ascending  injection .  "When  the  bacteria  causing  cystitis  decompose  urea, 
the  ammonia  evolved  is  an  additional  eroding  factor;  certain  streptococci 
act  in  this  way,  but  not  the  tubercle  or  colon  organisms.  Bacteria 
usually  ascend  from  cystitis  along  the  ureters,  producing  ureteritis,  then 
pyelitis  and  perhaps  a  pyelonephritis,  but  usually  reach  the  kidney  along 
the  lymph  vessels,  entering  through  erosions  in  the  vesical  mucosa,  (c) 
Infection  may  be  hematogenous,  as  in  typhoid,  etc.  (d)  Less  common 
factors  include  traumatism,  extension  by  contiguity  from  neighboring 
inflammations,  pyelonephritis  (usually  an  ascending  process,  in  which 
the  kidney  is  secondarily  involved,  and  only  rarely  a  process  descending 
from  the  kidney  to  the  pelvis;,  toxic  factors,  irritating  diuretics,  such  as 
turpentine;  hemorrhagic  diseases;  cold,  venous  stasis  and  diabetes; 
arteriosclerosis  induces  a  form  of  p>-elitis  attended  by  hemorrhage  and 
fibrin  coagula. 

Pathology. — Pyelitis  may  be  solitary  or  combined  with  cystitis;  uni- 
lateral or  less  often  bilateral.  Acute  catarrhal  forms  present  redness, 
edema,  desquamation,  mucopus  and  ecchymoses.  Chronic  forms  show 
grayish  to  brown  pigmentation.  Croupous  or  diphtheritic  inflammation 
or  even  gangrene  may  develop.  Urates  and  triple  phosphates  may  pre- 
cipitate. Small  retention  cysts  may  form  in  the  pelvis  or  ureter;  the 
small  lymph  nodes  may  enlarge  and  in  rare  cases  the  epithelium  may 
hypertrophy,  causing  cholesteatoma. 

Ssmiptoins. — (a)  In  the  ascending  type  early  vesical  symptoms  ante- 
date and  often  obscure  the  pyelitis,  (h)  The  symptoms  are  most  clear 
in  primary  pyelitis  from  calculus  or  hematogenous  infection. 

Pyuria  is  the  chief  symptom.  The  amount  of  albumin  is  generally 
held  to  parahel  the  number  of  pus  cehs  but  often  it  exceeds  the  latter 
(the  converse  being  true  in  cystitis;.  The  pyuria  varies;  when  the 
ureter  is  obstructed,  pyuria  is  suspended  and  when  the  obstruction  is 
removed  the  pus  escapes  in  increased  amounts.  Polyuria  and  a  low 
specific  gravity  are  usual  in  chronic  cases;  the  writer  observed  a  case  in 
which  6  quarts  daily  were  voided,  simulating  diabetes  insipidus;  polyuria 
results  from  decreased  absorption  of  water  from  the  meduUary  portion 
or  from  compensatory  hypertrophy  of  the  sound  kidney.  In  acute  cases  the 
urine  is  decreased.  The  often  cloudy  urine  is  usually  acid  but  frequently 
alkaline  from  coincident  or  causal  cystitis  or  from  bacteria  decomposing 


PYELl  ri.S—P  YELONEPHRI TISS  UPP  UP  A  TI VE  NEPHRITIS    653 

the  urea.  Large,  caudate,  club-like  epithelial  cells,  often  overlapping 
like  shingles,  are  present  in  moderately  severe  pyelitis,  but  they  occur, 
though  less  frequently,  in  ureteritis  and  cystitis.  When  pyelitis  extends 
to  the  papillae  or  higher  (pyelonephritis),  cylindrical  plugs  of  pus  cells, 
epithelium,  but  chiefly  of  cocci,  are  seen.  Red  cells  (calculus),  triple 
phosphate  or  uric  acid  crystals,  fibrin  (croupous  or  diphtheritic  pyelitis) 
and  various  bacteria  (the  colon  bacillus,  in  90  per  cent.,  perhaps  the 
tubercle  bacillus)  may  occur.  Pain  over  the  kidney  is  usually  dull,  but 
in  acute  cases  may  suggest  stone.  The  desire — probably  reflex — to 
urinate  frequently,  may  lead  to  an  erroneous  diagnosis  of  cystitis.  Fever 
and  rigors  are  common,  especially  in  severe  calculous,  colon  bacillus  or 
tuberculous  types  or  those  invading  the  kidney  substance.  Tempera- 
ture is  sometimes  sudden  and  high,  at  other  times  intermittent  from 
septic  absorption. 

Complications. — (a)  There  may  be  extension  to  the  renal  substance 
(liyelonephritis)  which  may  be  reduced  to  a  pulpy,  inspissated  and  even 
calcified  mass.  (&)  Prolonged  inflammation  may  lead  to  fibrosis — the 
"ascending  contracted  kidney.''  (c)  Plugging  of  the  ureter  may  occasion 
distention  of  the  pelvis  by  retained  urine  (hydronephrosis)  or  pus  (pyo- 
nephrosis), both  of  which  are  described  below,  (d)  Anuria,  described 
by  ]Morgagni,  is  occasioned  by  reflex  suppression  of  the  sound  kidney 
or  by  extensive  lesions  in  both  kidneys,  (e)  Amyloidosis  may  develop. 
(j)  Intoi'ication  may  occur  by  bacterial  toxins  and  renal  inadequacy 
resembling  uremia  in  some  respects;  Senator  described  a  dyspnea  like 
that  of  diabetic  coma.  Treitz  and  v.  Jaksch  ascribe  intoxication  to 
absorption  of  ammonia  {ammoniemia)  from  decomposed  urea,  ig) 
Perforation  outward  causes  the  paranephritic  abscess  (v.  i.).  In  some 
cases  a  "spinal  paraplegia"  is  described,  probably  resulting  from  an 
ascending  neuritis. 

Prognosis. — The  prognosis  is  influenced  by  the  basic  simple,  tuber- 
culous or  calculous  infection  and  by  the  complications.  In  acute  cases 
the  outlook  is  generally  good.  Chronic  cases  without  much  necrosis 
may  last  many  years  and  may  even  recover. 

Diagnosis. — Much  depends  on  careful  analysis  of  the  pyuria  (g.  v.). 
Cystitis  may  be  confused  or  combined  with  pyelitis;  no  absolute  reliance 
can  be  placed  on  the  reaction,  acidity  or  alkalinity,  though  pyelitic 
urine  is  more  often  acid.  The  tailed,  clubbed  or  shingle-like  epithelia 
are  more  common  in  pyelitis,  though  not  pathognomonic.  Thorough 
vesical  irrigation  and  gentle  compression  of  the  suspected  kidney  to 
force  pus  or  cells  into  the  bladder  and  into  the  catheter  is  easier  but  less 
certain  than  cystoscopy  and  ureteral  catheterization.  In  nephritis  the 
leukocytes  are  mononuclear  and  casts  and  cardiovascular  changes  are 
decisive. 

Treatment. — Prophylaxis  involves  care  in  the  use  of  catheters  or 
irritating  diuretics,  the  expectant  treatment  of  gonorrhea,  etc.  Water, 
milk  and  mineral  waters  should  be  used  freely  to  flush  out  the  urinary 
tract.  Paiji  is  relieved  b\'  hot  applications  to  the  kidney;  opium  is 
seldom  indicated.  For  pyuria,  phenylis  salicylas  and  hexamethylenamine, 
aa  gr.  x,  p.  c,  are  most  efficient.     Methylene  blue,  gr.  j-ij,  t.  i.  d.,  may 


654  DISEASES  OF  THE  KIDNEYS 

induce  digestive  disturbances.  Colon  vaccines  are  less  efficacious  than 
pelvic  irrigation.  Surgical  interference  may  be  necessary  when  ureteral 
drainage  is  incomplete.  Nephrotomy  is  the  best  operation,  nephrectomy 
being  seldom  indicated. 

II.  Suppurative  Nephritis. — Its  etiology  is  partly  that  of  pyelitis. 
The  microorganisms  encountered  are  the  staphylo-,  strepto-  and  pneu- 
mococcus,  gonococcus,  proteus,  colon,  typhoid  and  tubercle  bacilli, 
actinomyces,  etc.  (a)  The  embolic  form  from  suppurative  processes 
elsewhere  represents  one  phase  of  septicopyemia;  suppurative  foci  are 
chiefly  bilateral  and  cortical;  the  glomeruli  are  filled  with  microorganisms 
and,  as  the  foci  enlarge,  they  show  as  yellowish  areas  through  the  cortex; 
some  deposits  may  also  occur  in  the  medulla.  Clinically,  pyuria,  hema- 
turia and  cylindruria  are  seldom  seen  and  a  diagnosis  seldom  can  be  made; 
anuria  or  oliguria  may  result  from  multiple  glomerular  involvement. 
(6)  The  ascending  type  is  essentially  a  cystopyelonephritis,  the  so-called 
"surgical  kidney";  infection  and  urinary  obstruction  are  its  usual 
antecedents;  pyuria,  polyuria  and  albuminuria  its  usual  symptoms; 
and  suppuration  in  the  medullary  rays  its  usual  anatomical  evidence; 
very  rarely  necrotic  renal  tissue  is  evacuated,  (c)  Suppuration  of  the 
kidney  may  result  from  its  invasion  by  contiguity  from  adjacent  pus  foci 
as  appendicular,  periuterine  or  vertebral  foci;  much  pus  may  be  voided 
at  once,  with  later  gradual  cessation  of  the  pyuria. 

The  diagnosis  is  uncertain,  save  when  sequestra  come  away.  In  100 
iiephrotomies,  17  died,  27  recovered  and  53  were  not  benefited  (Kiister). 

PERINEPHRIC  ABSCESS. 

A  distinction  is  made  between  perinephritis,  inflammation  of  the  fibrous 
capsule  and  paranephritis,  inflammation  (suppuration)  of  the  fatty  capsule 
and  surrounding  tissue. 

Etiology. — (a)  The  most  common  cause  is  suppurative  disease  of 
the  kidney,  as  pyelitis,  pyelonephritis,  pyonephrosis  and  tuberculosis, 
from  which  extension  occurs  by  actual  rupture  or  along  the  blood  or 
lymph  vessels.  (6)  Extension  by  contiguity  may  occur  from  vertebral 
caries,  appendicular,  hepatic,  pelvic  or  pancreatic  suppuration,  etc.  (c) 
It  may  result  from  trauma  plus  infection,  {d)  The  so-called  idiopathic 
abscess  is  probably  embolic.  Most  cases  occur  between  thirty  and  forty 
years  of  age  and  70  per  cent,  occur  in  males. 

Symptoms. — (a)  The  onset  is  acute,  with  a  rigor  and  sudden  fever 
in  the  embolic  (so-called  primary),  but  it  is  insidious  in  the  secondary 
group.  (6)  Fever  of  a  continuous  or  remittent  type  is  usual,  (c)  Pain 
and  tenderness  are  experienced  over  one  kidney,  more  often  the  right. 
Sometimes,  with  coincident  involvement  of  the  kidney,  pain  shoots 
along  the  ureter  to  the  pubes  or  thigh.  To  relieve  tension  the  patient 
lies  on  the  back  with  the  knee  flexed  and  the  thigh  rotated  outward. 
Pain  may  also  arise  from  simple  perinephritis,  relieved  by  nephrotomy. 
{d)  Local  findings.  In  some  patients  there  are  lumbar  edema,  redness 
and  swelling,  as  suppuration  usually  occurs  behind  the  kidney.  The 
surgeon  finds  a  diffuse  phlegmon  and  less  often  diffuse  serous  infiltration 


HYDRONEPHROSIS  655 

or  circumscribed  abscess;  the  pus  may  be  odorless;  it  may  smell  of 
urine  when  the  abscess  has  arisen  from  perforation  outward  of  a  pyelitic 
lesion;  a  fecal  odor  results  from  infection  (without  perforation)  from 
the  bowel  or  appendicular  abscess.  Necrotic  fat  and  sometimes  altered 
blood  are  voided,  (e)  The  urine  "is  negative,  unless  there  is  a  pyelitic 
origin  or  rupture  of  the  abscess  into  the  urinary  tract.  (/)  The  chief 
complication  is  rupture,  which  occurs  in  about  a  quarter  of  the  cases, 
twice  as  often  upward  into  the  lung  and  pleura,  as  downward,  chiefly  into 
the  intestine.  Burrowing  occurs  along  the  ureter  toward  the  pelvis, 
when  the  abscess  is  anterior  to  the  renal  fascia,  and  toward  the  lumbar 
region  or  iliac  fossa,  when  the  abscess  is  behind  the  fascia.  Amyloidosis 
from  neglected  or  obscure  cases  of  paranephritis,  pleurisy,  subcutaneous 
emphysema,  portal  compression,  icterus  and  septicemia  may  result. 

Diagnosis. — Diagnosis  depends  on  local  pain,  edema  or  swelling, 
fever  and  exploratory  aspiration.  Psoas  abscess,  appendicular  abscess 
l^ehind  the  kidney  or  rupture  downward  of  empyema  are  more  often 
etiological  factors  than  separate  questions  for  differentiation. 

Treatment. — The  only  treatment  is  incision  and  drainage.  In  Kiister's 
230  cases  66   per  cent,   recovered. 


HYDRONEPHROSIS. 

Definition. — Hydronephrosis  is  a  sac-like  dilatation  of  the  pelvis 
and  calices,  with  accumulation  there  of  a  watery  fluid;  obstruction  to 
the  urinary  flow  is  its  cause  and  atrophy  of  the  renal  substance  is  its 
result.    It  was  first  described  by  Tulp  (1674)  and  named  by  Rayer. 

Etiology  and  Pathology. — (a)  The  congenital  form  is  most  often  due  to 
anomalies  in  the  ureters;  these  include  atresia,  stenosis,  valve  formations, 
twists,  compression  by  peritonitic  bands,  vestiges  of  Midler's  or  Gartner's 
ducts,  abnormal  bloodvessels,  imperfect  insertion  into  the  bladder  or 
insertion  too  high  into  the  pelvis,  in  the  lower  part  of  which  the  urine 
accumulates;  of  the  latter  form  the  author  observed  2  cases.  When 
there  are  double  ureters,  one  may  end  blindly  in  the  bladder  wall  and 
dilating,  may  compress  its  fellow  of  the  same  side.  Hydronephrosis  may 
occasion  dystocia  and  is  commonly  associated  with  other  congenital 
malformations;  65  per  cent,  of  congenital  cases  are  bilateral.  (6)  The 
acquired  form  may  be  bilateral  or  unilateral;  its  cause  may,  in  rare  cases, 
be  in  the  kidney  itself,  producing  partial  hydronephrosis.  One  or  both 
ureters  may  be  compressed  by  malignant  pelvic  growths,  as  uterine  cancer, 
and  this  explains  the  large  proportion  (67  per  cent.)  of  bilateral  hydro- 
nephrosis in  autopsy  figures;  in  clinical  cases  62  per  cent,  are  unilateral. 
Ureteral  obstruction  may  arise  from  calculus,  tumors,  tuberculous 
detritus,  ulceration,  cicatrization,  floating  kidney  or  rarely  clots  from 
trauma  or  parasites.  Large  sacs  are  usually  caused  by  affections  of  the 
ureter.  Other  possible  types  are  obstruction  from  urethral  stricture, 
enlarged  prostate,  phimosis  and  atresia  of  the  hymen. 

Cohnheim  contended  that  a  slow  development  with  intermissions  is 
more  potent  in  the  production  of  large  sacs  than  is  acute  obstruction. 


656  DISEASES  OF  THE  KIDNEYS 

The  writer  has  seen  G.  D.  Scott's  experiments  which  prove  that  acute 
obstruction  rapidly  produces  marked  hydronephrosis. 

The  results  of  urinary  accumulation  are  (a)  distention  of  the  pelvis, 
(5)  flattening  of  the  papillae,  (c)  renal  atrophy  and  (d)  the  formation  of  a 
fibrous  sac. 

Symptoms. — The  chief  finding  is  a  fluctuating  renal  tumor,  (a)  It 
is  located  at  first  in  the  renal  region  but  later  assumes  an  abdominal 
importance.  (6)  Its  size  varies,  being  largest  when  the  ureter  is  ob- 
structed and  in  slowly  developing  cases  becoming  as  large  as  the  head 
and  even  simulating  ascites;  Peter  Frank's  case  contained  60  quarts. 

(c)  The  chief  causes  of  intermittent  hydronephrosis  are  valve  formation, 
stenosis  or  abnormal  insertion  of  the  ureter  into  the  renal  pelvis.  The 
amount  of  urine  is  (i)  normal  from  hypertrophy  of  the  sound  kidney, 
(ii)  decreased  in  bilateral  disease  or  from  increased  pressure  in  the  diseased 
kidney,  reflexly  lessening  the  secretion  from  the  sound  kidney  (Israel) ; 
or  (iii)  when  the  sac  evacuates,  suddenly  very  abundant  and  then  the 
tumor  disappears ;  this  point  is  often  volunteered  in  the  patient's  history. 

(d)  Its  form,  on  bimanual  palpation,  is  irregularly  oval;  in  moderately 
severe  cases  the  kidney  itself  may  be  palpated,  as  well  as  its  irregularly 
protuberant  calices  and  sometimes  the  dilated  ureter,  (e)  The  ballotte- 
ment  renal  is  a  repercussion  shock  obtained  by  tapping  the  tumor  with 
one  hand  while  the  other  is  spread  broadly  over  it.  (/)  Small  tumors 
are  covered  by  the  colon,  which  imparts  a  modified  tympanitic  note  on 
percussion.  Distention  of  the  colon  by  air  brings  out  tympany  over  the 
tumor.  Very  large  sacs  push  the  colon  aside.  The  ren  saccatus  may 
develop  in  a  floating  or  horseshoe  kidney,  (g)  Its  contents  are  albumin, 
paralbumin,  mucus,  urea  and  other  urinary  constituents,  which  are 
usually  absorbed  only  after  a  long  time.  Diagnostic  puncture  is  not 
always  safe,  (h)  Sometimes  pain  may  arise  from  torsion  of  the  ureter. 
The  author  noted  hematuria  and  renal  colic  in  hydronephrosis  due  to  an 
insertion  of  the  ureter  high  up  in  the  renal  pelvis,  (i)  Complications 
include  rupture,  infection  (pyonephrosis)  or  anuria  and  uremia  if  both 
kidneys  are  implicated. 

Diagnosis. — Diagnosis  is  easy  (a)  by  recognizing  the  cause,  if  possible, 
as  stone  or  tumor;  (6)  by  careful  bimanual  palpation  and  (c)  by  cysto- 
scopic  proof  that  urine  does  not  flow  from  one  ureter.  Differentiation 
concerns  especially: 

1.  Other  Renal  Tumors. — (a)  Pyonephrosis,  a  dilatation  of  the  pelvis 
and  calices  by  purulent  fluid,  is  caused  by  obstruction  plus  infection, 
especially  from  pyelitis  with  obstruction.  It  occasions  the  same  kind  of 
tumor  as  to  location  and  physical  examination,  but  it  is  generally  smaller 
and  more  irregular  than  hydronephrosis;  its  walls  are  thicker  and  more 
tender  from  infection;  there  is  more  renal  necrosis;  systemic  septic 
symptoms  prevail ;  its  contents  are  pus,  pulpy  detritus,  triple  phosphates, 
bacteria,  disorganized  blood,  fat,  cholesterin,  fetid  ammonium  compounds 
and  even  gas.  Puncture  in  doubtful  cases  is  more  dangerous  than 
operation.  Its  prognosis  also  is  clearly  more  unfavorable,  (b)  Cystic 
kidneys,  (c)  malignant  renal  growths  and  (d)  echinococcus  {v.  ?'.). 


RENAL  CALCULUS  G57 

2.  Other  Abdominal  Tumors. — (o)  Ovarian  tumor  is  connected  with 
the  uterus  and  grows  upward.  Ovarian  tumor  with  a  long  pedicle  may 
deceive,  but  it  pushes  the  cecum  backward.  The  dulness  is  greater, 
though  in  large  renal  sacs  the  colon  is  pushed  aside.  Confusion  is 
likely  when  hydronephrosis  develops  in  a  floating  kidney.  Exploratory 
puncture  is  an  unsafe  procedure;  when  made,  the  fluid  from  ovarian 
cysts  shows  a  high  specific  gravity  (1.020);  much  paralbumin  is  present, 
also  cylindrical  epithelium,  colloid  or  chocolate-colored  material  and  no 
urea.  (6)  Ascites  and  pregnancy  are  readily  difi^erentiated.  (c)  Encapsu- 
lated peritonitis  may  be  harder  to  differentiate,  but  the  urinary  condition 
and  sac-like  distention  are  usually  decisive,  (d)  Splenic  and  hepatic 
tumors  are  more  flat  on  percussion,  encroach  more  upon  the  lungs  and 
are  above  or  anterior  to  the  gas-distended  colon.  In  a  renal  growth  a 
furrow  and  tympanitic  loop  of  bowel  may  lie  between  it  and  the  liver 
or  spleen. 

Prognosis. — ^The  prognosis  is  generally  unfavorable,  as  the  cause  is 
often  inaccessible  or  the  process  well  advanced.  The  prognosis  is 
better  in  cases  of  renal  stone  than  in  cancer  or  in  the  generally  inviable 
congenital  forms.     The  course  is  often  intermittent  and  protracted. 

Treatment. — Nephrotomy  is  indicated;  nephrectomy  is  poor  surgery 
since  Ayrer  proved  that  some  sound  renal  tissue  nearly  always  remains. 
The  mortality  resulting  from  nephrectomy  for  hydronephrosis  is  5.7 
per  cent.,  for  pyonephrosis  15.3  per  cent.  (Schmieden);  Rosving  reports 
0  per  cent,  and  19  per  cent,  mortality  in  his  cases  of  nephrotomy  for 
hydro-  and  pyonephrosis,  respectively;  34  per  cent,  of  his  cases  recovered" 
completely,  27  per  cent,  recovered,  though  with  fistula,  and  secondary 
operation  was  necessary  in  20  per  ce^nt.  Fenger  advised  conservative 
operation  in  partial  hydronephrosis.  Israel  and  Rosving  prefer  to  cut 
down  on  both  kidneys  before  extirpating  either  one,  to  tests  of  the  renal 
function. 

RENAL  CALCULUS  (NEPHROLITHIASIS). 

Etiology. — Stone  in  the  kidney  or  its  pelvis  results  from  deposition 
of  the  solid  constituents  of  the  urine.  Probably  bacteria,  especially 
colon  and  typhoid  bacilli,  form  the  nucleus  of  stones.  An  albuminous 
cement  substance  is  found  even  in  slight  urinary  deposits  or  renal  sand. 
Renal  stone  was  described  by  Hippocrates. 

The  predisposing  factors  are  obscure,  (a)  A  sedentary  life  and  over- 
indulgence in  food  and  alcohol  are  apparently  predisposing  factors. 
Galen  noted  the  coincidence  of  gout  and  renal  calculus.  Stones  are  said 
to  be  uncommon  in  very  active  persons,  (b)  Most  cases  occur  between 
'thirty  and  sixty  years  of  age;  in  the  extremes  of  life  vesical  calculus  is 
more  common,  (c)  Seventy-five  per  cent,  of  cases  are  in  males.  Stonies 
are  passed  more  easily,  and  therefore  are  possibly  less  often  detected  in 
women,  {d)  Renal  calculus  occurs  most  frequently  in  Asia  and  there  are 
certain  foci,  where  it  is  particularly  frequent,  as  central  Russia,  Holland, 
Italy,  Altenberg,  Munich,  Hungary,  Scotland,  west  France  and  southeast 
England,  (e)  Other  possible  factors  are  heredity,  especially  formation 
of  uric  acid  and  cystin  calculi;  paraplegia  (Miiller  reported  10  cases  of 
42 


658  DISEASES  OF   THE  KIDNEYS 

spinal  fracture  with  calculus  formation)  and  foreign  bodies  in  the  renal 
pelvis,  as  blood  clots  from  trauma  and  parasites. 

Chemistry  and  Pathology. — According  to  their  size,  urinary  deposits 
are  spoken  of  as  sand,  gravel  or  stones;  sand  and  gravel  consist  of  uric 
acid  or  its  salts.  They  may  range  from  the  size  of  a  pea  to  that  of  a  hazel- 
nut. The  heaviest  recorded  stone  weighed  thirty-six  ounces.  Though 
most  often  round,  oval  or  cylindrical,  they  may  be  dendritic  or  coral- 
shaped.  A  number  of  them  may  exist,  perhaps  15  to  20;  1000  to  2000 
may  be  found,  (a)  The  uric  acid  and  urate  stone  constitutes  66  per  cent, 
of  renal  stones.  It  is  hard,  smooth  or  slightly  uneven,  sometimes  facetted 
or  lamellated  and  consists  of  uric  acid,  ammonium  and  sodium  urates 
and  a  small  amount  of  xanthin.  Its  broken  surface  is  amorphous.  Its 
color  is  yellow,  red  or  brown,  depending  on  the  amount  of  urinary  pig- 
ment. It  may  contain  some  oxalates  and  phosphates.  Under  the  micro- 
scope needles  are  seen.  Uratic  calculi  turn  carmine-red  on  adding  nitric 
acid  and  ammonia.  They  dissolve  in  caustic  potash.  They  are  deposited 
in  acid  urine,  but  the  exact  reason  is  not  known;  a  decrease  of  the  urinary 
pigments  is  considered  of  great  importance;  disturbed  metabolism  or 
indigestion  may  occasion  uratic  deposits,  though  little  is  known  of  the 
"uric  diathesis."  ih)  Oxalate  stones  are  next  in  frequency;  they  are  very 
hard,  warty  or  prickly  (the  mulberry  calculus);  for  this  reason  they 
cause  more  pain  and  hematuria  than  the  uratic  stones  and  are  more  often 
removed  surgically.  They  are  usually  single  and  gray,  but  may  be  dark 
colored  from  the  bleeding  they  induce.  Lamellation  is  never  observed. 
Uric  acid,  calcium  carbonate  or  xanthin  may  also  enter  into  their  com- 
position. No  effervescence  occurs  on  adding  acetic  acid  unless  carbonates 
are  also  present.  They  dissolve  in  mineral  acids  and  oxalate  of  lime 
crystals  gradually  precipitate  on  the  addition  of  ammonia.  Oxalates 
precipitate  from  acid  urine,  (c)  Phosphatic  calculi  are  formed  in  alkaline 
or  neutral  urine.  They  are  usually  calcium  salts,  but  if  the  urine  is 
ammoniacal  triple  phosphates  may  be  formed.  Admixture  of  bacteria, 
calcium  carbonate  and  xanthin  may  be  noted;  phosphatic  stones  are 
small,  soft  and  clay-colored.  They  are  infrequent  and  usually  only  form 
a  coating  to  calculi  of  other  composition,  (d)  Other  forms  are  rare. 
Calculi  of  (i)  calcium  carbonate  and  more  rarely  ammonium  or  magnesium 
carbonate  may  occur  in  the  aged;  they  are  white  and  dissolve  with 
effervescence  in  mineral  acids,  (ii)  Cystin  calculi  are  smooth,  yellow  and 
waxy,  never  exceed  the  size  of  a  pea,  are  soluble  in  acids  and  alkalies  and 
deposit  hexagonal  crystals  when  dissolved  in  acetic  acid  and  ammonia. 
Only  60  cases  are  reported,  (iii)  Xanthin  stones  occur  almost  exclusively 
in  children;  only  10  cases  are  recorded;  they  are  smooth,  yellow  or  brown, 
dissolve  in  nitric  acid  and  on  evaporation  leave  a  residue  which  turns 
red  on  adding  caustic  potash,  (iv)  Only  3  indigo  stones  are  on  record. 
(v)  Urostealiths  probably  result  from  fatty  substances  deposited  in  the 
bladder;  they  are  85  per  cent,  fat  and  are  soft,  rubber-like  and  com- 
bustible. 

Symptoms. — Stones  may  be  first  discovered  accidentally  at  autopsy 
or,  very  exceptionally,  may  pass  wdthout  symptoms.  Gravel  or  renal 
sand  is  more  often  latent  than  is  stone. 


RENAL  CALCULUS  659 

1.  Paix. — Pain,  the  most  common  symptom,  is  of  two  kinds:  (a) 
The  dull  pain  in  the  loin,  often  associated  with  local  tenderness  over  the 
kidney;  localized  pain  without  any  urinar}'  changes,  may  indicate  stone 
in  the  medullary  substance.  Pain  may  be  felt  over  the  opposite  kidney. 
(6)  The  renal  colic,  which  arises  from  incarceration  of  the  stone  as  it 
attempts  to  leave  the  pelvis;  it  is  often  preceded  by  pain  in  the  loin 
and  may  be  initiated  by  exercise  or  indigestion;  Eichhorst's  patient 
had  renal  colic  every  time  he  drank  white  T\'ine.  The  pain  begins  over 
the  kidney  and  radiates  down  the  ureter  to  the  testis,  labia,  bladder  or 
urethra ;  the  testicle  is  retracted  (in  the  descent  of  the  testis,  its  envelopes 
receive  a  twig  from  the  first  lumbar  nerve) .  It  may  rarely  radiate  to  the 
chest,  heart,  shoulder,  epigastrium  or  to  the  opposite  side.  During  the 
colic,  the  kidney  is  sensitive;  when  it  is  not  so^  Israel  hesitates  to  diag- 
nosticate stone.  The  i^o-in  is  cutting  and  very  severe;  it  often  occasions 
reflex  nausea  and  vomiting,  sometimes  chills,  sweats  and  fever  or  in 
children  convulsions  and  rarely  collapse  or  even  death  in  most  exceptional 
cases.  If  the,  stone  passes,  the  pain  is  greatest  as  it  enters  the  bladder. 
It  lasts,  vrith  intermissions,  a  few  hours,  rarely  days;  movement  may 
excite  recurrence.  The  patient  lies  on  his  back  with  the  leg  drawn  up 
and  the  abdominal  wall  rigid.  After  the  attack  there  may  be  dull  pain 
{v.  s.),  which  may  be  caused  by  large,  numerous  or  sharp  stones. 

2.  Urine. — The  urine  is  almost  invariably  altered,  (a)  Hematuria 
occurs  independently  of  pain  and  colic,  as  well  as  after  them.  Absence  of 
hematuria  after  a  renal  colic  argues  strongly  against  stone  (Israel). 
It  is  often  macroscopic  and  red  disks  are  found  with  the  microscope, 
except  in  the  rare  cases  when  stone  is  imbedded  in  the  renal  tissue  or 
there  is  permanent  occlusion  of  the  ureter.  At  the  time  of  the  colic  the 
scanty,  bloody  urine  is  frequently  voided  with  considerable  tenesmus. 
In  exceptional  cases  early  profuse  hematuria  may  result  from  vascular 
erosion,  (b)  Anuria  (suppression  of  urine)  is  not  common.  Legeau 
collected  30  autopsied  cases  of  calculous  anuria;  there  was  stone  in  one 
kidney  and  the  opposite  kidney  (a)  contained  a  calculus  in  14  cases,  {^) 
was  h^-poplastic  in  3,  (7)  sclerotic  in  6,  (5)  its  ureter  was  stenosed  by 
calculi  in  6  and  (e)  in  one  case  the  opposite  kidney  was  absolutely  normal 
(Morgagni's  reflex  suppression  via  the  splanchnic).  The  urethra  may  be 
plugged  with  a  calculus.  The  resulting  symptoms  are  called  "latent" 
uremia.  However,  in  41  cases  collected  by  Herter  convulsions  were 
present  in  but  12  per  cent.,  headache  in  14  per  cent,  and  vomiting  in  29 
per  cent.;  consciousness  is  usually  preserved  and  the  temperature  is 
low;  11  cases  of  anuria  persisted  over  four  days,  IS  cases  seven  to 
fourteen  days  and  7  cases  over  fourteen  days.  Ilussel  records  recovery 
after  twenty-eight  days  of  anuria.  With  its  relief  large  quantities  of 
urine  are  voided,  (c)  Pyuria  results  in  protracted  cases  from  pyelitis, 
secondary  to  the  calculus;  infrequently  a  renal  intermittent  fever  is 
obser\ed,  resembling  the  hepatic  intermittent  fever  of  gall-stones. 
Pyelitis  may  be  catarrhal,  suppurative,  ulcerative  or  perforative,  (d) 
Crystals  of  pointed  uric  acid  and  oxalates  are  considered  important  in 
diagnosis,    (e)  Stones  in  the  urine  are  not  frequently  found. 


660  DISEASES  OF   THE  KIDNEYS 

3.  The  X-rays. — Oxalate  stones  throw  a  shadow  m  every  instance; 
uric  stones  often  are  invisible.  Leonard  reports  but  3  per  cent,  of 
errors;  he  found  calculi  in  the  ureter  tmce  as  often  as  in  the  renal 
pelvis.     Kiimmel  insists  that  90  per  cent,  of  stones  cast  a  shadow. 

4.  Physical  Findings. — ^The  physical  findings  as  tenderness  {v.  s.) 
are  less  important  than  the  urinary  findings  and  the  colic.  Palpation  of 
the  stone  in  the  ureter  is  rarely  possible,  either  from  without  or  bj^  the 
rectum  or  vagma;  once  the  writer  felt  a  calculus  at  McBurney's  point. 
Stones  have  been  felt  to  crepitate  in  the  renal  pelvis  (Piorry).  Cysto- 
scopic  examination  and  catheterization  of  the  ureters  are  most  valuable 
methods. 

Complications. — L  Icerative  pyelitis  may  lead  to  perforation,  pyeloneph- 
ritis and  paranephric  abscess.  Hydronephrosis  results  from  mechanical 
occlusion  of  the  ureter  and  pyonephrosis  from  obstruction  with  infec- 
tion. Injury  to  one  kidney  may  be  compensated  by  hypertrophy  of  its 
fellow.  Amyloid  degeneration,  renal  tuberculosis  or  even  cancer  may 
develop.  The  ureter  may  rupture  from  ulceration  or  tejision.  Troja 
instances  a  pregnant  woman  in  whom  abortion  occurred  after  each 
of  fourteen  attacks  of  colic. 

Diagnosis. — The  diagnosis  is  based  on  (aj  the  colic,  particularly  after 
exertion,  (6)  hematuria,  (c)  pyelitic  pyuria,  {d)  a:-ray  findings  and  (e) 
less  often,  the  anuria  and  swelling  of  the  kidney.  If  the  .r-rays  are 
negative  stone  is  not  excluded.  A  diagnosis  of  stone  is  found  correct 
in  only  60  per  cent,  of  the  cases  operated  on. 

1 .  Paix  and  Colic. — Pain  and  colic  may  rarely  occur  in  renal  embolism ; 
also  in  passage  of  blood  clots,  parasites,  echinococcus  vesicles,  malignant 
tissue  or  tuberculous  detritus;  renal  aneurysm  and  floating  kidney. 
In  one  case  pain,  colic  and  hematuria  resulted  from  high  insertion  of  the 
ureter.  Confusion  may  result  with  vertebral  disease,  the  crises  of  tabes 
or  angioneurotic  edema,  herpes  zoster,  gall-stones,  appendicitis,  dia- 
phragmatic pleurisy  or  hysteria. 

2.  Hematuria. — Associated  -u-ith  pain,  it  may  cause  errors  in  diag- 
nosis, usually  corrected  only  at  operation;  thus  acute  congestion  or 
capsular  fibrosis  may  be  found;  Israel  describes  a  unilateral  nephritis 
(a)  with  colic,  ih)  with  albumin  and  ^^dthout  casts;  (c)  with  casts  and 
without  albumin;  {d)  with  hemorrhage,  simulating  tumor;  but  {e)  the 
bleeding  never  causes  the  colic.  Hematuria  from  cancer  and  tuber- 
culosis does  not  improve  with  rest  in  bed,  while  calculous  hematuria 
usually  does.  Hematuria  and  renal  colic  may  develop  in  ordinary 
chronic   nephritis   from   acute   renal   congestion. 

Prognosis. — The  course  is  usually  chronic  and  relapsing,  yet  the  author 
knows  of  four  physicians  who  passed  calculi  without  symptoms  after- 
ward. Rupture  of  the  meter,  collapse  during  the  colic,  pyelitis  becoming 
pyelonephritis,  anuria  and  uremia  must  be  considered  in  the  prognosis. 
Pyuria  is  more  ominous  than  hematuria. 

Treatment. — 1.  Prophylaxis. — Little  is  known  regarding  the  patho- 
genesis of  renal  calculus.  It  is  usually  stated  that  regulation  of  the  diet 
concerns  moderation  in  both  proteids  and  carbohydrates;  foods  rich 
in  nuclein,  acid  foods  and  alcohol  are  interdicted,    water  given  freely 


TUMORS  OF  THE  KIDNEY  661 

and  exercise  insisted  upon;  vegetables  may  be  allowed.  In  uric  acid 
calculi,  the  alkaline  waters  are  valuable,  as  those  of  Karlsbad,  Vichy, 
Marienbad,  Saratoga,  Bedford,  Poland  and  Mountain  Valley.  Sodium 
phosphate,  gr.  x,  or  bicarbonate,  5  ss,  t.  i.  d.,  is  indicated.  Lithium  carbon- 
ate, piperazin  and  glycerin  possess  no  proved  solvent  powers.  In  localities 
where  calculi  develop  very  frequently,  the  drinking  water  must  be  used 
with  caution.    Stones  once  formed  cannot  be  dissolved  by  drugs. 

If  the  oxalates  are  deposited,  treatment  is  the  same  as  in  oxaluria 
{q.  v.).  In  alkaline  urines  from  which  phosphates  are  precipitated,  the 
urine  must  be  made  acid  by  phenylis  salicylas,  gr.  x,  t.  i.  d.;  acid  waters, 
as  Seltzer  or  Apollinaris,  may  be  employed;  meats  should  be  restricted; 
hexamethylenamine,  gr.  x,  t.  i.  d.,  is  excellent  in  bacteriuria. 

2.  Colic. — The  colic  is  treated  as  in  gall-stones. 

3.  Surgical. — Intervention  is  indicated  by  (a)  anuria;  (b)  severe 
pyelitis;  (c)  septic  or  aseptic  obstruction  of  the  ureter;  (d)  exhausting 
hematuria  and  (e)  repeated  attacks  of  colic.  The  ideal  operation  is 
myelotomy;  next  is  nephrolithotomy  (nephrotomy),  closing  the  renal 
wound  if  there  is  no  infection;  operation  on  the  aseptic  kidney  entails 
a  mortality  of  3  per  cent.,  and  operation  in  the  presence  of  infection  10 
per  cent.  (Albarran) ;  in  these  cases  the  pelvis  should  be  drained  (nephros- 
tomy). Tenny  collected  134  cases  of  ureteral  calculns;  122  were  operated 
on,  with  a  mortality  of  19  per  cent,  or  of  47  per  cent,  if  pyelitis  was 
present;  anuria  is  a  serious  complication,  for  52  per  cent,  of  the  operated 
cases  die;  without  pyelitis  or  anuria  the  fatalities  were  6  per  cent. 

TUMORS  OF  THE  KIDNEY. 

I.  Cancer.  —  Etiology.  —  The  etiology  is  obscure.  It  constitutes  but 
2  per  cent,  of  all  cancers  and  but  1  per  cent,  of  primary  cancers  in  adults 
(Rubinstein);  62  per  cent,  occur  in  males  and  32  per  cent,  in  the  first 
ten  years  of  life.  Its  frequency  in  children  was  noted  by  Bright.  Weigert 
observed  1  case  in  a  newborn  child.  Cancer  in  the  renal  pelvis  may 
result  from  stone.  In  the  Albarran  and  Imbert  series  of  380  renal  tumors 
cancer  constituted  50  per  cent. 

Pathology. — The  primary  form  is  usually  infiltrating  and  the  second- 
ary form  consists  of  nodules.  Medullary  cancer  is  more  common  than 
scirrhus,  colloid  and  other  forms.  It  usually  begins  in  the  convoluted 
tubules  of  the  cortex,  and  is  limited  by  the  renal  capsule.  The  average 
kidney  weight  in  children  is  8^  pounds  and  in  adults  10  to  15  pounds 
(or  even  50).  The  opposite  kidney  and  the  sound  parts  of  the  affected 
viscus  may  show  compensatory  hypertrophy.  Hemorrhages  into  the 
neoplastic  tissue,  invasion  of  the  renal  veins,  ureter,  cava,  pancreas, 
adrenals  or  intestine  and  metastases  (58  per  cent.)  in  distant  organs 
sometimes  develop. 

Symptoms. — Some,  particularly  secondary,  cancers  are  latent. 

1.  Renal  Tumor. — Renal  tumor  occurs  in  97  per  cent,  of  cases.  It 
begins  in  the  renal  region,  but,  resisted  by  the  firm  lumbar  tissues,  it 
grows  forward.  Bimanual  palpation  demonstrates  its  origin.  If  large, 
it  may  fall  forward.     It  is  tender  and  firm.     The  form  of  the  kidney 


662  DISEASES  OF  THE  KIDNEYS 

is  usually  preserved,  though  nodules  may  be  palpated.  It  attains  large 
dimensions  (v.  s.),  compressing  and  dislocating  the  liver  and  spleen  up- 
ward, crowding  the  abdominal  viscera  and  even  pushing  the  heart  up  to 
the  clavicle.  On  tapping,  a  repercussion  wave  is  sometimes  noted  (ballotte- 
ment  renal).  Percussion  gives  a  dull  note,  except  so  far  as  the  colon 
overlies  the  kidney,  running  from  left  to  right,  from  above  downward; 
on  the  left  side  this  relation  is  more  clearly  distinguished;  on  inflation 
of  the  colon  with  air  its  tympanitic  note  in  some  degree  obliterates  the 
renal  dulness,  in  less  than  50  per  cent,  of  large  renal  tumors;  in  tumors  on 
the  right  side  the  colon  is  often  dislocated  laterally  or  even  downward. 
There  is  but  little  if  any  respiratory  excursion.  In  rare  instances  the 
tumor  may  pulsate  and  by  pressure  on  the  aorta  produce  a  systolic 
murmur,  which,  as  in  Richard  Bright's  case,  may  simulate  aneurysm. 
If  the  tumor  grows  into  the  ureter  hydronephrosis  may  augment  the 
swelling. 

2.  Pain. — Dull  pain  is  an  early  and  frequent  symptom,  from  pressure 
on  the  lumbar  plexus,  which  also  may  cause  some  sensory  disturbance 
in  the  legs.  Only  rarely  is  the  pain  colic-like,  due  to  passage  of  clots  or 
bits  of  tumor  {v.  i.). 

3.  Hematuria. — According  to  Guillet  it  occurs  in  50  per  cejit.  and 
is  the  first  symptom  in  25  per  cent,  of  cases;  Israel  holds  that  it  occurs 
in  92  per  cent,  and  is  the  first  manifestation  in  70  per  cent.;  it  is  less 
frtequent  in  children  (16  per  cent.) .  Sometimes  worm-like  clots  are  passed, 
with  great  colic;  they  sometimes  measure  one-half  to  one  inch;  clots 
in  a  clear  urine  are  almost  pathognomonic  (Israel).  The  cystoscope  and 
ureteral  catheterization  prove  that  the  hematuria  is  unilateral.  The 
hemorrhage  usually  originates  in  the  diseased  kidney,  rarely  from  the 
opposite  hyperemic  kidney.  Albarran  asserts  there  is  more  albumin 
than  the  blood  accounts  for.  Very  rarely  bits  of  cancer  tissue  pass.  The 
urea  is  increased  as  in  all  cancers.      Pyuria  is  no  part  of  renal  cancer. 

Complications. — Compression  symptoms  include  paraplegia  dolorosa, 
constipation,  intestinal  obstruction,  edema  from  compression  of  the 
iliac  veins  and  ascites;  varicocele,  first  noted  by  Guy  on,  is  due  to  late 
compression  of  the  spermatic  vein  by  the  tumor  or  contiguous  lymph 
nodes.  Metastases,  enlarged  glands,  rarely  perforation  into  the  lumbar 
muscles,  skin,  peritoneum  or  intestine  with  fatal  hemorrhage,  uremia, 
fever  from  cachexia  or  terminal  infection  may  be  observed.  According 
to  Israel,  tumor  of  the  renal  pelvis  causes  greater  hematuria,  more 
hydronephrosis  and  therefore  greater  variations  in  the  size  of  the  tumor; 
it  sometimes  grows  down  the  ureter  and  with  the  cystoscope  is  seen  to 
project  into  the  bladder;  particles  of  tumor  tissue  and  cells  are  more 
often  obtained. 

Course  and  Prognosis. — Death  is  invariable  without  operation;  it 
usually  results  from  cachexia,  in  two  years  in  adults  and  in  eight  months 
in  children;  6  cases  lived  over  ten  and  1  case  seventeen  years. 

Diagnosis. — The  following  are  important:  renal  tumor,  pain,  hematuria 
and  cachexia.  Imbert  speaks  of  the  complete  type  (tumor  and  hematuria), 
the  hematuric  type  (without  tumor,  6  per  cent.)  and  the  tumor  type 
(without  hematuria,  23  per  cent.). 


TV  MOM  OF  THE  Kidney  663 

Differentiation. — (a)  Liver  tumor  encroaches  much  more  upon  the 
diaphragm  and  is  characterized  by  its  respiratory  excursion,  location  of 
the  tumor  within  the  edge  of  the  Uver,  icterus  and  ascites.  There  are 
no  suggest  iAe  urinary  findings.  Bimanual  palpation  clearly  differentiates 
uncomplicated  cases.  Between  a  kidney  tumor  and  the  liver  a  furrow 
and  loop  of  resonant  intestine  are  frequently  found.  (6)  A  splenic  tumor 
maintains  the  form  of  the  spleen,  lies  above  the  colon  (whose  distention 
does  not  modify  the  splenic  dulness),  moves  on  inspiration,  shows  the 
characteristic  notches  and  seldom  causes  confusion  except  when  it  so 
rotates  that  only  its  convexity  can  be  felt,  (c)  An  ovarian  tumor  projects 
upward  from  the  pelvis,  with  which  its  connection  can  be  demonstrated, 
save  when  it  has  a  long  pedicle.  It  is  more  central  and  sustains  no  char- 
acteristic relation  with  the  colon,  (d)  Retroperitoneal  growths  are  much 
more  difficult  to  differentiate,  especially  enlarged  lymph  glands  and 
lymphosarcoma.  They  are  generally  more  central  and  less  movable.  Of 
perirenal  retroperitoneal  lipoma  50  cases  are  reported,  (e)  Cystic  degen- 
eration (».  -i.)  is  usually  bilateral  and  runs  a  most  chronic  course. 
Sarcoma  cannot  be  differentiated.  In  hydro-  or  pyonephrosis  the  tumor 
varies  and  presents  characteristic  urinary  changes.  Tuberculosis  is 
distinguished  by  pyuria  and  tubercle  bacilli  in  the  urine. 

n.  Sarcoma. — Sixty-six  per  cent,  occur  under  ten  years  and  most  in 
the  first  two  years  of  life.  Sarcoma  constitutes  20  per  cent,  of  renal 
growths.  It  is  slightly  more  common  in  girls  than  in  boys  and  in  the 
left  than  in  the  right  kidney.  Cohnheim's  theory  of  embryonal  inclusion 
is  supported  by  the  occasional  presence  of  cartilage,  bone,  striated 
and  unstriated  muscle  and  even  carcinomatous  tissue.  Sarcoma  is 
of  the  round-,  spindle-cell  or  melanoid  type  and  may  w^eigh  6000  gm. 
Secondary  sarcomata  may  develop  by  metastasis  from  other  organs  or 
by  invasion  by  contiguity. 

Its  symptoms  are  essentially  those  of  carcinoma,  from  which  an  intra 
vitam  diagnosis  is  rarely  possible,  except  when  sarcomatous  tissue  is 
passed  in  the  urine  or.  excised  at  operation.  Hematuria  and  cachexia 
are  infrequent;  age  and  glandular  involvement  are  of  no  diagnostic 
value.  A  remarkable  overgrowth  of  the  pubic  and  axillary  hair  and 
pigmentation  of  the  skin  may  be  observed.  Operated  cases  live  on  an 
average  sixteen,  and  non-operated,  eight  months. 

m.  Hypernephroma. — This  "struma  lipomatodes  aberrans  renis"  of 
Grawitz  develops  from  aberrant  (included)  particles  of  adrenal  tissue. 
Lately  their  origin  is  considered  Wolffian.  Small  tumors  are  not  a  rare 
autopsy  finding.  They  constitute  20  per  cent,  of  renal  tumors  and  consist 
of  a  scanty  vascular  stroma,  containing  fatty  cells  like  those  of  the  adrenal 
bodies.  Hemorrhage,  cystic  degeneration,  a  tendency  to  invade  the 
veins  and  a  large  proportion  of  glycogen  are  considered  characteristic. 
Fatty  cells  may  be  found  in  the  urine.  Hematuria  occurs  in  80  per  cent, 
of  cases.  Bone  metastasis  is  the  first  symptom  in  16  per  cent,  but  may 
develop  as  a  late  symptom  only.  Fever  is  noted  in  57  per  cent.;  it 
occurs  in  but  1  to  2  per  cent,  of  other  tumors  of  the  kidney  (Israel) . 

rV.  Other  Tumors. — Fibroma,  lipoma,  myxoma,  angioma,  endothe- 
lioma and  rhabdomyoma  are  very  rare;  33  cases  of  tumor  of  the  capsule 
are  on  record. 


664  DISEASES  OF   THE  KIDNEYS 

Treatment  of  Renal  Tumors. — Symptomatic  therapy  concerns  the  pain. 
Surgical  treatment  alone  is  of  value.  Thirty-three  recoveries  after 
radical  operation  are  on  record,  one  patient  being  alive  after  eighteen 
years.  Israel  in  43  cases  reported  a  mortality  of  18.6  per  cent.,  of  which 
two-thirds  died  of  heart  paralysis;  19  per  cent,  enjoyed  perfect  health 
for  three  and  a  half  to  fourteen  years.  Schede  in  18  operations  obtained 
22  per  cent,  apparent  recoveries  after  four  to  nine  years.  Recurrence 
after  two  years  is  very  exceptional.  Advanced  cachexia,  large  or 
bilateral  tumors,  metastases  and  groT^i;h  into  the  cava  are  contra- 
indications. 

CYSTIC  DEGENERATION. 

Various  renal  cysts  are  observed,  (a)  The  most  frequent  occur  in 
chronic  interstitial  nephritis  from  snaring-off  of  the  tubules  and  glomeruli. 
(6)  Parasitic  cysts  are  next  in  frequency  (v.  ?'.).  (c)  But  three  dermoid 
cysts  are  on  record,  (d)  Cysts  of  the  fatty  capsule,  retroperitoneal 
cysts  and  degenerated  lymph  glands  are  very  rare,  (e)  Hydrops  renuin 
cysticus,  degeneratio  renum  -polycystica  was  first  separated  by  Rayer  from 
the  above-mentioned  varieties  and  constitutes  cystic  degeneration,  as  it 
is  generally  understood. 

Etiology. — Over  50  per  cent,  are  observed  in  men  between  forty  and 
fifty  years  of  age.  Cystic  kidneys  are  observed  in  later  fetal  life,  at  birth 
and  in  the  adult.  Probably  they  are  congenital  and  remain  latent  lintil 
middle  life. 

Pathogenesis. — Three  main  theories  obtain;  (a)  that  they  are  retention 
cysts,  (6)  new  formations,  i.  e.,  neoplastic  (cystadehomata),  the  most 
acceptable  hjqDothesis,  and  (c)  malformations. 

Pathology. — Congenital  cases  are  usually  bilateral;  Lejars  found  1 
unilateral  case  in  67  and  Luzzatto  41  in  226  cases.  The  kidneys  may 
contain  innumerable  small  cysts,  when  the  shape  of  the  kidney  is  pre- 
served, or  it  contains  larger  cj'sts,  when  its  contour  is  more  irregular. 
The  kidneys  may  be  the  size  of  a  child's  head  -and  weigh  twenty-one 
pounds.  On  section  the  kidney  is  honey-combed.  The  cyst  walls  consist 
of  fibrous  tissue.  The  cysts  contain  thin,  yellow,  transparent  fluid, 
less  often  milky,  gelatinous  or  bro^^aiish  contents  (altered  blood).  They 
are  multilocular,  are  lined  with  cells  like  the  urinary  tubules  or  mth  flat 
polygonal  cells  and  contain  albumin,  oxalate  of  lime,  leucin-like  crystals, 
red  disks,  epithelial  detritus,  fat  granules  and  rarely  urea.  According 
to  Englander,  only  23  unilocular  cysts  are  on  record.  Between  the 
cysts  are  found  vestiges  of  renal  tubules  or  glomeruli,  which  may  be 
vicariously  hj^pertrophied.  Cysts  may  occur  in  the  pelvis,  ureter,  pan- 
creas and  liver  {v.  i.).  Other  congenital  deformities  are  sometimes 
found,  particularly  in  the  genitals,  brain  and  fingers. 

Symptoms. — In  congenital  forms  the  cystic  kidneys  may  obstruct 
delivery;  if  the  infant  is  born  alive  death  from  asphyxia  is  usual,  for  the 
diaphragm  is  crowded  upward.  Adult  forms  generally  come  to  autopsy 
undiagnosticated  or  with  the  diagnosis  of  nephritis.  The  symptoms 
may  be  classified  as  follows:  (a)  Renal  cysts  are  detected  clinically  in 
20  per  cent,  of  cases  only.    Their  general  characteristics  are  those  of 


RENAL  PARASITES  665 

solid  kidney  tumors,  but  they  are  bilateral  {v.  s.).  Fluctuation  seldom 
is  elicited.  '  In  2  cases  which  the  author  demonstrated,  the  individual 
cysts  could  be  clearly  palpated.  Echinococcus  cysts,  hydro-  and  pyo- 
nephrosis, sarcoma  and  cancer  of  the  kidney  are  only  distinguished  by 
their  unilateral  occurrence.  (6)  The  urine  may  be  normal,  increased  or 
decreased.  The  urinary  findings  are  typically  like  those  of  interstitial 
nephritis,  i.  e.,  the  urine  is  abundant,  with  few  solids^  low  specific  gravity 
and  traces  of  albumin.  Red  disks  are  found  in  20  per  cent.,  sometimes 
in  great  numbers.  In  2  of  the  author's  cases  many  red  cells  appeared 
each  time  the  kidneys  were  palpated.  Leucin-like  bodies  may  appear 
in  the  urine  or  in  exploratory  punctures;  Beckmami  first  described 
these  small  colloid  bodies  ("rosettes")  with  structureless  centres  and  one 
to  five  concentric  rings  and  clearly  radiating  striations.  (c)  Cardio- 
vascular changes  (left  ventricular  hypertrophy  and  sclerosed  arteries) 
are  common  and  herghten  the  resemblance  to  contracted  kidney,  (d) 
Uremia  is  the  common  cause  of  death.  The  clinical  course  is  very 
chronic  and  is  broken  by  attacks  of  periodic  uremia;  digestive  disorders 
are  very  frequent.  Patients  may  live  fifteen  and  twenty  years  after  the 
cj^sts  are  found. 

Diagnosis. — The  diagnosis  can  be  made  when  there  are  (a)  bilateral 
(perhaps  palpably  cystic)  renal  swellings;  (6)  the  cardiovascular  and 
urinary  findings  of  contracted  kidney,  with  hematuria  and  colloid 
"rosettes,"  obtained  in  the  urine  or  by  puncture;  (c)  uremia  and  (d) 
perhaps  renal  pain  like  calculus,  tenderness,  or  congenital  cysts  in  the 
liver  (in  28  per  cent.,  Lejars);  in  a  case  of  Dr.  W.  F.  Dickson  renal 
cysts  were  found  with  cystic  liver,  atrophic  heart  and  pain  resembhng 
appendicitis.     (See  Echinococcus  of  the  Liver.) 

Treatment. — Operation  is  permissible  only  in  the  exceptional,  uni- 
lateral cases;  about  one-third  of  the  operated  cases  die  immediately 
and  in  few  only  are  any  lasting  results  obtained.  The  treatment  is  that 
of  chronic  nephritis.     Multiple  punctures  are  advocated. 

RENAL  PARASITES. 

Echinococcus  Cysts. — Renal  cysts  occur  in  9  per  cent,  of  echino- 
coccus disease  (Neisser's  900  cases).  In  970  cases  (Vegas  and  Cranw^ell) 
the  liver  was  diseased  in  64  per  cent.,  the  lungs  in  7  per  cent.,  the  spleen 
in  .3  per  cent,  and  the  kidneys  in  2  per  cent.  Baradulin  in  1906  collected 
142  renal  cases  (see  page  305). 

Symptoms. — (a)  A  renal  tumor  is  found  in  50  per  cent,  when  the 
cyst  attains  large  dimensions.  Without  the  exploratory  puncture  and 
the  urinary  findings,  it  is  easily  confused  with  other  cysts,  hydroneph- 
rosis, cancer  or  tuberculosis.  Fluctuation  and  the  hydatid  thrill  are  not 
often  found  (see  Liver  Echinococcus).  The  cyst  begins  in  the  cortex, 
usually  in  either  pole  of  the  kidney;  it  is  unilateral  in  96  per  cent,  of 
cases  and  is  left-sided  in  62  per  cent.  If  the  cyst  calcifies  it  may  be  seen 
})y  the  .r-rays.  The  opposite  kidney  may  hypertrophy,  (b)  Exploratory 
aspiration  may  show  (i)  fiuid  or  pus  containing  urinary  constituents, 
chok'sterin,  succinic  acid,  much  sodium  chloride  and  a  reducing  sub- 


666  DISEASES  OF  THE  KIDNEYS 

stance;  (ii)  vesicles,  booklets  or  particles  of  lamellated  membrane,  (c) 
The  2irine  may  contain  vesicles,  booklets,  membrane,  pus  from  pyelitis 
and  blood  from  rupture.  As  many  as  100  vesicles  bave  been  passed. 
(d)  Passage  of  vesicles  is  attended  by  severe  colic,  fever,  chill  and  vomiting. 

Complications. — Seventy-five  per  cent,  rupture,  chiefly  into  the  renal 
pelvis;  perforation  may  occur  into  the  intestines,  lumbar  muscles, 
lung  or  pleura;  the  patient  may  feel  the  rupture.  The  toxic  substances, 
liberated  by  rupture  or  puncture,  may  cause  urticaria,  severe  heart 
symptoms  or  even  fatal  syncope.  Adhesions  to  the  liver,  spleen  and 
intestine  may  form.  Suppuration  or  gangrene  may  develop  (pyonephrosis 
or  paranephritis).  Obstruction  of  the  ureter  causes  hydronephrosis; 
vesicles  plugging  the  lower  end  of  the  ureter  have  been  seen  with  the 
cystoscope. 

Prognosis  and  Treatment. — The  course  is  chronic,  covering  even  twenty 
to  thirty  years.  Suppuration  may  cause  pyemia.  The  cyst  may  shrink 
or  calcify.  Bilateral  involvement  makes  the  prognosis  unfavorable. 
Spontaneous  recovery  by  rupture  into  the  urinary  tract  occurs  in  32 
per  cent.  Extra-peritoneal  nephrotomy  is  indicated,  as  there  is  seldom 
more  than  a  single  cyst.  In  30  nephrotomies  by  Schede  there  were  no 
fatalities;  87  per  cent,  completely  recovered  and  10  per  cent,  recovered 
but  had  fistulee.    Nephrectomy  entails  a  higher  mortality  (8  per  cent.). 


SECTION  VI. 

DISEASES  OF  THE  BLOOD, 


Anemia  is  a  reduction  in  the  blood  as  a  whole  or  more  often  a  reduc- 
tion of  its  important  constituents,  as  the  red  corpuscles,  their  number, 
hemoglobin  or  albumin.  Every  anemia  has  a  cause,  yet  in  our  present 
ignorance  we  adhere  to  the  older  division  of  anemia  into  primary  and 
secondary  forms.  Primary  anemia  includes  chlorosis  and  pernicious 
progressive  anemia. 

CHLOROSIS. 

Definition.^Chlorosis  is  a  disease  of  hemogenesis,  occurring  in  women, 
chiefly  in  the  developmental  years,  in  which  the  cardinal  symptom  is 
anemia;  the  red  cells  are  reduced  butthe  hemoglobin  is  disproportionately 
reduced;  chlorosis  responds  to  therapy  by  iron.  Chlorosis  is  a  disease, 
while  anemia  is  but  a  symptom. 

Etiology. — Its  etiology  is  uncertain,  (a)  All  cases  occur  in  loomen, 
especially  in  girls  who  menstruate  before  the  pubes  and  mammae  develop 
(Niemeyer).  It  is  more  common  in  blondes  than  brunettes.  (6)  Chlorosis 
occurs  largely  between  the  fourteenth  and  seventeenth  years,  rarely  after 
the  twenty-fourth  year,  (c)  Heredity,  chlorosis,  tuberculosis  and  hys- 
teria are  not  infrequently  associated  in  the  family  history,  (d)  Malnu- 
trition, lack  of  hygiene,  working  in  dark  quarters,  insufficient  or  excessive 
exercise,  wearing  of  corsets  and  emotional  or  sexual  factors  are  indirect 
causes.  Various  theories  are  advanced  as  to  the  nature  of  the  disease, 
as  adynamia  of  the  hlood-making  organs  at  puberty,  insufficient  absorption 
of  iron,  auto-intoxication  from  the  internal  genitalia  and  intestines. 

General  Symptoms. — Among  the  early  frequent  symptoms  are  rapid 
tiring,  dyspnea  and  palpitation.  Pallor  is  the  earliest  and  most  constant 
sign,  the  skin  being  of  a  yelloioish-green  hue  (chlorosis,  as  named  by 
Varandel  in  1670).  Sometimes  the  face  is  flushed,  probably  from  per- 
ipheral vasomotor  irritability  {chlorosis  rubra) ;  hence  the  mucous  mem- 
branes should  be  examined  also.  The  eyes  are  often  brilhant.  Lack 
of  mental  and  muscidar  energy  is  noted,  associated  with  headache,  which 
may  be  dull  or  sharp,  sometimes  migraine-like  or  increased  at  the  time 
of  menstruation,  spots  before  the  eyes,  tinnitus,  vertigo  and  syncope, 
especially  from  standing,  travel  and  exposure  to  the  sun.  Menstrual 
disturbances  are  frequent,  the  flow  being  often  decreased  in  younger 
subjects.  Digestion  is  very  often  disturbed.  The  hands  are  cold,  the 
skin  dry  and  the  peripheral  circulation  sluggish.    Circulatory  symptoms 


068  DISEASES  OF  THE  BLOOD 

appear,  as  the  bruit  de  diahle  in  the  neck  veins,  anemic  heart  murmurs 
and  rapid  pulse. 

Special  Symptoms.— 1.  The  Blood. — The  blood  is  fluid  and  its  coagu- 
lability is  increased.  The  red  blood  cells  are  decreased  {oligocythemia)  and 
average  3,000,000  to  4,000,000;  as  few  as  900,000  have  been  observed. 
In  rare  cases  they  are  not  decreased.  Formation  of  rouleaux  is  poorly 
marked.  The  red  cells  appear  yale  and  their  average  size  is  reduced. 
Irregularity  in  contour  (poikilocytosis) ,  megalocytosis  and  microcytosis 
are  rare;  normo-  and  megaloblasts  are  found  in  the  severest  cases,  or 
in  "blood  crises."  More  suggestive  than  the  oligocythemia  is  the  reduc- 
tion of  hemoglobin  {oligochromemia) ,  which  is  reduced  more  than  the  red 
cells  (Duncan,  1867) ;  the  hemoglobin  averages  30  to  40  per  cent.  This 
reduction  in  the  color  index  to  one-half  or  less  always  suggests  chlorosis, 
and  is  less  conspicuous  in  relapses  and  in  older  individuals.  The  white 
cells  are  essentially  normal,  therein  differing  from  many  other  forms  of 
anemia;  occasionally  lymphocytosis  and  eosinophilia  occur.  The  iron 
and  nitrogen  of  the  blood  and  its  specific  gravity  are  reduced  proportion- 
ately to  the  decrease  in  hemoglobin. 

2.  The  Vascular  System. — (a)  Rokitansky  and  Virchow  observed 
hypoplasia  of  the  aorta  and  vessels,  which  may  coexist  with  hypoplasia 
of  the  genitalia,  muscles  and  bones,  but  cannot  be  regarded  as  causative. 
(6)  Palpitation  is  almost  constant  on  exertion ;  the  apex-beat  is  strong  to 
compensate  for  the  poverty  in  hemoglobin,  (c)  Heart  murmurs  occur  in 
two-thirds  of  the  cases;  they  are  functional  and  caused  by  insufficient 
tension  of  the  mitral  valve,  relative  mitral  insufficiency,  weakened  heart 
muscle  (producing  a  muscular  murmur  in  place  of  the  tone)  or  vibration 
of  the  pulmonary  artery.  The  murmurs  are  largely  systolic;  undoubted 
diastolic  venous  bruits  have  been  heard,  {d)  Dilatation  of  the  heart  may 
occur  from  anemia  or  myocardial  degeneration,  though  usually  it  is  not 
real  but  apparent,  retraction  of  the  lungs  away  from  the  heart,  because  of 
insufficient  lung  expansion  being  seen  by  the  .x-rays,  {e)  The  pidse  may  be 
rapid,  throbbing  or  excitable.  Dicrotism  and  capillary  pulsation  are 
frequent  and  double  tones  have  been  noted  in  the  crural  vessels  from  de- 
creased tension  and  diastolic  recoil.  (/)  A  venous  hruit  de  diahle  in  the 
neck  occurs  more  frequently  than  in  other  anemias  (in  over  50  per  cent,  of 
cases  and  in  two-thirds  of  the  cases  over  the  right  jugular  vein,  because  it  is 
more  vertical).  It  is  increased  by  turning  the  head  and  deep  inspiration. 
It  is  referred  to  change  in  the  tonus  of  the  vessel,  waves  in  the  veins  above 
their  valves  or  change  of  the  blood  plasma.  (</)  Arterial  murmurs  may  be 
heard,  as  over  the  subclavian  artery;  pulsation  in  the  peripheral  veins, 
angiospasm  and  erythromelalgia  have  been  observed,  (li)  Edema  is 
seen  in  12  per  cent,  of  cases  and  is  usually  slight,  occurring  chiefly  about 
the  ankles  and  eyes. 

3.  Respiratory  Tract. — Dyspnea  is  common,  explained  as  a  hema- 
togenous respiratory  insufficiency.  The  respiration-rate  is  26  to  30. 
Sometimes  a  paroxysmal  cough  develops. 

4.  Digestive  Tract. — The  digestive  tract  is  involved  in  one-third  of 
the  cases,  (a)  Pain  is  frequent  near  the  ensiform  with  tenderness, 
especially  in  nervous  individuals.     Vomiting  and  perversity  of  appetite 


CHLOROSIS  669 

are  occasional.  (6)  Dyspepsia  may  be  purely  nervous.  Exceptionally 
the  stomach  is  dilated  and  atonic,  (c)  The  hydrochloric  acid  is  often 
increased,  probably  from  nervous  irritability,  (d)  Constipation  is  no 
more  frequent  than  in  the  average  case;  intestinal  fermentation  is  not 
the  cause  of  chlorosis. 

5.  Sexual  Sphere. — Menstruation  is  decreased  or  absent  in  80  per 
cent.;  menstrual  disturbance,  the  uterus  infantilis  or  small  ovaries  are 
neither  the  cause  nor  result  of  chlorosis,  but  result  from  some  common 
factor.  Conception  is  unlikely  to  occur.  Chlorotics  are  first  treated  by 
the  gynecologist  for  leucorrhea  in  22  per  cent,  of  cases. 

6.  Special  Senses. — The  usual  symptoms  of  anemia,  as  spots  before 
the  eyes  and  weakness  of  accommodation,  are  observed.  The  retinal 
vessels  may  be  transparent  or  pulsating;  retinitis  and  neuroretinitis 
or  "choked  disk"  exceptionally  simulate  brain  tumor.  Retinal  hemor- 
rhage is  rare. 

7.  Skin. — The  skin  is  usuallv  anemic;  angiospasm,  coldness  and 
paresthesia  occur.  In  chlorosis  rubra  the  cheeks  are  flushed.  Seborrhea 
and  acne  are  very  common.  Sweats,  urticaria,  eczema,  purpura,  chloasma 
and  trophic  disturbance  of  the  hair  and  nails  may  occur. 

8.  Nervous  System. — Chlorosis  often  brings  out  a  latent  neurosis— 
especially  hysteria — and  psychosis. 

9.  Metabolism. — Metabolism  is  not  essentially  disturbed.  Usually 
the  body  weight  is  maintained,  less  from  decreased  oxygenation  than 
from  inactivity.  The  urine  is  clear,  of  low  specific  gravity,  often  alkaline 
with  decrease  of  urea  and  uric  acid  and  sometimes  albuminuria.  Leube 
found  fever  frequently  in  mild  chlorosis.  When  present,  we  may  suspect 
"tuberculous  pseudochlorosis." 

Complications. — Chlorosis  may  favor  acute  infections  and  render  their 
course  severe.  Venous  tliromhosis  complicates  2  per  cent,  of  cases  and  is 
probably  inflammatory.  In  Quensted's  series  67  per  cent,  involved  the 
veins  of  the  leg  and  25  per  cent,  the  cerebral  sinuses;  pulmonary  embol- 
ism occurred  in  19  per  cent.  Virchow  emphasized  the  frequency  of  septic 
endocarditis.  Rheumatic  endocarditis  with  organic  valvular  lesion  is 
frequent,  as  also  are  ulcer  of  the  stomach,  tuberculosis  and  Basedow's 
disease.  The  spleen  is  enlarged  in  16  per  cent,  and  often  the  thyroid 
gland.  Hemorrhages  are  not  infrequent  from  the  nose,  stomach  or  intes- 
tine, although  less  than  in  severe  secondary  or  pernicious  anemia. 

Clinical  Course  and  Prognosis. — Chlorosis  develops  abruptly  and  runs  a 
short  course  of  two  to  four  months.  The  prognosis  is  generally  good.  The 
tendency  to  recurrence  is  great,  especially  in  unmarried  or  childless  women; 
the  blood  may  not  return  absolutely  to  normal,  shown  by  persistent  pallor 
or  irregular  menstruation.  Acute  chlorosis  is  observed  in  young  girls 
after  their  first  menstruation ;  it  is  attended  by  severe  headache,  nervous 
symptoms,  weakness  and  optic  neuritis  or  "choked  disk,"  which  may  be 
confused  with  brain  tumor.  The  periodic  type  occurs  in  the  higher  classes 
and  in  those  who  acquire  the  disease  in  their  seventeenth  to  nineteenth 
year.  The  disease  may  last  for  years  with  chronic  chlorotic  blood,  men- 
strual, dyspeptic,  muscular  and  nervous  symptoms,  with  alternate  exacer- 
bation and  amelioration;   there  is  poor  development  of  the  bones,  muscles. 


07(1  DISEASES  OF   THE  BLOOD 

genitalia,  mamma?  and  adipose  tissue;  marriage,  pregnancy  and  iron 
often  benefit  these  cases,  but  they  may  last  until  the  menopause. 

Diagnosis. — The  diagnosis  is  made  by  the  grouping  of  symptoms, 
positive  and  negative,  for  no  single  symptom  is  pathognomonic.  The 
obtrusive  symptom  is  anemia,  especially  when  there  is  disproportionate 
reduction  in  the  hemoglobin,  when  the  color  index  is  less  than  one  and  the 
white  cells  are  normal.  Rhomberg  described  exceptional  cases  in  which 
the  blood  was  normal.  The  age,  rapid  derelopment,  periodic  manifesta- 
tion and  successful  treatment  with  iron  are  important  features.  Second- 
ary anemia  is  most  difficult  to  differentiate  and  is  usually  attended  by 
some  leukocytosis  (r.  page  677).  Hemorrhage  from  latent  ulceration 
of  the  stomach,  early  pregnancy  in  unmarried  girls,  the  anemia  of  heart 
disease,  etc.,  must  be  considered.  Splenic  anemia,  especially  in  children, 
recjuires  dift'erentiation;  cases  of  chlorosis  with  enlarged  spleen  are  a 
transitional  form  between  chlorosis  and  splenic  anemia  proper.  Malig- 
nant disease  and  incipient  tuhercidosis  are  important. 

Treatment. — 1.  Prophylaxis. — General  hygiene  and  development  of 
adipose  tissue  to  a  reasonable  extent  are  prophylactic.  More  albumin 
should  be  given  to  growing  children  than  to  adults,  together  with  fruit 
and  vegetables,  for  their  iron,  and  butter,  cream  and  oils,  rather  than 
animal  fats.  Physical  culture  and  trips  to  the  country  are  valuable. 
Children  at  this  age  are  confined  too  much  to  the  school-room;  they 
should  be  kept  children  as  long  as  possible.  In  societv  or  in  the  struggle 
for  existence  young  girls  too  often  overtax  their  strength. 

2.  Specific  Therapy. — Iron  exists  in  the  hemoglobin  of  the  blood 
cells  as  an  oxygen  carrier  and  is  a  food  as  well  as  a  medicine;  it  is  found 
in  blood,  meat,  oatmeal,  peas,  spinach  and  beans. 

Physiological  Action  of  Iron. — (a)  The  nervous  tonus  is  increased; 
an  excess  produces  frontal  headache  from  constipation;  some  persons 
exhibit  a  peculiar  intolerance  of  iron,  as  shown  by  headache,  vertigo  and 
palpitation.  (6)  It  increases  the  number  of  red  disks  and  the  hemoglobin. 
(f)  Iron  stains  the  teeth  because  of  the  acid  it  contains.  Small  doses  stimu- 
late digestion,  improving,  by  their  astringent  action,  the  tone  of  the 
tissues.  Hydrogen  is  generated  and  from  it  sulphuretted  hydrogen,  which 
causes  eructations.  Small  doses  constipate  but  large  doses  relax  the 
bowels;  diarrhea  sometimes  follows  small  doses.  Sulphide  of  iron 
darkens  the  stools,  {d)  The  amount  of  urine  is  increased.  Iron  is  found 
in  the  urine  in  very  small  quantities.  The  kidneys  may  be  irritated  by 
very  large  doses,  ie)  It  is  absorbed  from  the  stomach  and  intestines 
as  an  albuminate,  reaches  the  blood  and  is  deposited  first  in  the  spleen 
and  then  in  the  liver,  by  which,  and  the  intestines  chiefly  and  kidneys, 
it  is  eliminated. 

Administration. — vSoluble  would  seem  to  be  better  than  insoluble  prepa- 
rations, but  Quevenne  has  shown  that  the>'  are  precipitated  by  the  gastric 
juice.  Headache  is  obviated  by  using  laxatives,  or  ferrous  salts,  which 
derange  digestion  less  than  ferric  salts,  and  can  be  reduced;  chlorotics 
cannot  reduce  the  ferric  salts.  Iron  is  said  to  be  best  absorbed  when  some 
gastric  catarrh  exists,  hence  Brunton  gives  large  doses  at  first  to  improve 
absorption.  There  are  only  38  to  45  grains  of  iron  in  the  body;  the  ordinary 


CHLOROSIS  071 

daily  diet  contains  but  one-sixth  of  a  grain  of  iron,  but  while  sufficient  as 
food,  does  not  stimulate  the  blood-making  centres.  The  doses  should  not  be 
too  small.  Statements  of  the  patient  that  she  has  previously  taken  iron 
should  not  be  regarded,  for  its  administration  may  have  been  irregular. 
In  the  first  week  the  dose  should  be  gradually  increased;  for  three  weeks 
the  maximum  dose  should  be  given  and  for  the  last  two  weeks  it  should 
be  gradually  decreased.  If  iron  is  not  beneficial  it  should  not  be  repeated 
but  other  methods  tried.  Relapses  are  less  easy  to  treat  than  the  first 
attack.  Idiosyncrasy,  as  gastro-intestinal  disturbance,  is  only  a  relative 
contra-indication.  The  administration  should  then  be  subcutaneous.  At 
mineral  springs  hygiene  is  more  important  than  iron;  the  water  should 
be  taken  on  an  empty  stomach,  for  the  gas  promotes  absorption  of  iron. 
When  bottled  it  is  precipitated  as  a  carbonate. 

Preparations. — Ferrum  reductum  (reduced  iron)  is  iron  gray  (if  it  is 
black  it  is  impure)  and  tasteless;  it  is  least  astringent,  but  may  cause 
eructation;  gr.  j.  (See  formula  on  page  377.)  Pilula  ferri  carbonatis, 
a  ferrous  salt  nearly  free  from  astringency;  grs.  ij-v.  Ferri  sulphas 
(green  vitriol),  a  ferrous  salt  which  is  very  astringent,  whence  its  use 
in  chronic  diarrhea.  It  stimulates  digestion,  but  in  large  quantities 
it  causes  vomiting  or  diarrhea;  gr.  ij  may  be  given  with  1  dram  of 
magnesium  sulphate  p.  c. 

I^ — Ferri  sulphatis  exsiccati, 

Potassii  carbonatis aa      Sij 

Syrupi q.  s. 

M.  et  fac  pilulas  no.  1. 

S. — One  to  three  pills  after  meals  (Blaud's  pills). 

Liquor  ferri  et  ammonii  acetatis  {Bashams  mixture)  is  diuretic  and 
excellent  for  chlorosis  in  the  obese,  oj-iv  given  after  meals,  well  diluted. 
Tindura  ferri  chloridi  is  the  chloride  of  iron  plus  hydrochloric  acid  and 
alcohol,  which  develop  hydrochloric  ether.  It  is  yellowish-red,  astringent, 
somewhat  corrosive  and  diuretic,  increasing  the  amount  of  urine  and 
frequency  of  micturition.  It  is  used  to  best  advantage  when  the  tongue 
is  white,  flabby  and  indented.  In  weak,  anemic  girls,  with  vomiting,  neural- 
gia and  epigastric  pains,  full  doses  should  be  given ;  when  poorly  tolerated, 
one  drop  in  a  full  glass  of  water  is  more  beneficial  than  chalybeate  waters. 
Iron  and  iodine  given  separately  are  usually  more  beneficial,  but  the 
syrupus  ferri  iodidi  may  be  given  in  doses  of  30  to  40  drops  in  adults  and 
of  5  to  10  in  children.  Ferri  citras  in  doses  of  gr.  v,  is  efficacious  in 
delicate  stomachs ;  for  hypodermic  use  it  is  painful ;  ferri  arsenas,  gr.  yV? 
or  ferri  cacodylas,  gr.  |  to  j,  is  better.  Most  organic  irons  are  useless. 
Arsenic  alone  seldom  increases  the  red  cells  or  hemoglobin;  ferri  phosphas 
solubilis,  gr.  v,  is  almost  free  from  astringency  and  taste.  Arsenic  is 
given  as  in  pernicious  anemia  {q.  v.)  uninterruptedly,  with  gradually 
increasing  doses,  sustained  doses  and  then  decreasing  doses  for  a  period 
of  four  to  six  weeks. 

High  altitude  increases  the  red  cells  and  hemoglobin. 

3.  Dietetic  Treatment. — The  amount  of  albumin  should  be  increased 
and  the  heavy  English  breakfast  is  indicated.  Equal  parts  of  milk  and 
cream  should  be  given  but  with  care  lest  the  appetite  be  spoiled,  too  much 


072  DISEASES  OF   THE  BLOOD 

fat  be  deposited  and  the  stomach  suffer  atony.  Alcohol  is  indicated  in  thin 
rather  than  in  obese  individuals.  Patients  should  rest  before  and  after 
eating  and  retire  early.  In  thin  subjects  the  diet  should  be  concen- 
trated, consisting  of  albumin,  vegetables,  fats,  alcohol,  and  milk  at 
breakfast  and  at  bed  time,  but  Avithout  increase  of  the  carbohydrates. 
Iron  produces  better  results  in  such  cases  after  limiting  the  amount  of 
water  to  about  one  quart.  Sweats  may  produce  the  same  results.  Gas- 
tric disturbance  disappears  after  administration  of  iron,  and  meals  at  two- 
hour  intervals — fluid  and  solid  meals  being  alternated.  Hydrochloric 
acid,  strychnine,  belladonna,  exercise  in  convalescence  (during  chlorosis 
the  patient  should  rest  in  bed)  and  cool  rubbings  early  in  the  morning 
are  advantageous;  cold  baths  produce  chills,  insomnia  and  digestive 
disturbances.  Marriage  may  help  mild  cases,  but  is  injurious  in  the 
severe  type. 

PERNICIOUS    ANEMIA. 

Definition. — A  primary  anemia  with  progressive  diminution  of  the  red 
cells  and  reduction  in  the  hemoglobin;  due  to  hemolysis  and  defective 
hemogenesis;  characterized  by  pallor,  adynamia,  edema  and  cardiac 
s^^Ilptoms  and  resulting  in  death  from  vomiting,  diarrhea,  hemorrhages 
and  fever.  It  was  described  by  Combe  Q822)  and  Andral  (1826j ;  Addi- 
son (1855)  gave  the  best  early  description  and  it  is  sometimes  called 
Addison's  anemia.  Since  Ehrlich  drew  the  blood  picture,  little  has 
been  added  to  our  knowledge  of  the  disease. 

Etiology. — The  disease  occurs  in  0.2  per  cent,  of  cases,  especially  in 
the  fourth  and  fifth  decades  of  life;  six-sevenths  of  the  cases  occur  after 
the  thirty-fifth  year  fCabot).  Baginsky  could  collect  but  16  cases  in 
children.  Sixty  per  cent,  occur  in  males.  The  ultimate  cause  is  to  be 
sought  in  some  hemolysin,  as  yet  unkno^m.  Although  caUed  a  primary 
or  essential  anemia,  some  undoubted  secondary  cases  may  be  included 
under  this  head  because  the  sjTuptom-complex  is  the  same.  Bothrio- 
cephalus  and  ankylostoma  anemias  present  identical  blood  findings, 
sjTuptoms  and  pathology.  Talquist  found  a  lipoid  substance  in  the 
alimentary  mucosa  and  in  tape-worms.  Pregnancy,  the  puerperium, 
s\'philis,  tj-phoid,  malaria,  and  diarrhea,  vomiting  and  oral  or  gastro- 
intestinal sepsis  have  been  considered  factors. 

Symptoms. — 1.  The  Blood  Chaxges  (Sorenson,  1874). — The  amount 
is  decreased,  several  punctures  often  being  necessary  to  obtain  enough 
for  the  blood  count;  it  is  often  watery.  The  specific  gra\-ity  is  low,  even 
1.027.  There  is  an  increase  in  the  albumin  in  the  individual  red  cell 
(hyperalbuminemia  rubra,  von  Jaksch).  The  serum  does  not  contain 
free  hemoglobin.  If  injected  into  normal  indiA'iduals  the  serum  has  a 
hemolytic  action.  In  contrast  to  chlorosis  and  secondary  anemias,  the 
coagulability  of  the  blood  is  decreased  and  the  blood  may  remain  fluid  for 
some  time  after  death.  Dropped  on  filter  paper,  there  is  a  white  zone 
outside  the  blood  stain  (Talquist).  The  hemoglobin  is  rarely  more  than 
50  per  cent,  and  may  be  reduceVl  to  10  per  cent.  In  90  per  cent,  of  cases 
and  in  contrast  to  other  anemias,  the  hemoglobin  per  corpuscle  is  propor- 
tionately increased,  i.  e.,  the  color  index  is  more  than  1   (even  2.25). 


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PERNICIOUS  ANEMIA  G73 

Laaclie's  explanation  is  that  certain  red  cells,  especially  giant  forms, 
contain  a  large  covipensatory  individual  amount  of  hemoglobin,  which  is 
also  true  of  the  microcytes,  but  less  so  of  normal-sized  red  cells.  Free 
hemoglobin,  acting  on  the  white  cells,  possibly  produces  a  fibrin  ferment, 
which  causes  fever,  hemorrhage  and  capillary  embolism.  The  red  blood 
corpuscles  are  greatly  reduced  in  number,  even  to  100,000,  the  average 
being  1,200,000.  Patients  often  die  when  this  figure  is  reached.  Poikilo- 
cytosis  is  marked,  the  irregularity  in  form  and  size  of  the  corpuscles  being 
great,  as  Litten's  horseshoe  or  pessary-shaped  corpuscles.  In  90  per 
cent,  the  red  corpuscle  is  above  the  average  size,  i.  e.,  11,  even  18m,  instead 
of  5  to  8fx,  the  highest  normal  measurement.  Polychromatism  is  frequent. 
Megalocytes  may  be  observed  in  numbers,  with  less  marked  or  absent 
umbilication;  they  probably  indicate  megaloblastic  degeneration  of  the 
bone-marrow.  (See  Plates  XVII  and  XVIII.)  Megaloblasts  are  rarely 
found  in  large  numbers ;  in  rare  cases  they  may  be  abundant,  as  just  before 
death,  whence  their  generally  ominous  significance;  they  may  be  absent 
for  months  or  weeks  at  a  time.  Normoblasts  occur  in  nearly  all  cases, 
especially  in  the  "blood  crises"  but  are  not  numerous;  they  are  immature 
ceils  and  indicate  activity  of  the  blood-forming  organs.  Microblasts 
are  frequently  absent;  their  teleological  significance  lies  in  the  increase 
of  the  respiratory  surface  of  cells  thus  afforded.  Cell  divisions  are  found. 
Granular  deposits  (staining  with  basophilic  dyes)  in  the  protoplasm  are 
noted;  according  to  Ehrlich,  they  are  not  due  to  polychromatophile 
degeneration  but  to  nuclear  degeneration.  The  cells  may  stain  only  at 
their  margins.  Decreased  formation  of  rouleaux  is  observed  as  well 
as  ameboid  movement  of  the  red  cells.  The  lohite  corpuscles  are  decreased 
absolutely,  the  lowest  record  being  1500;  the  polymorphonuclears  are 
decreased.  Leukocytosis  is  a  distinct  complication,  is  often  ominous  and 
indicates  inflammation  or  suppuration.  The  lymphocytes  are  relatively 
increased,  even  to  62  per  cent,  of  the  total  white  cells.  Marked  decrease 
of  the  eosinophiles  is  an  unfavorable  sign.  Pernicious  anemia  due  to 
parasites  shows  increase  in  the  eosinophiles  to  6,  36  and  even  50  per  cent. 

2.  Subjective  Syimptoms. — The  most  marked  are  weakness,  muscular 
adynamia,  vertigo,  palpitation  and  dyspnea. 

3.  Skin. — The  skin  presents  a  peculiar  pallor,  often  of  a  somewhat 
characteristic  lemon  tint.  Slight  icterus  is  not  infrequent.  The  skin  is 
usually  dry.  Edema  is  invariable,  especially  about  the  ankles  and  eye- 
lids. It  is  obstinate  and  may  produce  pronounced  general  anasarca;  it 
is  due  to  degenerative  vascular  permeability.  Hemorrhages,  usually 
punctate,  are  frequent  in  the  skin  and  mucosse.  Large  hemorrhages  occur 
in  25  per  cent,  of  cases.  Pigmentation  is  sometimes  as  marked  as  in 
Addison's  disease.    The  author  observed  herpes  zoster  and  crural  herpes. 

4.  Metabolism. — The  nutrition  is  maintained  in  61  per  cent,  of  cases 
because  tissue  waste  is  lessened  and  water  is  retained  in  the  tissues; 
in  39  per  cent,  the  weight  and  strength  finally  decline  with  persistent 
vomiting  and  diarrhea  (Cabot).  In  the  urine  indican,  putrescin,  cada- 
verin,  leucin  and  sometimes  tyrosin,  acetone  and  albumose  are  found. 
Albuminuria,  due  to  tubular  degeneration,  is  frequent.  Urobilin  is  fre- 
quently increased  and  indicates  hemolysis.    The  chlorides  are  decreased. 

4.3 


674  DISEASES  OF   THE  BLOOD 

The  iron  in  the  urme  and  uric  acid  are  sometimes  increased  and  the  phos- 
phates are  greatly  increased.  Irregular  fever,  present  in  80  per  cent,  of 
cases,  bears  no  constant  relation  to  the  severity  of  the  disease.  It  may 
rise  considerably;  the  temperature  may  fall  below  normal  in  the  ante- 
mortem  coma.  It  is  probably  due  to  a  ferment  from  the  destroyed  red 
cells  or  from  the  leukocytes  (v.  page  673). 

5.  The  CmcviiATiON.— Palpitation,  precordial  anxiety  and  dyspnea  are 
observed,  sometimes  only  on  exertion.  The  heart  impulse  is  fallaciously 
strong  to  the  palpating  hand.  Its  outlines  are  usually  normal,  save  that 
dilatation  of  the  right  heart  may  develop.  Almost  always  a  blowing 
systolic  murmur  is  heard,  usually  with  a  clear  diastolic  tone;  the  murmur 
is  rarely  presystolic  or  diastolic.  No  parallelism  exists  between  the 
degree  of  anemia  and  the  loudness  of  the  murmur.  Leube  reports  cases 
of  chlorosis  and  pernicious  anemia  in  which  there  was  relative  tricuspid 
insufficiency  with  a  positive  venous  pulse  but  no  cyanosis.  A  venous 
hum  in  the  neck,  carotid  pulsation  and  thrills,  a  loud,  clear  systolic  tone 
and  murmurs  or  double  tones  over  the  peripheral  arteries  are  often 
present.  The  pidse  is  collapsing,  decreased  in  tension  and  increased  in 
rate,  usually  between  90  and  120.  Anatomically,  vestiges  of  hemorrhage, 
atrophy  and  the  fatty,  "tabby-cat  heart"  are  almost  constant. 
Degeneration  in  the  smaller  vessels  is  noted,  especially  in  the  brain. 

6.  Digestive  Tract. — Anorexia,  distaste  especially  for  meats,  pain 
and  sensitiveness  throughout  the  alimentary  tract  are  noted.  The 
tongue  and  gums  often  exhibit  circumscribed  hemorrhages.  Pain  in  the 
mouth  (50  per  cent.)  and  esophagus  is  due  to  the  anemia  or  administra- 
tion of  arsenic.  The  gums  may  ulcerate;  erythema  bullosum  and  other 
eruptions  may  occur.  Vomiting  is  frequent  and  often  incoercible;  the 
vomitus  consists  of  food,  greenish  mucus  and  sometimes  traces  of  blood. 
The  writer  has  observed  profuse  hematemesis  and  cyclic  vomiting  as  the 
first  symptoms.  Crises  of  abdominal  pain  occur  in  60  per  cent.,  and  the 
writer  observed  simulation  of  gall-stones  by  the  pain  and  subicterus.  Epi- 
gastric pulsation,  abdominal  distention  and  achylia  are  observed.  The 
author  saw  expansile  abdominal  pulsation,  diagnosticated  as  aneurysm. 
The  glands  in  the  gastro-intestinal  tract  may  atrophy,  which  probably 
toxemic  condition  is  coordinate  with  and  not  causal  of  pernicious  anemia. 
The  mesenteric  glands  are  not  infrequently  enlarged.  Paroxysmal 
diarrhea  occurs  in  50  per  cent.,  constipation  in  35  per  cent,  and  an  alter- 
nation of  these  conditions  in  15  per  cent.  The  stools  are  not  characteris- 
tic; parasites  or  their  eggs  may  be  noted.  Leucin  and  tyrosin  crystals 
are  frequently  caused  by  diarrhea,  but  are  not  characteristic  of  the 
disease.  Fermentation,  indicanuria,  edema,  hemorrhage  and  follicular 
swelling  in  the  bowel  are  frequently  observed.  Some  ascites  is  found 
in  the  terminal  stage.  A  deposit  of  iron  (siderosis)  in  the  liver,  in 
the  outer  and  middle  zones  of  its  lobules,  especially  in  acute  types,  in 
the  spleen,  bone-marrow,  kidneys  and  lymphatic  glands  is  usual  and 
results  from  hemolysis;  it  is  very  unusual  in  other  anemias.  The  liver 
is  slightly  swollen  and  tender  in  one-third  of  the  cases. 

7.  Blood-making  Organs. — The  lymph  glands  are  not  usually  en- 
larged. In  the  prevertebral  hemolymph  glands  Warthin  found  their 
sinuses  dilated  and  evidences  of  hemolysis,  shown  by  increased  phago- 


PERNICIOUS  ANEMIA  075 

cytosis  and  sometimes  hyperplasia.  The  hones  are  tender,  especially  the 
sternum  and  tibise,  and  sometimes  painful;  the  fatty  marrow  may  become 
lymphoid  (leukoblastic  degeneration),  as  in  other  anemias,  cachexia  or 
fevers;  in  pernicious  anemia  the  red  cells  of  the  marrow  are  abnormally 
large,  abnormally  dark  from  increase  of  the.  hemoglobin  and  are  oval 
rather  than  round;  the  megaloblastic  degeneration  develops  at  the 
expense  of  the  other  elements  in  the  bone-marrow.  These  probably 
secondary  bone  changes  were  first  described  by  Wood,  Pepper  and 
Tyson  (1875).  The  syleen  is  not  enlarged  save  from  accidental  causes; 
in  it  are  found  phagocytosis  and  evidences  of  hemolysis. 

8.  The  Nervous  System. — The  psychical  functions  are  depressed,  the 
memory  is  weak  and  psychoses,  delirium,  hallucinations,  mania  and 
insomnia  may  develop  temporarily  or  antecedent  to  the  terminal  coma. 
The  pupil  reflexes  sometimes  disappear.  Paresis,  apoplectiform  attacks, 
cramps,  convulsions,  paresthesia,  aphasia  or  vertigo  may  develop.  The 
cord  is  more  frequently  involved  (in  84  per  cent,  of  cases)  than  the  brain. 
The  weakness  may  amount  to  paresis,  not  due  simply  to  muscular 
adynamia  but  to  spinal  changes.  The  picture  may  resemble  tabes  as 
concerns  the  pupils,  patellar  reflexes,  ataxia,  bladder  and  rectal  changes, 
crises,  pains,  anesthesia  and  paresthesia;  or,  less  often,  the  symptoms  of 
spastic  spinal  paralysis  prevail,  as  increased  reflexes  and  spastic  paresis. 
In  one  group  of  cases  the  nervous  symptoms  are  slight,  and  in  a  second 
they  are  so  conspicuous  as  to  overshadow  the  anemia  itself.  Early 
paresthesia  occurs  in  all  cases,  usually  in  the  hands  and  feet,  sometimes 
in  the  mouth;  sometimes  there  is  hyperesthesia  or  disturbance  of  the 
temperature  sense.  The  sexual  function  is  decreased  in  males  and  amen- 
orrhea is  regular  in  women.  There  is  a  sclerosis  of  the  posterior  (which 
rarely  wholly  escape)  and  lateral  columns,  most  marked  in  the  lower 
cervical  and  upper  dorsal  segments,  oftener  diffuse  than  focal,  and 
involving  chiefly  the  white  substance,  but  not  the  entire  neuron.  Small 
foci  of  degeneration  with  secondary  connective-tissue  growth  occur 
about  the  bloodvessels,  which  foci  may  fuse  into  small  plaques  with 
secondary  degeneration,  whence  the  symptom-complex  of  a  system 
disease. 

The  discrepancy  between  the  anatomical  and  clinical  findings  is  re- 
markable, i.  e.,  there  may  be  many  symptoms  with  few  autopsy  findings, 
and  conversely;  probably  the  nervous  symptoms  are  less  sequences  of 
anemia  than  coordinate  toxic  manifestations.  The  peripheral  nerves 
present  few  symptoms. 

In  the  eyes  the  general  symptoms  of  anemia  occur;  hemorrhages  in 
the  retina  are  found  by  Hasse  in  94  per  cent,  of  cases  but  not  in  other 
anemias  requiring  differentiation.  Occurring  on  a  pale  background, 
with  tortuous  veins  and  a  strong  light  reflex  from  the  vessels,  the  punctate 
hemorrhages  form  a  striking  picture  (see  Plate  VI,  Fig.  9).  Labyrinthine 
hemorrhage  with  vertigo  is  recorded. 

Clinical  Course  and  Prognosis. — The  initial  pallor  and  weakness  increase 
insidiously  antl  later  dyspnea,  weak  heart  action,  edema,  complete 
anorexia,  languor,  spinal  and  gastro-intestinal  disturbance  and  finally 
capillary  hemorrhages  and  fever  develop;  the  vomiting  and  diarrhea 
may  resemble  acute  poisoning.    In  other  instances  remissions  may  occur 


676  DISEASES- OF  THE  BLOOD 

with  treatment  or  independently  of  it,  perhaps  after  violent  gastro- 
enteric manifestations.  In  Ehrlich's  case,  the  red  cells  in  seventeen 
days  rose  from  1,340,000  to  4,115,000.  The  disease  with  remissions  may 
cover  a  period  of  years,  the  longest  duration  being  seventeen.  Death 
usually  occurs  within  half  a  year.  The  writer  observed  recovery  for 
fourteen  years  after  a  count  of  400,000. 

The  prognosis  is  usually  poor  when  many  megaloblasts  are  present 
or  when  the  color  index  is  over  one. 

Cabot  recognizes  two  forms: 

The  Sevebe,  Rapidly  Fatal  Type— and  the  Less  Severe,  Slow  Type. 

(a)   Extreme  progressive  anemia.  Remissions. 

(6)    Color  index  high.  Normal  or  low. 

(c)  Red  cells  increased  in  size.  Normal. 

(d)  Degenerative  changes.  None. 

(e)  Many  megaloblasts.  Many  normoblasts,  few  megaloblasts. 
(/)    Lymphocytosis.  Normal  ratio  of  the  various  white  cells. 

Emerson  distinguishes  three  groups,  according  to  the  blood  count: 
(i)  With  1,000  000  reds,  weakness  and  shortness  of  breath  on  exertion;  (ii) 
with  1,000,000  to  2,000,000  reds,  alimentary  symptoms;  and  (iii)  in  higher 
counts,  various,  perhaps  severe,  but  particularly  nervous,  symptoms. 

Death  usually  occurs  in  coma.  There  are  only  6  recoveries,  according 
to  Cabot,  yet  he  found  27  cases  which  lived  eight  or  more  years.  The 
mortality  in  the  parasitic  form  is  17  per  cent. 

Diagnosis. — No  single  finding  is  absolutely  characteristic,  though  the 
pallor,  apathy,  adynamia,  edema,  weak  heart,  retinal  hemorrhages, 
maintained  nutrition  and  the  blood  findings  are  highly  suggestive.  The 
yellow  color  is  very  often  mistaken  for  icterus.  Ewing  states  no  impor- 
tance should  be  attached  to  the  increased  diameter  of  the  red  cells  unless 
33  per  cent,  of  the  red  disks  show  it. 

Differentiation. — (a)  From  metastatic  bone  tumors,  in  which  the 
white  cells  are  increased  (the  polymorphonuclear,  neutrophile  and 
eosinophile  marrow  cells);  (6)  from  parasitic  anemia,  for  which  the 
stools  should  be  examined  for  parasites  and  their  eggs;  (c)  fever,  if 
dominant,  may  suggest  typhoid,  meningitis  or  acute  endocarditis;  (c?) 
from  latent  carcinoma;  the  gradual  cachexia,  anorexia,  nausea,  vomiting, 
hematemesis  and  absence  of  hydrochloric  acid  may  suggest  gastric  car- 
cinoma, but  the  blood  examination  determines  the  point;  (e)  spinal 
disease,  Addison's  disease  and  hemorrhagic  pleuritis  are  usually  excluded 
with  ease;  and  (/)  from  other  anemias.  The  table  on  page  677  is 
constructed  after  Cabot's  table. 

Aplastic  anemia,  generally  regarded  as  a  type  of  pernicious  anemia, 
is  characterized  by  its  low  blood  count  and  reduced  hemoglobin.  It 
was  so  named  by  Ehrlich  because  the  bone-marrow  was  aplastic;  there- 
fore in  the  blood  there  are  no  evidences  of  regeneration,  such  as  nucleated 
red  cells,  the  red  cells  are  small  and  the  color  index  is  low.  The  white 
cells  may  number  only  200  per  c.mm.  and  80  to  90  per  cent,  of  them  are 
lymphocytes.  Two-thirds  of  the  cases  are  women.  There  may  be 
hemorrhages,  especially  purpura,  fever  or  hyperplasia  of  the  spleen  and 
lymph  glands.  The  outcome  is  rapidly  fatal,  80  per  cent,  dying  within 
three  months. 


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DftAWN  BY  J,N Z  CHASe 


PLATE  XVIII 

BLOOD. 

(Ehrlich  Triple  Stain.) 
(Prepared  by  Dr.  I.  P.  Lyon.) 

Fig.  L— types   OF   LEUKOCYTES. 

a.  Polymorphonuclear  Neutropliile.  6.  Polymorphonuclear  Eosinophile.  c.  Myel- 
ocyte (Neutrophihc).  d.  Eosinophilic  Myelocyte.  e.  Large  Lymphocyte  (large 
Mononuclear).    /.  Small  Lymphocyte   (small  Mononuclear). 

Fig.  II.— NORMAL   BLOOD. 
Field  contains  one  neutrophile.     Reds  are  normal. 

Fig.  III.— ANEMIA,    POSTOPERATIVE  (secondary). 

The  reds  are  fewer  than  normal,  and  are  deficient  in  hemoglobin  and  somewhat 
u-regular  in  form.  One  normoblast  is  seen  in  the  field,  and  two  neutrophils  and  one 
small  lymphocyte,  showing  a  marked  posthemorrhagic  anemia,  with  leukocytosis. 

Fig.  IV.— leukocytosis,    INFLAMMATORY. 

The  reds  are  normal.  A  marked  leukocytosis  is  shown,  with  five  neutrophiles  and 
one  small  lymphocyte.  This  illustration  may  also  serve  the  purpose  of  showing  the 
leukocytosis  of  malignant  tumor. 

Fig.  v.— trichinosis. 
A  marked  leukocytosis  is  shown,  consisting  of  an  eosinophilia. 

Fig.  VI.— lymphatic   LEUKEMIA. 

Slight  anemia.  A  large  relative  and  absolute  increase  of  the  lymphocytes  (chiefly 
the  small  lymphocytes)  is  shown. 

Fig.  VII.— SPLENOMYELOGENOUS   LEUKEMIA. 

The  reds  show  a  secondary  anemia.  Two  normoblasts  are  shown.  The  leukocytosis 
IS  massive.  Twenty  leukocytes  are  shown,  consisting  of  nine  neutrophiles,  seven  myelo- 
cytes, two  small  lymphocytes,  one  eosinophile  (polymorphonuclear)  and  one  eosinophilic 
myelocyte.  Note  the  polymorphous  condition  of  the  leukocytes,  i.  e.,  then-  variations 
from  the  typical  in  size  and  form. 

Fig.  VIII. —varieties   OF   RED   CORPUSCLES. 

a.  Normal  Red  Corpuscle  (normocyte),  b,  c.  Anemic  Red  Corpuscles,  d-g.  Poikilo- 
cytes.  h.  Microcyte.  i.  Megalocyte.  j-n.  Nucleated  Red  Corpuscles,  j,  k.  Normo- 
blasts.    I.  Microblast.     m,  n.  Megaloblasts. 


PERN  I  CIO  US  A  XEMIA 


677 


Pernicious  anemia. 


Chlorosis. 


Secondary  anemia. 


Red  Celi^ 

Shape. 

Size. 

Hemoglobin-. 

Staining. 
Nuclei. 

Rouleaux. 
CoLOE  Index. 

Leukocttes. 


LTilPHOCTTES. 

Myelocytes. 


Aditlt 

IiEtrKOCYTES. 


Average  number 
1,000,000. 

Poikiloc3rtosis  great,  sau- 
sage-shape, etc. 

Average   increased,    some 
dark. 

Increased  p>er  corpuscle. 


Rarely  under 
2,000,000. 


Somewhat   deformed. 


Findings  as  in  chlorosis.     May  be 
1,000,000  or  less,  though  rarely. 


Diminished,  light  col-    Various,  not  increased, 
ored. 


Reduced      per      cor- 
puscle. 


Polychromatophile  ceUs. 

Micro-,  megalo-.  normo- 
blasts. Megaloblasts 
constitute  majority  of 
nucleated  red  blood  cells. 

Xot  present,  or  decreased.  I 

High  color  index  (not  in 
chronic   or   mild   cases). 


Megaloblasts       rare.    Normoblasts  far  more  than  mega- 
Normoblasts     more       loblasts    in    malignant    diseases, 
than    megaloblasts.        Normoblasts  common  (more  than 
in  chlorosis). 


WMte  blood  cells  decreased, 
except  in  blood  crises, 
hemorrhage,  etc.  I 


Lymphocytosis  (relative). 
Small  number  only. 

Usually  decreased. 


Index  less  than  1; 
lower  than  in  sec- 
ondarj'  anemias. 

Usually  normal. 


Ljrmphocytosis. 

Rare;     less    than    in 
I>emicious  anemia. 

Decreased. 


Coagulation.       Slow. 


Rapid. 


Relatively  low  (this  rule  does  not 
hold  positively). 


Polj-morphonuclear  leukocj-tosis 
in  maUgnant  disease;  when  red 
blood  cells  are  low,  e.  g  , 
1,000,000,  speaks  for  second- 
ary  anemia. 

Rarely  increased  (no  decrease). 

^lyelocytes  verj-  rare. 

Usually  increased. 

Often  rapid. 


Treatment. — 1.  Htgiexic. — The  patient  should  have  absolute  rest  in 
bed,  if  possible  in  a  warm  climate.  A  full,  nitrogenous  diet  increases 
tissue  vraste  and  produces  diarrhea.  Patients  display  a  distaste  to 
nitrogenous  foods.  A  vegetable  diet  is  better  tolerated,  with  bread, 
zwieback,  beef -tea,  peptones,  milk,  honey  or  porridge.  Nutrient  enemata 
are  indicated  in  the  gastric  crises.  In  pregnant  women  labor  should  not 
be  induced. 

2.  Hematixic. — (a)  Transfusion  of  human  blood  is  seldom  beneficial. 
(h)  Lepine  recommends  the  physiological  salt  solution,  based  on  INIarag- 
liano's  findings  that  the  serum  in  pernicious  anemia  has  a  globulicidal 
action  on  the  red  blood  ceUs  (^the  blood  of  a  patient  clears  in  a  test-tube 
on  standing).  (Following  Talquist's  experiments,  Yetlesen  employed 
glycerin  with  success  to  neutralize  the  hemol\i:ic  oleic  acid  in  the  blood.) 
(c)  Phosphorus  is  without  value  and  iron  is  often  injurious,  {d)  Arsenic, 
recommended  by  Bramwell,  is  said  to  have  cured  the  disease,  and  is 
the  best  remedy  known,  probably  acting  upon  the  blood-forming  centres. 

Physiological  Action  of  Arsenic— {a)  The  smallest  dose  increases  the 
appetite,  (h)  Small  doses  stimulate  the  appetite  by  gastric  irritation, 
increasing  secretion  and  stimulating  peristalsis;  tissue  waste  is  lessened. 
It  is  an  alterative,  increases  the  muscular  strength  and  endurance, 
improves  the  quality  of  the  blood,  the  complexion,  sexual  powers  ancl 
lung  capacity,  (c)  Continuous  administration  produces  constitutional 
effects,  as  puflSness  of  the  eyes,  first  seen  in  the  morning  (Wier  ]\Iitchellj; 


678  DISEASES  OF   THE  BLOOD 

this  may  be  followed  by  general  edema,  due  to  vascular  and  sometimes 
renal  alteration,  {d)  Large  doses  result  in  nausea,  diarrhea,  abdominal 
colic,  sj^mpathetic  headache,  and  neuritis.  Arsenic  is  absorbed  by  the 
bloodvessels.  The  circulation,  respiration  and  digestion  are  stimulated 
by  small  and  depressed  by  large  doses,  although  some  deny  the  stimulant 
action  of  any  dose.  Elimination  is  very  rapid  and  mostly  by  the  kidneys 
and  intestinal  mucosa,  but  also  by  the  skin,  bile,  lungs,  saliva  and  mother's 
milk. 

Administration. — -Children  tolerate  large  doses,  while  the  aged  stand 
the  drug  poorly  and  their  digestion  suffers;  after  the  fifth  year  adult 
doses  are  given;  girls  tolerate  the  drug  better  than  boys.  When  sus- 
ceptibility is  marked  a  few  drops  of  laudanum  may  be  added,  but  its 
administration  should  always  be  stopped  when  the  eyes  become  puffy  or 
itch,  the  tongue  becomes  furred  or  colic  develops.  It  may  be  given  in 
the  following  forms:  (i)  Arseni trioxidum,  gr.  -g^j-  p.  c,  with  ext.  glycyr- 
rhizse  and  piper  (black  pepper)  aa  gr.  iv  ("Asiatic  pill")-  (See  formula  on 
page  377.)  (ii)  Liquor  potassii  arsenitis  (Fowler's  solution,  1786);  for 
hypodermic  use  it  must  be  sterilized,  because  fungi  are  likely  to  grow 
in  it.  Even  with  great  care  abscess  may  develop.  Minims  v  equal  gr  -^-^ 
of  arseni  trioxidum.  Treatment  should  commence  with  TTliij  and  each 
day  the  dose  should  be  increased  a  drop  until  lUxij  are  given;  rarely 
can  larger  doses  (TTlxv-xxv)  be  given,  (iii)  The  cacodylate  of  soda  pill 
(gr.  I)  may  be  given  one  to  five  times  daily;  it  is  seldom  toxic. 

3.  Symptomatic  Treatment. — Opiates  for  diarrhea,  cardiants  for  weak 
heart,  dilute  HCl  for  gastric  achylia,  colonic  flushings,  salvarsan  and 
splenectomy  are  recommended. 


SECONDARY   ANEMIA. 

1.  Acute  Posthemorrhagic  Anemia. — Etiology. — It  may  result  (a)  from 
trauma  of  large  vessels:  (b)  from  postpartum  hemorrhage,  a,bortion  or 
tubal  pregnancy;  (c)  from  hemoptysis,  aneurysm  or  cardiac  disease; 
(d)  from  carcinomatous  ulcerations  in  the  uterus,  gastro-intestinal  tract, 
etc.;  (e)  from  peptic  ulcer;  (/)  from  varicosities,  as  in  the  leg,  stomach, 
esophagus  and  liver  cirrhosis;  (g)  from  blood  conditions,  hemorrhagic 
states  or  constitutional  diseases. 

Symptoms. — 1.  The  blood  is  (a)  hydremic,  the  loss  of  fluid  being  sup- 
plied by  the  tissues,  and  its  specific  gravity  is  lowered.  (6)  The  red 
disks  are  reduced  to  50  or  even  20  per  cent.,  are  often  irregular  in  contour, 
pale  and  poor  in  hemoglobin;  generally  there  are  some  normoblasts. 
(c)  The  hemoglobin  is  lessened  even  more  than  the  red  cells,  {d)  The 
leukocytes  show  a  moderate  increase;  the  polymorphonuclears  are 
decreased  and  the  mononuclears  increased.  In  anemia  with  rapidly 
resulting  death  the  red  cells  are  seldom  nucleated  and  there  is  no 
leukocvtosis,  because  the  bone-marrow  makes  no  effort  to  regenerate 
the  blood.     (See  Plate  XVIII,  Fig.  3.) 

2.  There  is  marked  anemia  of  the  skin  and  mucovs  membranes.  Some 
edema  results  from  changes  in  the  blood  or  increased  permeability  of  the 


SECONDARY  ANEMIA  679 

vessel  walls.  The  vasomotor  system  accommodates  itself  ta  a  loss  of 
one-quarter  of  the  blood  volume;  a  greater  loss  produces  cardiac  weak- 
ness. Sometimes  the  heart  action  seems  more  violent  and  respiration 
deeper  and  more  rapid  than  normal. 

3.  Albuminuria  is  due  to  permeability  of  the  renal  vessels. 

4.  Amblyopia  and  amaurosis,  known  to  Hippocrates,  are  at  first  func- 
tional, but  usually  later  degeneration  of  the  retina  develops;  as  the 
blood-pressure  rises,  retinal  hemorrhages  may  follow.  The  patient 
sees  spots  before  the  eyes.  Occasional  nervous  manifestations  include 
aphasia  or  vertigo;  delirium  and  hallucinations  are  chiefly  terminal 
events;    sometimes  lasting  psychoses  develop. 

5.  The  autopsy  findings  are  fatty  degeneration,  particularly  of  the 
heart,  endothelium  of  the  vessels,  liver,  brain,  stomach  and  kidney  cells, 
which  is  usually  caused  by  imperfect  oxygenation.  Hemorrhages  in 
the  uterus,  gums  and  retina  are  due  to  impaired  nutrition  of  the  vessel 
walls.  The  bone-marrow  changes  from  a  yellow  to  a  red  color  and  abounds 
in  normoblasts. 

Prognosis. — The  patient  may  survive  the  loss  of  one-half  of  the  blood; 
Hayem  reports  recovery  after  the  number  of  red  cells  fell  to  550,000. 
Men  stand  hemorrhage  better  than  women  and  young  children;  the  loss 
of  a  pint  may  cause  death  in  arteriosclerotics.  Recovery  is  more  rapid 
in  acute  than  chronic  hemorrhage;  water  and  albumin  are  readily 
yielded  to  the  blood  by  the  tissues;  the  red  cells  regenerate  more  slowly 
and  the  hemoglobin  is  the  last  element  to  reach  normal.  Increase  in 
the  coagulability  of  the  blood  is  a  favorable  prognostic.  According  to 
Bierfreund,  a  loss  of  10  to  15  per  cent,  of  the  blood  is  restored  in  eight 
days;  of  16  to  20  per  cent.,  in  twenty  days;  of  21  to  25  per  cent.,  in 
twenty-two  days  and  of  more  than  25  per  cent.,  in  thirty  days. 

Treatment. — This  has  been  considered  under  gastric  ulcer  and  intestinal 
hemorrhage  in  typhoid,  viz.,  absolute  rest,  morphine  to  insure  quiet 
and  salt  infusions  only  in  extreme  cardiac  failure. 

n.  Chronic  Secondary  Anemia. — Etiology. — Its  possible  causes  are 
numerous;  the  chief  types  are  (a)  hemorrhages  like  those  listed  under 
Acute  Posthemorrhagic  Anemia,  but  frequent  and  persistent,  as  chronic 
hemorrhoidal  bleeding.  (6)  Poor  hygiene;  overwork,  long  hours  in 
poorly  ventilated,  sunless  oflices  or  factories;  insufficient  food  or  food 
poor  in  iron,  (c)  Exhausting  discharges  or  loss  of  albumin,  as  frequent 
pregnancies  with  prolonged  lactation,  albuminuria,  respiratory  or  ali- 
mentary catarrh  or  protracted  suppuration,  (d)  Acute  infections,  as 
typhoid,  diphtheria  or  malaria,  in  which  the  activity  of  blood-making 
centres  is  diminished  and  food  is  poorly  assimilated;  chronic  infections, 
as  syphilis  and  tuberculosis,  (e)  Gastro-intestinal  and  possibly  other 
intoxications.  (/)  Neopjlasms  acting  as  mechanical  obstructions  (as  those 
of  the  esophagus  or  pylorus),  affecting  sometimes  the  bone-marrow 
by  metastases  deposited  there,  sometimes  causing  repeated  losses  of 
blood  or  elaborating  toxins,  which  break  down  the  tissue  albumins;  in 
neoplasms  the  red  cells  and  hemoglobin  average  ob  to  66  per  cent,  of 
normal,  {g)  Parasites  (uncinaria,  etc.);  and  (h)  poisons  (alcohol,  lead, 
arsenic  or  phosphorus). 


6S0  DISEASES  OF   THE  BLOOD 

Symptoms. — The  blood  is  yale  and  its  specific  gravity  is  lowered.  The 
red  disks  and  hemoglobin  are  reduced  in  rather  close  parallelism.  The 
hemoglobin  may  fall  even  to  14  per  cent,  of  normal  and  the  red  cells 
may,  in  rare  instances,  approach  the  count  of  pernicious  anemia.  The 
red  cells  stain  unequally  and  their  umbilication  is  clearer,  so  that  the 
hemoglobin  ma}'  appear  only  as  a  slight  peripheral  ring;  many  of  them 
are  undersized;  they  show  less  poikilocA'tosis  and  less  of  nucleated 
erythrocytes  than  in  the  acute  posthemorrhagic  form.  The  white  cells 
vary  with  the  causal  conditions;  the  polymorphonuclear  neutrophiles 
are  increased  and  the  eosinophiles  decreased.  The  latter  are  often 
increased  in  parasitic  anemias,  up  to  10  or  even  50  per  cent.  In  some 
chronic  anemias  the  leukocytes  are  diminished. 

It  may  be  doubtful  whether  the  general  symptoms  result  from  the 
anemia  or  from  its  cause.  An  anemic  skin,  muscular  adynamia,  irritable 
weakness,  edema  and  hemorrhage  into  the  skin,  mucosae  and  serosa  may 
be  noted.  There  may  be  anorexia,  tenderness  over  the  stomach,  nausea 
and  decrease  or  increase  of  the  HCl.  The  intestinal  functions  are  normal. 
The  aromatic  sulphates  are  frequently  increased.  Exceptionally  per- 
nicious s^TQptoms  may  develop,  as  alteration  of  the  bone-marrow,  fatty 
heart,  cerebrospinal  degeneration,  atrophy  of  the  gastro-intestinal  cells 
and  retinal  hemorrhage.    For  differentiation  see  page  677. 

Treatment. — The  treatment  depends  upon  the  cause,  for  which  thor- 
ough and  repeated  search  should  be  made.  The  hygiene  of  the  home 
and  place  of  work  should  receive  consideration.  Fresh  air,  sunlight 
and  proper  food  are  often  difficult  to  obtain  for  the  lower  classes.  Iron 
and  arsenic  are  valuable  in  simple  t\"pes  {v.  pages  670  and  677). 

LEUKEMIA. 

Definition.- — Leukemia  (leukocythemia)  is  a  disease  of  hemogenesis, 
characterized  by  an  increase  of  the  circulating  leukocytes,  hj'perplasia 
of  the  leukoblastic  tissues  (bone-marrow,  lymph  glands  and  spleen) 
and  by  secondary  infiltration  into  various  tissues.  It  was  discovered 
by  Bennett  and  Virchow  (1841). 

Classification. — The  older  classification  embraced  (a)  the  splenic,  (6) 
glandular  and  (c)  medullary  form  (and  also  a  gastro-intestinal  and  a 
dermal  variety).  This  classification  is  clinical,  but  that  of  Ehrlich  is 
based  on  the  blood  findings: 

I.  Lymphatic  leukemia,  (i)  Acute  lymphemia.  (ii)  Chronic  lym- 
phemia. 

II.  Myelogenic  leukemia  with  great  polymorphism  in  the  blood. 

I.  Acute  Lymphatic  Leukemia. — Acute  lymphemia  includes  nearly  all 
acute  leukemias.  This  infrequent  disease  occurs  at  any  age,  but  especially 
in  children,  and  66  per  cent,  in  males.  The  bacteriological  findings  are 
inconstant.  The  lymph  glands  are  not  necessarily  the  cause;  there  is 
evidence  that  the  bone-marrow  may  be  the  seat  of  the  causal  change 
and  that  it  may  contain  a  parent  cell  for  both  leukocyte  and  lymphocyte. 
The  chief  pathological  finding  is  hyperplasia  of  the  lymphadenoid  tissue. 
The  course  is  that  of  a  rapid  infective  disease,  usually  with  an  acute  onset, 


LEUKEMIA  681 

lymphemic  blood  findings,  asthenia  and  often  fever;    it  is  fatal  in  a  few 
days  to  a  few  weeks. 

Symptoms. — The  prodromal  symptoms  may  be  headache,  pain  in  the 
neck,  spleen,  joints  or  head,  epistaxis,  mental  obscuration,  dyspnea  or 
stomatitis,  after  which  four  cardinal  findings  develop: 

1.  Lymphadenoid  Changes. — Lymph  gland  intumescence  is  very  fre- 
quent and  usually  moderate.  Reed  published  a  case  without  glandular 
enlargement.  Splenic  enlargement  occurs  in  66  per  cent,  and  is  of  slight 
degree;  in  children  it  may  be  enormous;  tonsillar  hypertrophy  occurs 
in  50  per  cent.,  sometimes  with  hemorrhage  and  necrosis.  The  hojie- 
marrow  is  constantly  involved,  especially  in  the  long  bones;  "the  lymphoid 
marrow"  is  red  and  jelly-like,  more  rarely  reddish-gray  or  hemorrhagic. 
The  typical  granular  neutrophile  myelocytes  are  few,  while  large  and 
small  lymphocytes  abound  as  in  the  circulating  blood.  Opinions  vary  as 
to  whether  the  lymphatic  or  the  medullary  lesions  are  the  primary  change. 

2.  Hemorrhages. — Hemorrhages  are  most  characteristic  and  fre- 
quent (in  areas  of  lymphemic  infiltration) ,  (a)  in  the  skin,  as  petechise  or 
larger  effusions,  with  necrosis  or  ulceration;  (b)  in  the  mouth,  gums, 
palate  and  pharynx,  as  petechia,  erosions  or  extensive  necrosis;  (c)  in 
the  retina  in  100  per  cent.;  (d)  in  the  viscera,  brain,  cerebral  nerves, 
labyrinth  and  spleen;  (e)  mucous  surfaces,  the  vagina,  urinary  passages 
and  intestines;  and  (/)  the  serous  membranes. 

3.  Necrosis — Necrosis  in  the  infiltrated  foci  of  the  mouth  occurs 
in  70  per  cent,  and  is  per  se  highly  suggestive  of  acute  lymphemia. 

4.  Lymphemia. — Lymphemia  is  the  crucial  finding.  The  lymphocytes 
may  reach  918,000  to  the  cubic  mm.;  in  general,  the  increase  is  less  than 
in  the  splenomedullary  form  and  averages  350,000.  The  polymorphonu- 
clears are  decreased,  the  eosinophiles  constitute  about  1  per  cent,  of  the 
white  cells,  a  few  myelocytes  may  be  found,  but  the  larger  lymphocytes 
may  constitute  90  or  even  99  per  cent,  of  the  leukocytes.  Very  large 
primordial  cells  are  found,  from  which  the  red  and  white  cells  are  probably 
derived.  The  red  cells  vary  between  1,000,000  and  3,000,000  and  exhibit 
some  nucleation.  The  hemoglobin  falls  below  50  per  cent.,  or  much 
lower  in  peracute  cases.  (See  Plate  XVHI,  Fig.  1,  Plate  XVH,  Fig.  2, 
and  Plate  XYHI,  Fig.  6.) 

Other  findings  are  pallor,  frequent  pulse,  priapism,  exophthalmos, 
swollen,  infiltrated  liver,  increased  flow  of  urine,  with  increased  urea  and 
uric  acid  (increased  nuclein  destruction);  albuminuria  and  nephritis  are 
sometimes  observed.  Lymphomatous  masses  may  cause  dyspnea.  The 
fever  is  irregular,  both  in  type  and  occurrence.  Intercurrent  sepsis  reduces 
the  splenic  and  lymphatic  enlargements,  the  white  cells  decrease  even  to 
normal  and  sometimes  an  ordinary  polymorphonuclear  leukocytosis 
replaces  the  lymphemia.  Lymphatic  deposits  occur  in  the  mouth, 
stomach,  intestines  (simulating  typhoid  ulcers),  muscles,  liver,  kidneys 
and  thymus.  Li  a  personal  case  the  teeth  were  hidden  by  the  infiltrated 
gums.  The  patient  emaciates.  Fatty  and  degenerative  changes  in  tlie 
viscera  are  observed. 

Diagnosis. — Though  the  splenic  and  lymphatic  enlargements,  stomati- 
tis, fever,  ulceration  and  hemorrhages  are  most  suggestive,  the  blood 


082  DISEASES  OF   THE  BLOOD 

findings  alone  differentiate  from  typhoid,  purpura,  scurvy,  trichinosis, 
diphtheria,  septicemia,  severe  acute  anemias,  etc, 

II.  Chronic  Lymphatic  Leukemia. — This  type  is  rarer  than  acute 
lymphemia  and  runs  a  chnical  course  of  years,  with  lymphadenoid 
hyperplasia  and  lymphemia. 

Etiology. — No  constant  bacteriological  cause  has  been  proved. 

Symptoms. — The  symptoms  begin  insidiously  and  the  disease  may 
be  first  detected  by  (1)  swelling  of  the  lymph  glands,  usually  in  the  neck, 
which  may  reach  enormous  dimensions.  The  axillary  glands  are  more 
massive  than  the  inguinal;  glandular  swelling,  as  a  rule,  extends  from 
above  downward.  Sometimes  the  internal  glands  alone  are  swollen  and 
in  rare  cases  the  lymphatics  are  not  enlarged.  The  glands  are  discrete, 
without  periadenitis,  oval  and  softer  than  in  pseudoleukemia.  Some- 
times moderate  pain  is  experienced  and  there  may  be  compression  of 
vital  structures,  as  the  vagus,  trachea  and  portal  vein.  The  glands 
grow  until  death,  unless  an  intercurrent  affection,  as  erysipelas,  causes 
temporary  shrinkage. 

2.  Splenic  hyperplasia  and  intumescence  are  practically  constant, 
though  not  extreme.  The  spleen  protrudes  beyond  the  costal  arch  an 
inch  or  so;  it  is  usually  proportionate  to  the  duration  of  the  disease. 
Intercurrent  sepsis,  cholera,  erysipelas,  etc.,  may  cause  the  splenic 
tumor,  lymphemia  and  the  lymph  nodes  to  disappear  temporarily,  but 
these  findings  may  persist  in  such  infections.  Diarrhea  and  arsenic 
may  likewise  effect  splenic  reduction.  Perisplenic  adhesions  and  thick- 
ening are  common  and  the  organ  is  hard,  in  cases  of  long  standing.  The 
tonsils  are  often  swollen,  in  which  hemorrhages,  with  or  without  necrosis, 
are  frequent. 

3.  The  changes  in  the  hone-marrow  seldom  cause  pain.  The  essential 
character  of  the  marrow  alteration  is  undetermined. 

4.  The  hlood  reveals  an  absolute  and  a  relative  lymphemia.  The  red 
and  white  cells  may  have  a  ratio  of  100  to  1,  yet  the  small  lymphocytes 
constitute  90  to  99  per  cent,  of  all  the  white  cells,  whereas  the  larger  forms 
occur  in  the  acute  lymphemia.  Many  of  them  are  degenerated  or  swollen. 
The  polymorphonuclears  are  reduced  to  10  or  even  1  per  cent.  Myelo- 
cytes are  usuall}^  absent.  The  red  cells  average  4,000,000,  and  seldom  fall 
lower  than  2,000,000.  The  lymphocytosis  may  temporarily  disappear 
during  infection  and  in  one  instance  this  was  permanent.  (See  Plate 
XVII,  Fig.  1.) 

5.  The  skin  may  be  the  seat  of  papular  eruptions,  or  lymphomata, 
sometimes  of  considerable  size;  they  may  precede  the  lymphemic 
blood  findings.  Edema  occurs,  while  hemorrhages  are  rarer.  Facial 
growths  are  observed  similar  to  chloroma  {v.  i.)  or  to  Mikulicz's 
disease. 

6.  The  heart  is  degenerated,  as  are  the  vessels,  from  which  hemor- 
rhages may  occur.  Intraperitoneal  hemorrhage  from  ruptured  adrenals 
is  reported.  The  nerve  trunks  may  degenerate  with  bulbar,  spinal  and 
nerve-trunk  symptoms.  Retinitis  leukemica  or  optic-nerve  involvement 
may  impair  vision.  The  liver  is  swollen  from  degeneration  and  lymphatic 
infiltration.     Dyspnea  is  most  common,  from  anemia,  mechanical  com- 


LEUKEMIA  683 

pressioii  of  the  air  tubes,  vessels  or  nerves  or  from  leukemic  changes  in 
the  follicles  of  the  throat  and  air  passages.    Renal  infiltration  is  frequent. 

Course. — The  disease  develops  gradually  and  passes  slowly  into  cachexia, 
though  now  and  then  extension  in  the  glands  is  "explosive."  Remissions 
of  weeks  or  months  are  not  uncommon.  Intercurrent  disease  may  be 
fatal,  and  mechanical  stasis,  suffocation  and  acute  exacerbations  of  the 
disease  itself  may  hasten  the  course. 

Diagnosis. — The  diagnosis,  suggested,  perhaps  by  the  skin  lesions, 
lymphomata,  splenic  enlargement  or  hemorrhagic  tendency,  is  positively 
made  only  by  the  blood  examination. 

III.  Myeloid  Leukemia. — Myelemia  or  myelogenic  leukemia  is  the 
most  common  form  and  occurs  for  the  most  part  between  the  twentieth 
and  fiftieth  years;  67  per  cent,  of  cases  occur  in  males.  The  disease  is 
frequent  among  the  Polish  Jews  and  the  poorer  classes.  A  history  may 
be  obtained  of  malaria,  syphilis,  typhoid,  stomatitis,  tonsillitis,  digestive 
disturbance,  pregnancy,  the  climacteric  and  trauma,  though  they  are 
only  accidental  occurrences.  The  disease  has  been  noted  in  three 
generations.    Leukemia  also  occurs  in  animals. 

Symptoms. — 1.  Blood. — The  specific  gravity  is  decreased  from  1.055 
to  1.045-36;  it  is  watery  or  sometimes  chocolate-colored;  it  coagulates 
slowly.  Large  white  clots  (leukemia)  are  observed  at  autopsy  and 
Virchow  thought  he  had  incised  an  abscess  when  he  opened  the  left 
ventricle  in  his  first  autopsy.  The  white  cells  are  enormously  increased, 
even  as  much  as  2.5  whites  to  1  red  cell.  Li  the  highest  count  the 
author  has  seen  the  whites  and  reds  numbered  1,200,000  each.  Ameboid 
movement  is  greatly  decreased  (Plate  XVII). 

The  characteristics  of  the  white  cells  are:  (a)  The  large  mononuclear 
neutrophiles  ("mark  cells,"  myelocytes)  amount  to  30  to  50  per  cent,  of 
the  leukocytes.  They  are  also  found  (in  small  numbers)  in  pneumonia, 
uremia,  chlorosis,  skin  diseases,  syphilis  and  normal  blood.  (6)  Mono- 
nuclear eosinopkiles  occur  in  other  diseases,  but  in  myeloid  leukemia  are 
absolutely  increased  and  are  necessary  to  the  diagnosis,  (c)  The  "mast 
cells"  are  constantly  increased;  they  are  polymorphonuclears  with 
basophile  granulations  which  do  not  show  with  the  tri-acid  stain.  Often 
they  are  relatively  increased  from  0.28,  the  normal  percentage,  to  1  or 
indeed  18  per  cent,  (fl)  The  'polymor'phonuclear  neutrophiles  and  eosino- 
philes  constitute  30  to  60  per  cent,  of  the  leukocytes,  (e)  The  lymphocytes 
are  increased.  (/)  Atypical  leukocytes,  dwarf  forms  and  white  cells 
containing  mitoses,  fat  globules  or  red  cells  mav  also  be  found.  (See 
Plate  XVIII,  Fig.  2.) 

The  red  cells  are  decreased  to  3,000,000  or  2,000,000  and  toward  the 
end  may  decrease  to  even  300,000.  The  reds  may  exhibit  degeneration 
necrosis,  polychromatism,  ameboid  movement,  mitoses  and  nucleation 
(more  frequently  than  in  any  other  anemia,  normoblasts  being  found 
regularlv).  The  color  index  is  1  or  less  than  1.  (See  Plate  XVII,  Fig.  1, 
and  Plate  XVIII,  Fig.  7.) 

2.  Splenic  Enlargement.  —  This  is  usually  the  first  symptom  to 
attract  attention  and  appears  with  the  blood  findings;  spleniculi,  if 
present,  are  enlarged.     Instead  of  a  weight  of  5  to  7  ounces,  18  to  28 


684  DISEASES  OF   THE  BLOOD 

pounds  are  reported;  from  the  normal  measurements,  3  to  5  inches, 
dimensions  of  15  inches  are  frequently  observed.  The  form  of  the  organ 
is  preserved,  the  notches  are  palpable  and  the  edge  plump,  rounded  and 
hard.  It  may  extend  into  the  pelvis,  displacing  other  organs.  The 
size  varies  during  intermissions,  from  administration  of  arsenic  and  from 
diarrhea  or  hemorrhages.  A  systolic  murmur  or  pulsation  is  sometimes 
detected.  Crackling  under  the  fingers  and  tenderness  indicate  soft 
adhesions  (perisplenitis).  Firm  adhesions  may  develop  and  the  capsule 
may  thicken.  Though  at  first  soft,  it  later  becomes  very  firm;  the 
pulp  and  trabeculse  hypertrophy  and  new  lymphoid  deposits  are  clearly 
marked  against  the  reddish  pulp  (myeloid  metaplasia).  The  author  has 
seen  3  cases  of  leukemic  floating  spleen,  2  of  which  had  been  operated 
on  as  uterine  tumors.    Rupture  is  a  rare  complication. 

3.  Glaxds. — Enlargement  occurs  in  33  per  cent.  The  glands  are 
heteroplastic,  due  to  new-formed  myeloid  tissue,  "metastases"  from  the 
bone-marrow.  Soft  at  first,  they  later  become  hard.  Caseation  and 
suppuration  are  most  infrequent.  As  in  the  other  types  of  leukemia, 
recurrent  compression  of  the  vagus,  trachea,  portal  vein  and  bronchi  and 
retrosternal  dulness  have  been  observed. 

4.  Bones. — In  the  spongy  and  long  bones  (ribs,  tibiae,  sternum  and 
vertebrae),  the  bone  is  mostly  rarefied  and  there  may  be  tender  or  yielding 
areas.  The  histological  changes  in  the  marrow  are  (a)  the  lymphoid 
(Neumann),  in  which  the  reddish  marrow  resembles  currant  jelly  and 
consists  of  small  lymphocytes;  it  is  sometimes  hemorrhagic;  the  normal 
fatty  appearance  disappears,  (b)  The  pyoid,  which  is  seen  mostly  in 
the  myelogenic  type;  the  marrow  is  not  transparent,  but  gray,  its  cells 
are  rich  in  protoplasm  with  one  or  many  nuclei.  In  both  forms  nucleated 
red  cells,  eosinophile  cells  and  large  cells  with  neutrophile  granules  and 
large  nuclei  abound. 

5.  Vascular  Syste:m. — The  heart  is  distended  with  white  clots  and 
the  muscle  is  pale,  fatty  and  displays  nodules  of  leukemic  infiltration 
and  foci  of  hemorrhage.  Cardiac  dislocation  from  pressure  by  enlarged 
glands  and  spleen,  anemic  bruits,  venous  pulsation,  bruit  de  diable,  palpi- 
tation, systolic  murmurs  from  pressure  by  the  glands  on  the  vessels 
and  centripetal  venous  pulse  are  observed.  The  radial  pulse  is  rapid. 
Dyspnea  results  from  weak  heart,  vagus  pressure,  nodules  in  the  lung, 
bronchitis,  hvdrothorax,  pressure  of  the  spleen  on  the  heart  and  com- 
pression by  the  glands. 

6.  Respiratory  Tract.- — Nodules  are  frequently  seen  in  the  larynx, 
trachea,  thyroid  and  thymus,  often  with  hemorrhage  and  sometimes 
with  tracheal,  bronchial  or  laryngeal  stenosis.  In  the  lungs  lymphoid 
nodules  may  necrose  and  form  cavities  like  those  of  caseous  tuberculosis; 
small  myeloid  foci  of  leukocytes  may  resemble  miliary  tuberculosis. 
Bronchitis  with  many  eosinophile  cells  in  the  sputum  and  pleural  hemor- 
rhage or  exudation  are  observed. 

7.  Fever. — Fever  occurs  in  the  majority  of  cases.  It  is  rarely  high; 
it  may  resemble  recurrent  fever,  t^q^hoid,  sepsis  or  malaria. 

8.  Digestive  Canal. — Stomatitis  or  pharyngitis  with  ulceration  of 
the    lymphoid    deposits,    dysphagia    from    glandular   pressure    on    the 


LEUKEMIA  G85 

esophagus,  eructations  and  vomiting  are  occasional  symptoms.  Diarrhea 
is  very  common,  with  leucin  and  tyrosin  in  the  stools.  In  the  enteric 
type  the  bowel  symptoms  are  conspicuous,  the  lymphadenoid  structures 
in  the  ileum  prominent  and  Friedreich  once  confused  this  form  with 
typhoid  on  account  of  the  ulceration,  enlargement  of  the  spleen  and 
hemorrhage  from  the  bowel.  The  abdominal  lymph  glands  may  be 
enlarged  alone.  The  liver  is  much  enlarged  and  may  weigh  13  to  25 
pounds.  Its  surface  is  smooth,  its  consistence  increased  and  its  edges 
plump.  Myeloid  deposits  occur  in  the  liver  and  deform  the  rows  of 
liver  cells.  The  portal  lymph  nodes  may  be  enlarged.  Icterus  is  infre- 
quent and  ascites  is  common  from  cachexia  or  leukemic  peritonitis.  The 
fluid  contains  many  myelocytes. 

9.  Kidneys. — Frequently  there  is  myeloid  infiltration  and  cloudy,  fatty 
and  amyloid  alteration.  The  urine  is  decreased,  pale  and  strongly  acid. 
The  uric  acid  may  amount  to  20  or  105  grains.  Normally  uric  acid  is  as 
1:50-80  of  urea,  but  in  leukemia  it  is  1:16.  The  xanthin  bodies  are 
increased.  Albuminuria  is  usual  only  in  the  last  stages.  The  amount 
of  urea  depends  on  the  degree  of  cachexia.  Priapism  occurs  from  nervous 
lesions  or  thrombosis  of  the  dorsal  vein.    Amenorrhea  is  frequent. 

10.  Nervous  Symptoms. — These  complications  include  delirium,  neu- 
ralgia, headache,  vertigo  or  mania  or  rarely  bulbar  palsy,  facial  paralysis, 
apoplexy  or  symptoms  like  those  of  brain  tumor. 

The  Eye. — Lymphoid  nodules  may  develop  in  the  orbit,  possibly 
with  exophthalmos.  The  retinitis  leukemica,  purely  a  leukemic  infiltra- 
tion, occurs  in  33  per  cent.;  the  retina  is  pale,  its  arteries  small  and 
veins  large;  the  papilla  is  "washed"  and  yellow  spots  with  red  borders 
and  hemorrhages  appear  (Plate  VI,  Fig.  9). 

The  Ear. — Vertigo,  deafness,  tinnitus  and  an  atactic  gait  may  result 
from  growths  in  the  labyrinth;  the  author  saw  within  one  year  3  cases 
of  sudden  deafness  from  hemorrhage. 

11.  Skin. — There  may  be  acne,  pigmentation,  edema,  pruritus, 
lymphoderma  perniciosa  (diffuse  or  tumor-like  infiltrations)  or  sweats. 

12.  Hemorrhages. — Cabot  found  them  in  80  per  cent.  Epistaxis  is 
the  most  common  and  may  be  fatal.  Stomach  and  bowel  hemorrhages 
rank  next  and  those  from  the  respiratory  and  genito-urinary  tracts,  the 
skin,  joints,  muscles,  or  brain  are  rarer.  The  writer  has  seen  three 
massive  hemorrhages  under  the  skin  of  the  thorax.  Death  has  followed 
the  extraction  of  teeth  in  a  leukemic  subject.  The  writer  saw  Kolisko 
autopsy  a  slow  ascending  paralysis  following  hemorrhage  between  the 
spinal  pia  mater  and  arachnoid. 

Complications. — Complications  are  nephritis,  pneumonia,  endocarditis, 
amyloid  degeneration,  diabetes  and  gangrene.  Dock  could  collect  but 
27  cases  of  complicating  tuberculosis;  the  author  saw  a  case  in  which 
tuberculous  pleurisy  developed;  tubercle  bacilli  were  recovered  from  the 
blood-stained  fluid. 

Diagnosis. — Formerly  the  difference  between  leukemia  and  leukocytosis 
was  made  one  of  degree  only  and  various  limits  were  placed,  beyond 
which  leukocytosis  was  said  to  cease  and  leukemia  begin.  The  mere 
number  of  white  cells  is  no  criterion,  because  a  ratio  of  1  to  20  may  be 


686  DISEASES  OF   THE  BLOOD 

leukocytosis  (as  in  gastric  cancer),  and  on  the  other  hand,  1  to  200  may 
be  leukemia.  Leukocytosis  from  digestion,  fasting,  marasmus,  pregnancy, 
acute  infections  or  in  the  death  agony  is  of  the  ordinary  polymorphonu- 
clear neutrophilic  type.  (Plate  XVIII,  Fig.  4.)  Leukocytosis  is  a  symptom, 
but  leukemia  is  a  disease.  The  polymorjjhiwi  of  the  blood  is  striking; 
there  must  be  (a)  mononuclear  leukocytes  with  granulations  (myelocytes) ; 
(h)  increased  mono-  and  polynuclear  eosinophiles;  (c)  absolute  increase 
in  the  '"mast  cells,"  and  (d)  nucleated  red  cehs.  The  gross  splenic,  med- 
ullary or  lymphatic  lesions  are  of  presumptive  value  in  diagnosis  but  the 
polymorphic  blood  picture  alone  differentiates  from  pseudoleukemia, 
typhoid,  purpura,  anemia,  sepsis,  etc. 

Caution  should  be  exercised  (a)  during  remission;  in  one  of  the  author's 
cases  the  leukocyte  count  dropped  from  1,250,000  to  9000  in  a  week, 
though  the  myelocytes  still  constituted  33  per  cent,  of  the  white  cells. 
(&)  The  leukemic  characteristics  may  disappear  during  typhoid,  acute 
miliary  tuberculosis,  influenza  or  sepsis,  (c)  The  blood  findings  may 
become  atypical  before  death. 

Similar  Conditions. — 1.  Chloroma  is  considered  a  malignant  type  of 
leukemia  or  a  "neoplastic  hyperplasia  of  the  red  bone-marrow,"  by 
Dock  and  \Yarthin;  80  cases  are  on  record.  Lymphomata  form,  causing 
orbital  pain,  tinnitus,  deafness,  temporal  and  orbital  swellings  and 
exophthalmos,  strabismus,  disturbed  vision  and  retinal  infiltration  and 
hemorrhages.  The  lymphomata  are  greenish,  whence  the  name  chloroma. 
Other  findings  are  ataxia,  pallor,  sternal  tenderness,  hemorrhages, 
greenish  urine  and  greenish  lymphomatous  infiltration  of  the  bone-mar- 
row, periosteum,  liver,  lungs  and  glands.  The  hemoglobin  and  red  cells 
are  reduced,  even  to  15  per  cent,  and  500,000  respectively.  The  leuko- 
cytes number  about  50,000,  even  500,000;  they  are  chiefly  lymphocytes, 
^his  form  is  called  lymphoid,  to  differentiate  from  the  rarer  myeloid 
type,  in  which  the  leukocytes  are  myelocytes;  Jacobseus  collected  10 
myeloid  cases  (1909).  Chloroma  is  always  fatal,  usually  within  six 
months. 

2.  Leukanemia  is  a  severe  blood  disease  in  which  the  myelogenous 
formation  of  both  the  red  and  white  cells  is  disordered,  i.  e.,  it  combines 
some  features  of  both  leukemia  and  pernicious  anemia,  e.  g.  (a)  a  pro- 

,. ,  gressive  anemia,  waxy  color  and  asthenia ;  (6)  numbers  of  normoblasts,  but 
*j  especially  megaloblasts;  (c)  no  abnormal  pigments  in  the  urine,  no  adenop- 
athy and  no  siderosis  of  the  tissues;  (d)  no  true  leukemic  blood  findings, 
but  considerable  myelocytosis  and  lymphocytosis;  (e)  firm  connective 
tissue  in  the  bone-marrow  and  (/)  enlargement  of  the  spleen  and  preverte- 
bral hemolymph  glands. 

3.  Secondary  Caxcer  ix  Bone. — There  are  instances  in  the  literature 
in  VN'hich  cancerous  bone  metastases  have  produced  blood  findings  rather 
like  those  of  pernicious  anemia  and  increase  of  the  leukocytes  (of  which 
the  myelocytes  constituted  4  to  17  per  cent.). 

.s^'^  'Prognosis. — Leukemia  may  last  five  or  even  ten  years,  but  a  little  over 
one  year  is  the  average  course.  The  heginning  is  insidicms  and  enlarge- 
ment of  the  abdomen,  dyspnea,  anemia  and  adenopathy  are  the  cause  for 
seeking  medical  treatment.     Sudden  death  may  occur  from  hemorrhage 


PSEUDOLEUKEMIA  687 

of  the  brain,  hematemesis,  marasmus,  anasarca,  diarrhea,  pleuritis, 
peritonitis,  deep  coma  or  pneumonia.  Remissions  occur,  but  the  blood 
findings  persist.  Twelve  acute  cases  were  collected  by  Gordinier  (1904); 
they  resemble  an  infection  with  hemorrhages,  moderate  splenic  and 
lymphatic  hyerplasia,  severe  anemia,  necrosis  of  the  throat  and  jaw  and 
low  fever.  A  permanent  cure  after  erysipelas  was  reported  by  Richter. 
Treatment. — Fats  and  carbohydrates  cause  dyspepsia,  whence  we  give 
eggs,  milk,  raw,  chopped  meat,  koumyss,  oysters,  zwieback,  spinach,  etc. ; 
an  ice-bag  to  the  spleen  may  mitigate  pain.  Benzol  causes  an  initial  rise 
in  the  leukocytes,  especially  after  small  doses  but  a  decrease  after  two  or 
three  weeks,  e.  g.,  from  988,000  to  1720;  an  aplasia  of  the  bone-marrow, 
spleen  and  lymph  glands  ensues.  Given  with  olive  oil,  aaTTlvij,  the  dose  is 
pushed  toTTlxv  (5j  daily);  larger  doses  produce  burning  in  the  stomach, 
eructations,  bronchitis,  vertigo  or  necroses  in  the  liver  and  kidneys. 
Acute  exacerbations  may  follow  its  exhibition.  The  drug  is  discontinued 
when  the  white  cells  reach  20,000.  Splenectomy  is  irrational,  for  leu- 
kemia is  a  primary  disease  of  the  bone-marrow;  94  per  cent,  of  Bissel- 
Hagen's  group  of  35  died,  chiefly  from  hemorrhage.  Caution  must  be 
observed  in  using  purges,  which,  as  in  Addison's  disease,  may  cause  sud- 
den collapse  and  death.  Inhalations  of  oxygen,  blood  infusions,  spleno- 
or  organotherapy  and  iron  are  inferior  to  arsenic,  which  decreases  the 
number  of  white  blood  cells  and  the  size  of  the  spleen,  and  inhibits 
hemorrhage.  In  tapping  an  ascites,  peritonitis  is  prone  to  develop.  The 
j-rays  may  prove  beneficial;  in  1  case  already  alluded  to,  the  patient 
lived  nineteen  months  after,  the  day  he  seemed  to  be  dying.  The  .T-rays 
produce  a  leukolytic  substance.  Wendell  thinks  90  per  cent,  are  benefited. 
The  exposure  to  the  .r-rays  should  average  fifteen  minutes  daily,  carefully 
avoiding  any  toxic  reaction.  In  some  cases  the  glandular  and  splenic 
enlargements  and  the  blood  findings  wholly  disappear. 

PSEUDOLEUKEMIA. 

Definition. — A  disease  resulting  in  chronic  anemia  or  cachexia,  with 
enlargement  of  the  spleen  or  lymph  structures.  The  definition  of  the  dis- 
ease as  "leukemic  appearance  without  leukemic  blood  findings"  no  longer 
holds,  as  it  would  include  glandular  tuberculosis,  lymphosarcomatosis, 
etc.  It  is  also  called  Hodgkin's  (1832)  disease,  pseudoleukemia  (Cohn- 
heim),  adenia  (Trousseau),  malignant  lymphoma  (Billroth)  and  anemia 
lienalis  or  lymphatica  (Wilkes). 

Etiology. — The  etiology  is  obscure.  Like  chloroma  and  leukemia,  75 
per  cent,  of  cases  occur  in  males  between  twenty  and  thirty  years  of  age. 
The  disease  often  occurs  in  the  lower  animals.  Local  lymphatic  disturb- 
ances in  the  neck  (following  otorrhea,  coryza  or  tonsillitis),  malaria, 
syphilis,  scrofulosis,  alcoholism,  rhachitis,  typhoid,  measles  and  scarla- 
tina are  often  noted  in  the  patient's  history,  but  their  relation,  if  any,  is 
obscure.  Bunting  and  Yates  cultivated  a  pleomorphic  diphtheroid 
organism.  The  disease  has  no  established  relation  to  leukemia,  yet  tran- 
sitions from  pseudoleukemia  to  leukemia  have  been  observed.  Neumann 
held  that  the  leukemic  blood  changes  depended  solely  on  the  hyperplastic 


688  DISEASES  OF   THE  BLOOD 

marrow  changes  and  that  as  long  as  the  hyperplasia  involves  only  the 
spleen  and  glands  pseudoleukemia  results.  Sternberg's  contention  that 
it  is  tuberculosis,  is  disproved. 

Symptoms. — Its  types  are  (a)  lymphatic,  (b)  lienal,  pseudoleukemia 
splenica,  splenomegalia,  (c)  mixed  and  {d)  myelogenic. 

1.  Ly:\iph  Glands. — Swelling  of  the  lymph  glands  is  generally  the 
earliest  symptom;  the  cervical  glands  enlarge  first,  then  the  axillary, 
later  the  subpectoral,  inguinal  and  other  groups.  They  are  soft  and 
elastic;  at  first  the  glands  are  oval,  discrete  and  smooth;  later  with 
increasing  size,  they  fuse  into  harder,  irregular  masses  as  large  as  the  fist 
or  a  child's  head,  particularly  those  in  the  neck.  They  may  be  painful 
from  periadenitis,  but  never  transcend  the  gland  capsule  and  seldom 
caseate  or  suppurate.  From  the  neck,  where  the  jugular  veins  may  be 
compressed,  the  glandular  enlargement  often  passes  to  the  mediastinal 
glands,  which  are  more  often  enlarged  than  the  other  internal  nodes; 
this  often  occasions  dyspnea,  compression  of  the  superior  cava  (whence 
the  development  of  a  large  collateral  circulation  on  the  chest  wall), 
dysphagia,  bronchi  compression  and  recurrent  laryngeal  or  vagus  par- 
alysis. The  veins  of  the  arra  may  be  compressed,  causing  edema.  In 
the  abdomen  the  retroperitoneal,  mesenteric,  periportal,  iliac  and  other 
groups  may  enlarge  greatly;  according  to  their  location,  abdominal  pain, 
edema  of  the  legs,  paraplegia,  hydronephrosis,  ascites  and  jaundice  may 
ensue.  Histologically,  the  lymphadenoid  changes  are  (a)  increase  in  the 
endothelial  and  reticular  cells;  (h)  hyperplasia  of  the  lymphoid  cells; 
(c)  formation  of  peculiar  giant  cells;  (d)  fibrosis  and  chronic  inflammation 
and  (e)  great  increase  of  the  eosinophile  cells  (Dorothy  Reed). 

2.  Spleen. — The  spleen,  enlarged  in  75  per  cent,  of  cases,  reaches  dimen- 
sions rarely  attained  in  leukemia,  but  maintains  its  form,  is  hard  and 
tender  and  presents  the  same  histological  appearance  as  in  leukemia, 
viz.,  nodes  of  lymphoid  cells  in  a  fibrous  reticulum.  The  greatest  spleno- 
megaly is  observed  when  the  lymphatic  glands  are  large  and  hard;  soli- 
tary splenomegaly  with  relative  increase  in  the  lymphocytes,  is  classed 
as  Hodgkin's  disease  by  Pinkus. 

3.  Bone-marrow. — The  bone-marrow  is  not  frequently  involved.  A 
myelogenous  pseudoleukemia  has  been  recorded,  but  its  status  is 
doubtful.    The  eosinophiles  abound  in  the  bone-marrow. 

4.  The  Blood. — The  hemoglobin  is  decreased  and  the  color  index  is 
usually  1.  There  is  moderate  anemia,  especially  in  advanced  cases. 
Poikilocytes  and  microcytes  often  occur,  megalocytes  rarely  and  normo- 
blasts sometimes,  but  the  eosinophiles  are  not  increased.  The  blood 
plates  are  increased.  There  is  a  relative  increase  of  lymphocytes  but  no 
total  increase  in  the  leukocytes.  The  polymorphonuclear  neutrophiles 
are  decreased.  Leukocytosis  generally  occurs  in  the  death  agony  or  in  a 
terminal  infection. 

5.  Other  Organs. — (a)  Lym'phatic  growths  in  the  shin  occur  more 
frequently  than  in  leukemia;  the  lymphoderma  perniciosa  of  Kaposi 
may  be  considered  pseudoleukemic  in  cases  with  an  absolute  lympho- 
cytosis. Erythema,  purpura,  furuncles,  pemphigus,  prurigo  from 
irritation  of  the  lymphatic  deposits  around  the  sweat  glands  and  pig- 


PSEUDOLEUKEMIA  689 

mentation  have  been  observed;  severe  sweats  are  frequent,  (b)  Symp- 
toms of  anemia  occur,  as  vertigo,  syncope,  palpitation,  dyspnea,  edema, 
hemorrhage,  dyspepsia  and  diarrhea,  (c)  Local  pain  over  the  liver  or 
spleen  indicates  perihepatitis  or  perisplenitis.  Swelling  of  the  liver  is 
due  to  lymphoid  deposits.  Severe  muscular  pain  has  suggested  trichin- 
osis, {d)  Gangrenous  stomatitis  or  pharyngitis  may  occur  in  degener- 
ated lymph  nodes  in  the  mouth,  tonsils,  tongue  and  throat.  Gastric 
and  intestinal  ulcerations  and  sometimes  perforation  are  noted  less 
frequently  than  in  lymphosarcoma.  Neusser  noticed  gastric  crises  like 
those  of  tabes,  (e)  Ross  and  Osier  described  lancinating  pains  in  the  feet 
and  edema  from  involvement  of  the  spine  and  cava  by  the  lymph  nodes. 
(/)  Amyloidosis,  bronchial  catarrh  and  pulmonary  phthisis  have  been 
noted,  {g)  The  uric  acid  in  the  urine  is  not  increased,  {h)  The  lymphatic 
hyperplasia  may  also  involve  the  tonsils,  circumvallate  glands,  mammae, 
eyelids,  thyroid,  thymus,  lungs,  heart,  pleura,  brain,  genitalia  and 
pelvis. 

6.  Fever. — Fever  is  common.  Gowers  and  Murchison  observed  a 
chronic  recurrent  type,  later  described  by  Pel  and  Ebstein,  but  also 
observed  in  chronic  malaria,  lymphosarcoma,  cancer  and  glandular  and 
splenic  tuberculosis.  The  urine  may  show  the  diazo  reaction.  When 
the  disease  involves  the  internal  glands  only,  the  fever  may  simulate 
typhoid.  Fever  is  rather  indicative  of  glandular  tuberculosis  or  of  inter- 
current (terminal)  infections. 

Course. — The  clinical  course  is  long.  The  glandular  swelling  sometimes 
decreases  with  or  without  therapeutic  measures.  The  extension  from  the 
cervical  to  other  lymphatic  glands  is  generally  gradual,  but  may  occur 
explosively,  as  in  Trousseau's  case.  An  acute  form  of  Hodgkin's  disease 
is  not  well  established;  many  are  sepsis,  tuberculosis  or  acute  sarcoma- 
tosis.  Death  most  frequently  results  from  chronic  cachexia,  but  also 
from  obstruction  of  the  air  passages,  twisting  of  the  pedicle  of  the  spleen 
or  from  hemorrhages  from  the  nose,  uterus,  stomach,  intestines  or  larynx, 
which  sometimes  resemble  purpura  hemorrhagica.  It  is  a  question 
whether  well-developed  types  ever  recover.  Pleural  effusions,  diarrhea, 
dysentery  and  vomiting  from  pressure  of  the  splenic  tumor  are  unfavor- 
able complications. 

Differentiation. — There  are  two  criteria;  (a)  the  lymphadenoid  hyper- 
plasia and  chronic  inflammation  observed  when  an  excised  node  is 
examined  histologically;  and  (6)  an  absolute  lymphocytosis,  with  a 
practically  normal  number  of  white  blood  cells. 

1.  Glandular  Tuberculosis. — Hodgkin's  disease  may  be  confused 
with  tuberculosis ;  in  pseudoleukemia  the  typical  structure  of  the  tubercle 
is  lacking,  but  in  tuberculous  adenitis  there  may  be  an  accumulation  of 
large  endothelioid  cells  between  which  lie  tubercle  bacilli,  without  casea- 
tion. Of  late  the  reports  of  glandular  tuberculosis  simulating  Hodgkin's 
disease  have  increased  enormously.  The  author  examined  two  supposed 
pseudoleukemias  in  which  tubercle  bacilli  (without  anatomical  tubercles) 
were  found  in  the  spleen  and  lymph  nodes.  In  the  neck  tuberculous 
adenitis  is  more  often  in  the  submaxillary  than  in  the  anterior  and  posterior 
glands,  in  the  latter  of  which  pseudoleukemia  is  more  common.  Tuber- 
44 


690  DISEASES  OF  THE  BLOOD 

culosis  is  more  frequently  attended  by  secondary  suppuration.  Fever 
and  glandular  tenderness  indicate  tuberculosis  and  node-like  swellings 
of  the  lymph  vessels  in  the  mouth  are  symptomatic  of  pseudoleukemia. 

2.  Anemia  Infantum  Pseudoleukemica. — This  disease  was  first 
fully  described  by  von  Jaksch;  it  is  kno^vn  in  Italy  as  anemia  splenica 
infettim  dei  bambini;  it  is  called  "  pseudopernicious  anemia  of  children" 
by  Ehrlich.  It  is  a  profound  anemia  in  which  the  blood  findings  suggest 
pernicious  anemia;  there  are  normoblasts,  megaloblasts,  decrease  of  the 
red  blood  cells  (1,500,000  to  3,000,000)  and  sometimes  poikilocytes  or 
polychromatophilia;  the  leukocytes  rarely  exceed  50,000.  It  occurs  in 
infants  from  nine  to  eighteen  months  of  age;  the  convalescence  is  very 
slow  or  death  may  result.  Its  other  symptoms  are  firm  enlargement  of  the 
spleen,  swelling  of  the  liver  and  hemorrhages  into  the  skin,  nose,  mouth 
stomach  or  intestines.  The  status  of  the  disease  is  not  yet  determined. 
The  diagnosis  is  especially  difficult  when  it  occurs  in  syphilitic  children; 
syphilis,  rickets  and  dyspepsia  are  common  antecedents. 

3.  Anemia  Splenica.^ — It  is  doubtful  whether  it  should  be  classed  as 
an  essential  anemia,  liver  cirrhosis,  chronic  splenitis  or  as  a  splenic  form 
of  Hodgkin's  disease,  (a)  The  s-pleen  is  enlarged,  its  capsule  thick,  its 
stroma  increased  and  the  endothelium  of  the  lymph  sinuses  sometimes 
proliferated  (endothelioma).  The  cause  is  possibly  toxic,  (b)  There 
is  an  anemia  of  the  secondary  type;  the  red  cells  average  3,500,000,  the 
hemoglobin  is  even  more  reduced  and  the  whites  are  decreased  to  3000 
or  4000.  (c)  Hemorrhages,  particularly  from  the  stomach,  occur  in 
one-third  to  one-half  the  cases,  {d)  In  many  cases  there  is  a  terminal 
liver  cirrhosis,  with  icterus  and  ascites  (Banti's  disease),  (e)  Its  course 
is  very  chronic.  In  some  cases  there  are  profound  alterations  of  nutrition, 
stunted  groulh,  clubbed  fingers  or  pigmentation  of  the  skin.  In  several 
cases  Dock  and  Warthin  found  portal  thrombophlebitis  and  hyperplasia 
of  the  hemolymph  glands.  Of  Armstrong's  cases  23  recovered  and  9 
died. 

4.  Lymphosarcomatosis. — According  to  Kundrat,  lymphosarcoma  is 
largely  a  locgl  glandular  involvement,  especially  of  the  cervical  glands, 
leading  to  infiltration  of  the  throat  by  contiguity;  the  disease  may  begin 
in  the  tonsils,  air  passages,  portal  glands,  etc.  Lymphosarcoma  ulcerates 
and  transgresses  the  gland  capsule;  this  never  occurs  in  leukemia  or  in 
pseudoleukemia;  though  the  glands  may  compress  neighboring  structures 
they  never  actually  invade  them.  Unless  lymphosarcoma  extends  beyond 
the  capsule  of  the  glands  it  cannot  be  distinguished  by  physical  examina- 
tion unless  it  lies  in  parts  which  can  be  easily  inspected,  as  the  mouth. 
The  spleen  may  enlarge  enormously.  According  to  Pinkus,  the  leuko- 
cytes are  increased  in  pseudoleukemia,  while  in  lymphosarcoma  they  are 
decreased. 

5.  Other  Splenic  Enlargements. — The  most  common  are  the  spleen 
of  cirrhosis,  malarial  spleen,  chlorosis  with  enlarged  spleen,  chronic 
polycythemic  cyanosis  and  rarer  forms,  as  miliary  tuberculosis  of  the 
spleen,  actinomycosis,  syphilis,  etc. 

6.  Multiple  Myeloma. — This  is  characterized  pathologically  by 
lymphoid  hyperplasia  of  the  bone-marrow,  in  the  ribs  and  body  ends  of 


ERYTHREMIA  691 

the  long  bones  chiefly  and  more  often  in  the  proximal  than  distal  bones; 
no  mestastases  occur.  Clinically,  it  occurs  in  males  over  forty-five  years 
and  is  characterized  by  severe,  deep-seated  pain  in  the  body,  chest,  spine, 
neck  and  more  rarely  in  the  extremities.  Prominences  in  the  bones, 
spontaneous  fractures,  especially  of  the  sternum  and  ribs,  and  kyphosis, 
from  softening  of  the  vertebrae,  may  result.  The  growths  may  pulsate 
or  rupture  externally.  The  x-rays  may  clearly  define  them.  Severe 
anemia  without  leukocytosis;  motor  and  sensory  paralyses,  which  develop 
late  and  involve  the  opticus,  hypoglossus,  facialis,  cord  (paraplegia 
dolorosa)  and  sciatic  nerve;  fever  and  Bence- Jones's  albumosuria  are 
observed.  To  call  this  disease  a  myelogenic  form  of  pseudoleukemia 
or  myelogadenia  there  must,  according  to  Pinkus,  be  a  lymphocytosis. 

7.  Other  Affections. — Syphilitic  lymphatic  glands;  Mikulicz's  lym- 
phoma of  the  lachrymal  and  salivary  glands  and  secondary  carcinoma  or 
sarcoma  must  be  differentiated.  Difficulties  of  diagnosis  are  met  when 
the  enlarged  glands  in  internal  parts  produce  topical  symptoms,  thus 
simulating  hypertrophic  cirrhosis,  etc. 

Treatment. — 1.  Local  Applications. — These  are  useless,  excepting  the 
x-rays;  two  cases,  seen  by  the  author  eleven  years  ago,  wholly  recovered. 
In  some  cases  the  rays  have  no  influence  on  the  spleen  and  glands  and  in 
others  the  cachexia  increases,  though  there  may  be  improvement  in  the 
local  findings.  Inunctions  of  green  soap,  once  or  twice  daily,  are  some- 
times beneficial. 

2.  Drugs. — Arsenic  is  most  efficacious  {v.  page  677) ;  it  acts  on  the  glands 
more  than  on  the  spleen.  Some  believe  that  the  fever  which  it  sometimes 
produces,  reduces  the  adenopathy.  Winnewarter  and  Billroth  recom- 
mended its  parenchymatous  injection  into  the  glands,  but  the  results 
are  not  very  encouraging.    Iodides  are  injurious. 

3.  Surgical  Treatment. — Extirpation  of  the  glands  is  seldom  bene- 
ficial. The  removal  of  the  spleen  is  attended  by  constantly  decreas- 
ing mortality;  the  average  mortality  in  splenomegaly  was  61  per  cent, 
before  1891  and  since  then  13  per  cent.  Carstens,  1905,  collected  739 
cases  of  splenectomy;  72  per  cent,  recovered. 


ERYTHREMIA. 

Vaquez's  disease  (1892)  is  a  syndrome  including  polycythemia,  spleno- 
megaly and  cyanosis.  Lucas  collected  189  cases  (1912).  The  etiology 
is  obscure;  lienal  tuberculosis  is  reported  in  the  earlier  cases,  but  the  cause 
iss probably  excessive  erythroblastic  activity  of  the  bone-marrow,  {a)  The 
red  cells  are  increased,  even  to  9,000,000  or  15,000,000  (polycythemia  rubra 
or  polyglobulism) ;  the  hemoglobin  may  exceed  200  per  cent. ;  the  white 
cells  number  from  4000  to  31,000,  with  increased  polymorphonuclears. 
The  viscosity,  specific  gravity  and  volume  of  the  blood  (plethora)  are 
increased.  (6)  There  is  chronic  cyanosis,  or  intense  redness  of  the  face, 
in  75  per  cent,  and  (c)  splenomegaly.  The  retina?  exhibit  congestion, 
even  choking.  There  may  be  vertigo,  headache,  dyspnea,  enlarged 
liver,  mental  and  physical  weakness,  albuminuria,  constipation',  vomiting. 


692  DISEASES  OF   THE  BLOOD 

pigmentation    and    a    hemorrhagic    diathesis.     The  arterial  tension  is 
increased  and  the  heart  h^-pe^t^ophies. 

The  prognosis  is  unfavorable  and  therapy  uncertain — arsenic,  benzol, 
.r-rays,  iodides,  nitrites,  phlebotomy  and  splenectomy. 

THE   HEMORRHAGIC   DISEASES. 

The  hemorrhagic  diseases  may  be  classified  as  follows: 

•1.  Purpura. 

(A)  Acquired  types.  |2_  Scu^^y. 

(B)  Congenital  fhereditary)  type.     3.  Hemophilia. 

Purpura.  —  Purpura  includes  a  number  of  affections,  more  or  less 
similar  and  differing  chiefly  in  degree,  some  symptomatic,  others  inde- 
pendent. 

I.  Symptomatic  Purpura. — Purpura  may  be  symptomatic  of:  (a) 
Various  infections,  as  endocarditis,  scarlatina,  measles,  smahpox,  rheu- 
matism, sepsis,  s^TDhilis,  etc.  (6)  Toxemias,  as  nephritis,  cholemia, 
snake-bites  and  drug  poisoning  (copaiba,  ergot,  beUadonna,  quinine, 
mercury,  iodides,  bromides  or  arsenic),  (c)  Cachexia;^  old  age,  mal- 
nutrition, carcinoma,  sarcoma,  leukemia,  pseudoleukemia  or  pernicious 
anemia,  (d)  Xervoiis  states;  tabes,  nem-oses  (bloody  stigmata  of  hysteria) 
or  neiu-algias.     (e)  Mechanical  conditions,  as  trauma,  embolism  or  stasis. 

II.  Purpura  Simplex. — In  purpura  simplex  (Zeller,  1684)  cutaneous 
hemorrhages  are  the  chief  s^Tnptoms.  Its  etiology  is  obscure.  It  develops 
most  often  in  middle-aged  males.  As  in  the  other  forms,  whose  descrip- 
tion follows,  there  is  no  constant  or  characteristic  pathology,  though 
vessel  thickening,  hyaline  and  fatty  degeneration,  thrombosis,  and 
pigmentation  sometimes  occiu-.  In  the  blood  itself  no  change  is  observed 
other  than  its  taxdy  coagulation,  in  10  to  30  minutes  instead  of  3  to  5, 
which  is  the  normal  time.  The  blood  platelets  are  decreased.  The 
enqjtion  begins  as  small  red  spots^  which  gradually  become  green  and 
black;  they  occur  largely  on  the  extensor  surfaces  of  the  limbs  and  more 
often  on  the  legs  than  on  the  arms  or  trunk.  They  do  not  fade  upon 
pressure.  The  initial  eruption  may  be  macular,  papular  or  luticarial 
fpurpiu-a  maculosa,  papulosa  or  m-ticans),  but  soon  becomes  blood- 
tinged.  Constitutional  s^^nptoms  are  usually  absent;  there  may  be 
slight  fever,  gastric  disorder  or  diarrhea.  The  course,  sometimes  with 
relapses,  is  1  to  2  weeks,  the  prognosis  good  and  the  treatment  hygienic. 

m.  Purpura  (or  Peliosis)  Rheumatica.— Piupura  rheumatica,  described 
by  Schonlein,  is  somewhat  arbitrarily  listed  by  itself  because  of  its 
articidar  symptoms,  although  joint  symptoms  also  occur  in  Werlhof  s 
disease  {x.  i.),  scurvj-  and  hemophilia.  INIost  cases  develop  in  males 
between  fifteen  and  thirty  years  of  age.  It  has  no  relation  to  rheumatism, 
being  a  pseudorheumatism.    Its  pathology  is  obscure. 

Sy^iptoms. — (a)  As  prodromes,  indisposition,  muscular  pains,  colic  and, 
particularly,  sore  throat  may  be  noted,  ih)  The  purpura  may  occur  as 
simple  hemorrhages  of  the  skin,  which  vary  from  red  to  greenish-black, 
according  to  their  age,  or  as  urticaria,  erythema,  pemphigus  or  edema, 


PURPURA  693 

which  becomes  stained  with  blood;  the  legs  are  most  often  involved, 
largely  on  the  extensor  surfaces,  (c)  Articular  symptoms  are  most  com- 
mon in  the  knees  and  ankles,  less  frequent  in  the  elbows  and  rare  in  other 
joints;  there  may  be  only  stiffness  and  pain,  or  actual  swelling;  if  the 
joints  are  first  involved  their  symptoms  frequently  abate  mth  the  appear- 
ance of  the  purpura,  (d)  Other  symptoms  are  inconstant,  as  fever,  which 
may  rise  to  102°  or  103°,  splenic  tumor,  albuminuria  or  nephritis.  The 
author  had  3  cases  at  one  time  in  the  Cook  County  Hospital,  in  which 
there  was  severe  sloughing  of  the  tonsils.  Osier  (1904)  described  29 
cases  in  which  visceral  lesions  occurred  with  purpuric,  urticarious  and 
erythematous  symptoms,  chiefly  in  children  and  often  with  relapses; 
(i)  digestive  complications  occurred  in  25  cases;  vomiting  in  15;  colic 
in  8  (resembling  renal  stone  or  appendicitis);  blood  in  the  stools  in  8 
and  diarrhea  in  15;  (ii)  acute  nephritis  occurred  14  times  and  5  cases 
died  of  uremia;  (iii)  arthritis  occurred  in  17  cases;  (iv)  swelling  of  the 
fauces,  edema  of  the  larynx,  aphasia,  transient  hemiplegia  and  least  often 
endocarditis  may  occur. 

Diagnosis. — The  diagnosis  chiefly  concerns  affections  characterized 
by  hemorrhages  of  the  skin,  articular  symptoms  and  fever.  Acute 
leukemia,  septicopyemia  and  endocarditis  must  be  excluded.  Genuine 
rheumatic  polyarthritis  is  differentiated  T\ith  ease  by  the  earlier  migrat- 
ing, inflammatory  arthritis,  the  fever,  sweating,  characteristic  cardiac 
complications  and  the  later,  accidental  and  wholly  secondary  purpura. 

Prognosis. — ^The  prognosis  is  generally  good,  relapses  are  common, 
perhaps  periodic  and  its  course  rarely  exceeds  two  weeks. 

Treatment. — ^The  joint  symptoms  yield  somewhat  to  acetanilide, 
though  the  salicylates  exert  no  specific  influence. 

IV.  Purpura  Hemorrhagica. — Morbus  macnlosns  Werlhofii  (Werlhof, 
1775)  closely  resembles  the  above  types,  but  differs  in  that  not  only 
are  the  skin  and  joints  the  seat  of  hemorrhage,  but  also  the  mucous 
membranes,  serous  membranes  and  perhaps  the  viscera. 

Etiology. — Of  this  little  is  knowni;  staphylo-,  strepto-  and  pneumo- 
cocci  and  Bacillus  pyocvaneus  and  coli  have  been  found.  It  occurs 
oftener  in  young,  weakly  women  than  in  robust  adults.  Exposure  ot 
cold  or  dampness  and  malnutrition  seem  predisposing  causes.  It  usually 
develops  as  an  apparently  primary  affection. 

Symptoms. — (a)  Hemorrhages  appear  on  the  extremities;  the  face  is 
not  often  involved;  they  occur  as  spontaneous  petechise,  blood-stained 
bullae  or  vibices  or  may  result  from  slight  trauma,  as  by  pinching  the  skin. 
(6)  Of  the  mucovs  membranes  the  nose  and  mouth  bleed  most  often; 
less  frequently  there  is  hemoptysis,  hematemesis,  enterorrhagia,  hema- 
turia or  metrorrhagia  in  various  combinations,  sequences  and  degrees. 
The  conjunctivse  may  be  blood-stained.  The  writer  saw  in  one  rapidly 
fatal  case  hemorrhage  from  the  middle  ear.  (c)  The  joints,  particularly 
the  knees,  ankles  and  elbows,  are  less  often  implicated.  Ecchymoses 
in  the  endo-  and  pericardium,  pleura,  peritoneum  and  meninges  are  com- 
mon autopsy  findings,  (d)  Hemorrhage  into  the  retina,  brain,  cord  or 
testis  is  far  less  common.  The  connective  tissues,  fascise  and  bones  are 
practically  exempt. 


694  DISEASES  OF  THE  BLOOD 

General  Symptoms  and  Complications.  As  to  the  blood,  there  Is  delayed 
coagulation  and  moderate  anemia;  some  nucleated  red  cells  may  be 
found,  as  well  as  leukocytosis,  reduction  in  the  blood  plates  and  methe- 
moglobinemia. Fever  is  inconstant  and  atypical.  The  pulse-rate  may 
be  raised;  palpitation,  delirium,  ^-ertigo,  albuminuria,  hepatic  enlarge- 
ment, splenic  tumor,  subicterus,  intestinal  ulceration  or  perforation 
and  nephritis  occasionally  occur. 

Diagnosis. — ^IMost  mistakes  result  from  confusion  with  purpura 
symptomatic  of  sepsis,  hemorrhagic  exanthemata  or  blood  affections. 
The  difficulties  in  diagnosis  are  often  great;  in  an  anemic  old  man,  who 
suddenly  vomited  blood  and  passed  bloody  urine,  the  diagnosis  of  purpura- 
was  made;  the  autopsy  revealed  a  round  ulcer  of  the  stomach  and  a  papil- 
loma of  the  bladder.  Scurvy  is  distinguished  by  its  gingivitis  and  muscular 
hemorrhages,  and  hemophilia  by  reason  of  its  hereditary  facts.  Henoch's 
purpura  (1874)  occurs  chiefly  in  children  and  is  characterized  by  (a) 
cutaneous  lesions,  which  resemble  erythema  nodosum  rather  than  purpura; 
(6)  hemorrhages  from  the  mucous  membranes;  (c)  gastro-intestinal  crises 
of  vomiting,  diarrhea  and  abdominal  pain;  {d)  pains  in  the  joints  and 
(e)  relapses,  often  extending  over  a  number  of  years.  Of  chronic  purpura, 
Bensaude  and  Rivet  collected  34  cases  (1905). 

Prognosis.— The  prognosis  is  uncertain;  50  per  cent.  die.  Unfavorable 
factors  are  high  temperature,  nephritis  and  cerebral  hemorrhages. 
Recurrence  is  not  uncommon.  Purpura  fulminans,  of  which  C.  A. 
Elliott  (1909)  collected  56  cases,  may  be  fatal  in  24  to  48  hours;  it  was 
described  by  Guelliot,  1884. 

Treatment. — ^W^erlhof's  therapy  was  dilute  sulphuric  acid,  TTlx,  and 
quinine,  gr.  v,  after  meals.  Everything  of  a  supportive  nature,  as  suffi- 
cient nourishment,  rest  in  bed,  iron  and  arsenic,  is  helpful.  The  hemor- 
rhages are  arrested  with  difficulty  and  the  author  doubts  the  value  of 
drugs  in  their  control.  Adrenalin  solution  to  the  nose  and  mouth, 
gelatin  by  mouth,  calcium  lactate,  gr.  xv,  t.  i.  d.,  to  increase  the 
coagulability  of  the  blood  and  antitoxin  or  simple,  fresh  serum  are 
indicated  (v.  Hemophilia). 

Hemorrhagic  Diseases  of  the  Newborn. — Syphilis  Hemorrhagica  Neo- 
natorum.— It  appears  soon  after  birth.  In  some  instances  the  syphilitic 
child  may  be  born  with  hemorrhages  in  the  skin,  mucosee,  internal  organs 
and  from  the  navel.  Occasionally  deep  jaundice  develops.  Mracek 
found  a  causative  endartertitis,  especially  of  the  capillaries,  in  14  per 
cent.    In  other  cases  an  added  sepsis  apparently  cooperates. 

Winckel's  Disease. — Winckel's  disease,  epidemic  hemoglobinuria,  is 
(a)  an  affection  of  the  newborn  in  the  first  four  days  of  life ;  (b)  it  appears 
epidemically  in  hospitals;  (c)  it  is  characterized  by  fever,  gastro-intestinal 
symptoms,  icterus,  dyspnea,  cyanosis,  albuminuria,  methemoglobinuria 
and  large  mortality,  and  (d)  pathologically  by  internal  hemorrhages, 
fatty  degeneration  (Buhl's  disease)  and  splenic  tumor;  it  is  doubtless 
a  hemolytic  sepsis. 

Morbus  Maculosus  Neonatorum. — It  is  no  clearer  etiologically  than  Werl- 
hof's  disease  in  adults;  some  cases  are  congenital  syphilis;  others  with 
fever,  jaundice  and  epidemic  occurrence  are  infections  (pyogenic  cocci. 


.    SCURVY      ^  695 

pneumococci,  pyocyaneiis  and  colon  bacilli) ;  and  still  others  seem  embolic, 
thrombi  forming  in  the  auricles  when  the  heart  is  weak.  Injuries  to  the 
head,  causing  hemorrhages  in  the  fourth  ventricle  and  cerebral  peduncles, 
and  other  vasomotor  disturbances  are  questionable  causes.  It  occurs 
once  in  500  to  1000  births. 

Symptoms. — In  the  first  week  of  life  hemorrhages  occur  from  the 
navel  and  mucous  membranes;  in  Townsend's  50  cases  they  occurred 
in  the  following  frequency:  from  the  bowel  (melena),  40  per  cent.;  navel, 
36  per  cent.;  mouth,  28  per  cent.;  stomach,  28  per  cent.;  and  nose,  24  per 
cent.  Death  occurs  mthin  a  week  in  63  per  cent.  Diisser,  in  78  cases, 
found  the  mortality  was  55  per  cent. 

Treatment. — Iron,  ergot  and  adrenalin  are  useless.  Diffuse  stimu- 
lants should  be  g'iven  when  there  is  a  weak,  rapid  pulse.  Injections  of 
gelatin  are  dangerous,  for  it  possibly  contains  some  ptomaine;  fresh 
serum  or  direct  transfusion  is  most  reliable. 

Scurvy. — Definition. — A  general  disease,  characterized  by  gingivitis, 
hemorrhages,  inflammations,  cachexia  and  chronicity  of  course. 

Etiology. — It  was  first  observed  in  the  Crusades  and  was  described 
most  fully  by  Vasco  de  Gama;  in  his  voyage  around  the  Cape  in  1498, 
33  per  cent,  of  his  sailors  were  stricken  with  scurvy.  It  has  developed 
among  prisoners,  Canadian  lumbermen,  Pennsylvania  miners  and  among 
workers  on  the  Chicago  Drainage  Canal,  where  in  1893-95  the  author 
saw  100  cases.  Insufficient,  possibly  spoiled  food  causes  the  majority 
of  cases,  sometimes  in  conjunction  with  lack  of  fresh  meat,  impure  water, 
damp  quarters  and  overexertion;  a  lack  of  fresh  meat,  vegetables  (potas- 
sium salts,  malic  and  citric  acids)  and  fats  predispose  to  scorbutus,  though 
no  single  group  is  solely  responsible.  The  Drainage  Canal  cases  were 
Poles  who  lived  on  coftee,  bread  and  preserved  and  fresh  meats.  In 
1849  there  were  260,444  cases  in  Russia  and  60,598  deaths;  it  is  still 
endemic  there. 

Symptoms. — Scorbutus  begins  insidiously  and  progresses  slowly;  its 
earliest  symptom  is  (1)  anemia  (cachexia  scorbutica).  The  skin  is  scaly, 
pale,  lustreless  and  perhaps  pigmented.  The  mucous  membranes  are 
livid.  The  blood  coagulation  is  slow,  the  red  cells  and  hemoglobin  are 
proportionately  reduced  and  leukoc}i;osis  is  absent,  except  with  inter- 
current inflammation  or  severe  hemorrhage.  Emaciation,  mental  depres- 
sion, muscular  weakness,  anorexia,  hj'pochlorhydria,  intestinal  fermenta- 
tion, constipation,  palpitation,  weak  and  irregular  heart  action,  a  sys- 
tolic functional  murmur  and  edema  about  the  ankles  accompany  the 
anemia.  Splenic  enlargement,  albuminuria,  peptonuria  and  oliguria 
are  common. 

2.  Gingivitis  begins  with  turgescence  of  the  gums,  which  is  due  to  a 
serohemorrhagic  infiltration,  noticed  first  about  the  canine  teeth;  the 
gums  are  spongy,  painful,  particularly  on  eating,  bleed  readily  and  may 
become  so  swollen  as  to  hide  the  teeth.  There  is  less  gingivitis  when  there 
are  no  teeth  or  roots.  The  breath  is  fetid.  In  severe  cases  the  gums 
necrose  and  bleed  profusely;  deep  ulcers,  on  healing,  leave  cicatrices; 
the  teeth  may  fall  out  and  the  sali\'ary  and  cervical  lymph  glands  and 
tongue  max  swell. 


696  DISEASES  OF  THE  BLOOD 

3.  Hemorrhages  occur  (a)  in  the  skin,  especially  on  the  extensor  surfaces 
of  the  legs  and  first  about  the  hair  follicles;  they  are  at  first  small  petechiae, 
but  later  enlarge  and  stretch  the  skin.  Less  frequently  the  first  erup- 
tion may  resemble  acne,  herpes  or  pemphigus,  hemorrhages  appearing 
later  in  these  exanthems.  The  face  is  usually  exempt.  As  the  hemor- 
rhages increase,  the  legs  are  diffusely  mottled  with  red,  green  and  black 
and  are  swollen  and  tense.  Similar  stains  may  run  upward  in  streaks 
along  the  lymph  vessels.  Some  of  these  changes  are  due  to  (6)  muscular 
hemorrhages  (scorbutic  sclerosis),  mostly  in  the  calf  and  thigh,  less  in 
the  buttocks  or  abdominal  wall.  The  legs  are  large,  extremely  hard, 
blood-stained  and  later  pigmented.  As  the  disease  regresses  the  muscles 
usually  recover  their  function,  but  in  some  instances  scorbutic  ulcers, 
suppuration,  muscular  cicatrization  or  shortening  of  the  tendons  leave 
permanent  deformity  and  contractures,  (c)  Mucous  membrane  hemor- 
rhages are  less  common  than  in  purpura  or  hemophilia,  though  epistaxis 
is  fairly  frequent.  Sometimes  hemorrhages  occur  in  the  conjunctiva, 
air  passages,  stomach,  bowels,  perhaps  with  intestinal  ulceration,  {d) 
Of  serous  membrane  hemorrhages,  articular  hemorrhage  (hemarthrosis) 
is  the  most  frequent.  Next  in  order  of  frequency  are  those  in  the  pleura, 
pericardium,  peritoneum  and  meninges.  They  are  usually  sudden  in 
onset,  extreme  in  degree  and  unfavorable  in  outcome,  (e)  Parenchy- 
matous hemorrhages  are  least  common,  as  in  the  eye,  brain  and  other 
viscera.  Subperiosteal  and  epiphyseal  hemorrhages  are  rare,  except  in 
Barlow's  disease  {v.  i.). 

4.  Scorbutics  are  subject  to  various  inflammations,  (a)  Painful  joint 
swellings  are  the  most  frequent  (in  35  per  cent,  of  the  author's  cases, 
chiefly  in  the  knees);  they  may  be  serous  or  hemorrhagic  or  in  severe 
cases  the  cartilages  or  bones  may  ulcerate  or  suppurate;  deformity 
and  ankylosis  are  possible  sequences.  (6)  Hemorrhagic  pericarditis  and 
pleuritis  are  very  dangerous,  (c)  Paronychia,  choroiditis  and  pan- 
ophthalmitis are  occasional  incidents.    Fever  is  uncommon. 

Course  and  Prognosis. — The  onset  is  insidious,  the  course  chronic  and 
convalescence  protracted.  Most  cases  recover  but  death  may  occur 
from  (a)  cachexia,  the  autopsy  showing  fatty  degeneration  of  the  heart, 
liver  and  bloodvessels;  (6)  profuse  hemorrhages,  into  the  pleura,  peri- 
cardium, gastro-intestinal  tract  or  rarely  into  the  brain;  (c)  infections, 
as  dysentery,  pleurisy,  pneumonia  or  septicopyemia  of  the  terminal  type, 
promoted  by  reduced  phj-siological  resistance. 

Diagnosis. — The  diagnosis  is  made  without  difficulty  by  the  cachexia, 
gingivitis,  tendency  to  hemorrhage  and  inflammation,  the  chronic 
course,  and  the  temporary  nature  of  the  condition  (as  contrasted  with 
the  permanent  tendency  to  hemorrhage  in  hemophilia). 

Treatment. — (a)  Hygienic;  avoidance  of  cured  or  smoked  foods  is  both 
prophylactic  and  curative.  In  Nansen's  polar  expedition,  which  lasted 
three  years,  not  one  case  of  scurvy  developed;  cooked  meats,  berries, 
sauerkraut,  potatoes,  radishes,  cress,  apples,  oranges  and  lemons  were 
used.  A  monotonous  dietary  is  particularly  to  be  avoided,  {b)  Anemia 
should  be  treated  by  strychnine,  iron  and  arsenic.  Yeast  5ijj  three 
times  daily,  is  recommended,    (c)  The  gingivitis  is  treated  by  local  appli- 


INFANTILE  SCURVY  ■  697 

cations  of  silver  nitrate  (10  per  cent.),  (d)  Symptomatic  treatment;  hemor- 
rhage is  benefited  by  rest  and  serum.  Stimulation  is  required  in  inter- 
current infections.  Drastic  cathartics  are  to  be  avoided.  Complicating 
arthritis  necessitates  rest  and  cold,  rarely  aspiration  or  drainage. 

Infantile  Scurvy. — Barlow's  Disease. — ]\Ioller  (1852-62)  described  the 
affection  as  acute  rhachitis,  and  Ingerslev,  Jalland,  Cheadle  and  Gee, 
but  particularly  Barlow  (1883),  described  an  infantile  cachexia  ^ith 
hemorrhages.    In  1898,  379  cases  were  collected  in  the  United  States. 

Etiology. — Unlike  scurvy  in  adults,  the  hygienic  conditions  are  good 
in  80  per  cent,  of  cases,  and  it  occurs  largely  in  the  better  classes,  (a) 
The  ob\dous  cause  is  feeding  with  malted,  condensed  or  cooked  milk  or 
baby  foods;  these  foods  lack  some  unknown  substance  essential  to  health. 
In  713  cases  only  2.5  per  cent,  occiu-red  in  infants  at  the  breast  (S.  Weiss, 
1905).  (b)  Ninety  per  cent,  of  cases  occur  between  the  sixth  and  twelfth 
months  (Heubner  and  Neumann). 

Symptoms. — There  may  be  anemia  without  hemorrhages,  hemorrhages 
without  anemia,  or  typically  both  together. 

1.  Suhyeriosteal  hemorrhage  is  the  leading  symptom.  The  primary 
vague  symmetrical  swelling  over  the  epiphj'ses  later  becomes  more  obvious, 
though  no  edema  is  noted.  There  is  pain  and  tenderness  usually  in  the 
thighs  or  legs,  which  are  drawii  up,  flexed  or  everted  and  immobile 
(pseudoparalysis).  The  anatomical  findings  are  subperiosteal  hemor- 
rhages; a  colloid  and  fibrillar  alteration  in  the  marrow  of  the  diaphyses; 
arrest  of  ossification;  decrease  of  the  osteoblasts;  rarefaction  of  the  bones, 
sometimes  leading  to  fractures  (spontaneously  or  after  slight  trauma) 
or  to  epiphyseolysis  (usually  at  either  end  of  the  femiu-  or  the  upper  end 
of  the  tibia);  the  joints  are  normal.  Seventy  percent,  of  the  lesions 
are  in  the  thigh,  24  per  cent,  in  the  leg  and  6  per  cent,  in  the  orbit; 
the  arms,  ribs,  spine,  skull,  sternum  and  scapidse  are  seldom  involved. 
Rib  involvement  results  in  depression  of  the  sternum. 

2.  The  cachexia  is  evidenced  by  the  moderate  anemia  (sometimes 
attended  by  slight  lymphoc^-tosis),  asthenia^,  anorexia,  constipation, 
irregular  temperature  (in  66  per  cent.)  and  severe  sweats. 

3.  Gingivitis  is  noticed  when  the  teeth  have  already  erupted  or  are 
about  to  erupt;  the  gums  are  normal  in  but  4  per  cent. 

4.  Other  symptoms  embrace  hemorrhages  in  the  skin  in  50  per  cent., 
from  the  bowels  (10  per  cent.),  nose  (9  per  cent.),  kidneys  (9  per  cent.) 
and  rarely  in  the  conjunctivae,  muscles  or  meninges. 

Diagnosis. — ^The  etiology,  typical  subperiosteal  hemorrhages,  gingi- 
vitis and  anemia  prevent  confusion  mth  genuine  paralysis,  for  the 
immobility  is  voluntary  to  escape  the  pain  of  movement.  S^'philitic 
bone  disease  (Parrot's  disease)  is  similar  as  to  the  crepitus,  epiphyseo- 
lysis and  pain,  but  other  sj^hilitic  or  scorbutic  stigmata  are  decisive. 

Prognosis  and  Treatment. — Proper  treatment  secures  immediate  im- 
provement in  the  majority  of  cases.  Death  is  uncommon  and  occurs  in 
the  third  or  fourth  month  of  the  disease.  The  diet  consists  of  raw  cow's 
milk,  potato  puree,  beef-juice  (not  broth  or  extracts),  orange-juice, 
apple  sauce,  pears,  cooked  berries  and  spinach.  Treatment  by  drugs  is 
superfluous. 


698  DISEASES  OF   THE  BLOOD 

Hemophilia. — Definition. — A  congenital  anrl  hereditary  affection,  char- 
acterized by  deficient  coagiilabihty  of  the  blood  and  profuse  hemor- 
rhages, which  are  most  difficult  to  arrest.     It  was  named  by  Schonlein. 

Etiology. — (a)  Ihredity  is  the  only  clear  etiological  fact  (Fordyce 
1784j;  as  Grandidier  lS77i  remarked, hemophilia  is  "the  most  hereditary 
of  all  hereditary  diseases."  Brown  traced  hemophilia  through  seven 
generations  in  200  years.  Sometimes  a  generation  may  be  exempt. 
(b)  Broadly  speaking,  the  males  of  the  "bleeder  families""  are  the  '"bleeders'" 
and  the  females — the  "conductors" — transmit  the  disease  to  their  male 
offspring  without  manifesting  the  disease  themselves.  In  200  families 
of  "bleeders,"  Grandidier  found  609  cases  in  males  ^93  per  cent.;  and 
48  in  females  (7  per  cent.;.  In  the  Mampel  family,  first  reported  by  von 
Chehus  in  1827,  Lessen  (1905;  found  212  members,  of  which  111  were 
males;  of  these  exactly  one-third  were  bleeders  and  48.7  per  cent,  died 
of  hemorrhage;  none  of  the  females  were  bleeders  and  all  transmission 
of  the  disease  occurred  through  the  women,  (c)  The  disease  occurs  in 
Germany,  England,  France  and  Xorth  America.  Consanguinity,  family 
gout,  rheumatism  and  tuberculosis  are  suggested  as  causes.  Bleeders 
are  generally  healthy  indivirluals  with  blond,  delicate  skins  and  blue 
eyes.  The  factors  involved  in  clotting  are  calcium  and  activation  of 
prothrombin  in  the  presence  of  some  unknown  substance  'thrombo- 
kinase;. 

Symptoms. — In  7.5  per  cent,  of  cases,  hemorrhages  derelop  in  the^/zr.?/  tiro 
years  of  life;  rarely  do  they  first  appear  after  puberty,  in  the  third  decade 
or  after  the  seventieth  year;  only  46  congenital  cases  are  known.  The 
hemorrhages  are  spontaneous  or  traumatic:  they  most  often  occur  as 
capillary  oozing  from  a  mucous  surface;  deep  interstitial  bleeding  is 
most  unusual.  They  are  copious  and  hard  to  still.  Epistaxis  is  the 
most  common  CoO  per  cent.;;  hemorrhages  from  the  gimis  fl2  per  cent.), 
intestine  Q2  per  cent.j,  lungs,  kidneys  and  stomach  ^each  6  per  cent.) 
and  uterus  are  next  in  frequency.  Arthropathies  are  the  rule.  According 
to  Konig,  the  joint  findings  are  (aj  an  hemarthros,  with  pain,  swelling 
and  fluctuation;  (h)  then  panarthritis,  whose  gross  pathology  resembles 
tuberctilous  arthritis,  with  flexion  of  the  joint;  (cj  regression,  or  ankylosis 
and  deformity,  which  rather  resembles  arthritis  deformans.  The  knees 
and  elbows  are  most  often  affected.  Subcutaneotis  hemorrhages  may 
occur.  The  first  bleeding  may  occur  from  the  naA^el  or  may  restilt  from 
vaccination,  extraction  of  teeth,  circumcision,  from  a  trifling  prick  or 
cut,  from  delivery  or  from  rtipture  of  the  hymen  on  the  wedding  night. 
In  various  attacks,  one  part  after  another  may  bleed  or  the  hemophilic 
disposition  may  be  confined  to  one  part,  a-  the  kidney  frenal  hemophiliaj 
or  nose;  in  Agnew's  celebrated  case,  the  patient  bled  from  cuts  on  the 
head  but  never  from  lesions  lower.  Hemophilia  differs  from  purpura, 
in  that  bleeding  seldom  occurs  into  a  serous  membrane  (excepting  the 
joints)  or  into  the  \d3cera.  The  amount  of  blood  lost  may  be  enormous 
and  in  Litten's  case  amounted  to  24  pounrls  in  eleven  days.  Hemophilics 
tolerate  loss  of  blood  better  than  other  individuals,  and  recover  from  it 
more  readily.  The  coagulation  time  of  the  blood  i-  delayed  to  sixty, 
even  eighty-ffjiir  minute-:  the  clot,  when  frjrmed.,  i-  porou-.  Ijut  retracts 


HEMOPHILIA  099 

normally.  The  white  cells  are  normal  or  slightl;^'  decreased,  with  relative 
lymphocytosis;  the  percentage  of  eosinophiles  and  mast  cells  is  high. 

Diagnosis. — The  diagnosis  may  be  for  a  time  uncertain,  when  hemor- 
rhage develops  after  an  operation  or  occurs  from  one  organ  only,  as  the 
kidney.  The  family  history  clearly  stamps  the  affection  and  readily 
differentiates  it  from  scurvy,  purpura  and  hemorrhages  in  the  newborn. 
It  is  peculiar  that  patients  often  deny  that  they  are  bleeders.  The  16 
cases  of  multiple  hereditary  telangiectases  with  recurring  hemorrhages, 
described  by  Osier,  may  be  hemophilic. 

Prognosis. — The  prognosis  is  grave.  Any  hemorrhage  may  prove  fatal. 
Sixty  per  cent,  of  cases  die  before  the  eighth  year  and  only  11  per 
cent,  reach  the  twenty-second  year;  if  middle  life  is  reached  the  danger 
gradually  lessens.  It  is  more  favorable  in  girls,  despite  the  apparent 
menstrual  dangers.  De  Bovis  (1905)  found  69  excessive  hemorrhages 
among  150  deliveries  in  hemophilic  women;  he  believes  pregnancy  has 
a  rather  favorable  effect  on  the  disease.  De  Lee  reported  premature 
detachment  of  the  placenta  in  hemoohilia.  Frankel  and  Bohm  found 
24  mortalities  in  104  hemophilics  with  genital  hemorrhages.  The  rudi- 
mentary or  local  forms  are  more  favorable  than  general  hemophilia. 

Treatment. — 1.  Prophylaxis.^ — Grandidier  lays  down  the  following 
rules :  (a)  Women,  with  a  hemophilic  family  tendency,  whether  bleeders 
or  not,  should  not  marry.  (6)  Men,  if  not  bleeders  themselves,  may 
marry,  unless  their  family  history  indicates  that  male  bleeders  have 
begotten  hemophilic  children.  General  measm-es  to  elevate  the  physio- 
logical resistance  and  avoidance  of  trauma  or  any  but  life-saving  opera- 
tions, are  indicated.    Vaccination  is  rarely  contra-indicated. 

2.  Control  of  Actual  Hemorrhage. — This  is  almost  impossible. 
Wounds  should  be  cauterized  or  enlarged,  as  Fordyce  discovered  that 
in  hemophilics  large  bleed  less  than  small  wounds.  Bruising  the  bleed- 
ing part  and  dusting  with  thyroid  extract  are  helpful.  The  Esmarch 
constrictor  controls  some  hemorrhages  of  the  extremities.  Styptics  as 
Monsell's  solution  or  tannic  preparations  are  useless.  Adrenalin,  locally 
and  internally,  has  no  apparent  effect.  Calcium  lactate  is  more  bene- 
ficial; gr.  XV,  t.  i.  d.,  should  be  given  intermittently,  because  protracted 
administration  decreases  the  coagulability  of  the  blood.  Gelatin  may 
be  given  by  mouth.  The  work  of  Wirth  and  Weil  indicates  that  normal 
serum  or  antitoxin  is  of  much  value.  Human  serum  or  the  entire 
blood  is  excellent.  Saline  cathartics  are  sometimes  efficacious,  possibly 
by  diverting  blood  from  the  seat  of  hemorrhage.  Very  acute  anemia 
necessitates  injection  of  salines  or  5  per  cent,  grape-sugar  solution  intra- 
venously or  under  the  skin;  when  the  hemorrhage  is  over,  regeneration 
of  the  blood  is  remarkably  rapid.  Joint  involvement  is  treated  by  rest, 
immobilization  and  rarely  aspiration. 


SECTION  VII. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 


Certain  organs  elaborate  secretions,  which  are  voided  externally  as 
it  were,  as  the  stomach,  duodenum,  liver,  kidneys,  pancreas,  testes, 
ovaries,  etc.  Each  of  them  also  secretes  substances  which  are  absorbed 
into  the  blood,  by  which  they  reach  other  organs,  as  secretin  (duodenum), 
products  from  the  islands  of  Langerhans  (pancreas),  etc. — an  internal 
secretion.  Although  all  the  cells  or  glands  of  the  body  probably  produce 
some  internal  secretion,  either  in  the  katabolic  process  or  as  stimulant 
to  the  activity  of  other  cells  or  organs,  yet  internal  secretion,  in  its  narrow 
acceptation,  relates  particularly  to  those  ductless  glands,  whose  sole 
secretion  is  internal,  e.  g.,  the  thyroid,  suprarenals,  parathyroids,  pituitary 
gland  and  perhaps  still  others,  as  the  spleen,  thymus  or  lymph  nodes. 
The  correlation  of  the  ductless  glands  is  effected  by  hormones,  acting 
through  the  circulation.  In  various  combinations,  these  internal  secre- 
tions supplement  or  antagonize  each  other.  The  subject,  aside  from 
certain  well-defined  clinical  syndromes,  is  still  in  its  infancy. 


DISEASES  OF  THE  SUPRARENAL  GLANDS. 


ADDISON'S  DISEASE.     OTHER  AFFECTIONS  OF  THE  SUPRA- 
RENAL GLANDS. 

Definition. — A  hypoepinephry  characterized  pathologically  by  lesions 
(usually  tuberculous)  in  the  adrenal  glands  or  chromaffin  system  elsewhere, 
and  clinically  by  muscular,  vascular  and  mental  adynamia,  digestive 
disorders,  and  pigmentation  of  the  skin. 

Etiology. — Suprarenal  disease  was  first  associated  pathologically  with 
melanoderma  by  Addison  in  1855.  By  far  the  most  common  lesion  is 
(a)  chronic  fibrocaseous  tuberculosis  of  the  adrenal  glands;  tubercles  of 
the  adrenal  glands  are  usually  bilateral,  destroy  most  of  their  structure 
and  frequently  involve  the  semilunar  ganglia  and  solar  plexus  by  the 
attendant  formation  of  connective  tissue;  there  is  a  primary  focus  in 
the  lungs  in  over  50  per  cent.,  in  the  genito-urinary,  alimentary  or  gland- 
ular system;  in  rare  cases  only  is  the  adrenal  tuberculosis  primary. 
(h)  Less  common  are  tumors,  atrophy,  fibrous  induration  (usually  tuber- 
culous), gumma,  amyloid  degeneration,  acute  inflammation,  hemorrhage, 


702  DISEASES  OE   THE  SUPRAREXAL   GLANDS 

embolism,  echinococcus,  adenoma  or  other  very  rare  lesions.  Addison's 
melasma  suprarenale  is  a  disease  in  "o-hich  the  chromaffin  cells  in  the 
medulla  of  the  adrenals  or  the  s\-mpathetic  ganglia  waste  (Weisel). 
The  adrenal  cortex  contains  epithelial  structures,  and  the  medulla  consists 
of  non-meduUated  nerve  fibers  and  large  mononuclear  cells ;  these  latter 
chromaffin  cells  are  also  found  in  the  sympathetic  ganglia,  along  the 
aorta  in  Zuckerkandl's  bodies,  the  carotid  glands,  and  perhaps  also  in  the 
coccygeal  gland,  etc.  Epinephrin  is  the  active  glandular  substance  of  the 
chromaffin  system;  it  stimulates  the  skeletal  muscles,  controls  pigmen- 
tation, maintains  vascular  tonus  and  stimulates  the  vasomotor  centres, 
the  vagus  and  respiration;  when  secreted  in  excess,  as  in  hyper- 
nephroma, the  blood  tension  may  be  much  elevated  (Frankel,  Xeusser, 
Kolisko)  and  this  may  induce  cerebral  hemorrhage.  The  cortex  is  con- 
cerned in  sexual  activity  and  hypertrophies  in  pregnancy;  it  is  hyper- 
plastic in  sexual  precocity  ('hirsutism;  virihsmj  and  hypoplastic  in  infan- 
tilism. The  glands  elaborate  an  internal  secretion  necessary  to  life  which 
renders  less  toxic  substances  produced  by  other  tissues,  e.  g.,  the  '"  fatigue 
stuffs"  of  muscle  metabolism. 

In  Lewin's  statistics  from  500  cases  the  adrenals  were  diseased  in  88 
and  sound  in  12  per  cent.;  on  the  other  hand,  disease  of  the  adrenals  is 
attended  by  pigmentation  of  the  skin  in  72  per  cent,  and  unattended 
by  it  in  28  per  cent.;  in  adrenal  tuberculosis  without  Addison's  disease, 
there  is  no  general  disturbance  of  the  chromaffin  system  and  in  Addison's 
disease  with  no  adrenal  tuberculosis,  the  chromaffin  cells  elsewhere  are 
affected. 

Most  cases  occur  between  the  fifteenth  and  fortieth  years,  (J6  per  cent, 
in  males  and  90  per  cent,  in  the  laboring  classes. 

Sjnnptoms. — 1.  AdyX-\:\iia. — Marked  physical  and  mental  adynamia 
is  usually  the  initial  symptom  and  persists  till  death.  The  insidious 
languor,  weakness,  apathy,  lack  of  initiative  and  muscular  relaxation 
contrast  sharply  with  the  healthy  appearance  of  the  patient  in  the  early 
stages.  These  symptoms  are  toxemic,  partly  from  hypoepinephry  and 
partly  from  the  tuberculous  lesion.  Obstinate  early  insomnia  and  head- 
ache and  later  attacks  of  vertigo,  tinnitus,  spots  before  the  eyes  and 
syncope  are  frequent.  The  intellectual  functions  are  weakened,  periodic 
irritability  is  frequent  and  the  deep  reflexes  are  somewhat  reduced. 

2.  DiGESTn'E  Sy^iptoms. — Digestive  symptoms  generally  appear 
next.  The  tongue  is  coated;  there  are  a  sense  of  abdominal  fulness, 
eructations  and  sensitiveness  over  the  abdomen.  Paroxysmal  pains 
in  the  epigastrium  or  back  radiate  widely,  especially  into  the  chest, 
like  severe  tabetic  crises.  J'omiting  is  the  most  distressing,  ominous 
and  intractable  alimentary  symptom:  it  may  occur  independently 
of  eating.  At  first  intermittent,  it  later  hastens  the  fatal  issue.  Early 
constipation  gives  way  to  terminal  diarrhea. 

3.  PiGMEXTATiox. — ^Iclanoderma,  bronzed  skin,  melasma  suprarenale 
develops  after  the  adynamia  and  alimentary  disturbance.  It  is  found 
in  the  deep  layers  of  the  rete  ^Nlalpighii,  to  which  it  is  apparently 
brought  from  the  blood  by  leukocytes.  At  first  the  skin  has  a  dirty, 
yellowish-gray  color  and  small  areas  appear  which  gradually  fuse  and  then 


ADDISON'S  DISEASE  703 

slowly  become  darker  and  more  diffuse;  extensive  pigmentation  may 
occur  with  focal  areas  of  deeper  discoloration.  Pigmentation  develops 
particularly  (a)  where  it  is  normally  deepest,  as  about  the  nipples,  anus 
and  genitalia;  (b)  where  pressure  or  friction  is  greatest,  as  over  folds 
of  the  skin,  over  the  clavicles,  spine,  ischia,  scapulae  or  waist  (from  belts 
or  corsets) ;  (c)  where  there  is  exposure  to  the  sun,  as  in  the  face,  neck 
or  arms;  (d)  where  accidental  irritation  occurs,  as  by  blistering,  eczema 
or  parasitic  affections.  The  soles,  palms  and  nail-beds  are  seldom  stained. 
Previous  scars  may  be  surrounded  by  a  zone  of  discoloration.  The  skin 
is  dry,  yet  sometimes  bathed  with  profuse  perspiration  and  may  have  a 
fish-like  odor.  Scattered  spots  of  pigment  may  atrophy  (vitiligo)  and 
impart  a  strange  appearance.  Drawing  a  sharp  object  across  the  skin 
may  elicit  a  "white  line,"  which  runs  parallel  with  the  cardiac  weakness 
(Sargent).  The  mucous  membrane  of  the  lips,  gums  and  palate  shows  pig- 
mentation later  than  the  skin.  The  horizontal  ink-like  stains  on  the 
cheek  where  the  teeth  touch  it  are  particularly  diagnostic.  The  con- 
junctivse  are  pearly  white,  though  frequently  small  aggregations  of 
pigment  can  be  seen  on  careful  examination.  Staining  of  the  larynx, 
nymphse,  vagina,  glans  penis,  serous  membranes  and  internal  organs  is 
infrequent. 

4.  Other  Findings:  (a)  The  /iear^  shares  in  the  general  adynamia;  its 
tones  and  apex  are  weak;  it  frequently  shows  brown  atrophy  at  autopsy. 
Pain  over  the  heart  is  reflected  from  the  abdomen;  palpitation  and 
dyspnea  are  common,  but  functional  murmurs  are  rare.  The  pulse 
is  compressible  and  somewhat  accelerated.  The  blood-pressure  is 
generally  low.  The  peripheral  vessels  and  abdominal  aorta  pulsate 
actively.  Atheroma  is  common,  even  in  young  subjects.  (6)  Anemia  was 
considered  characteristic  by  Addison,  though  Nothnagel  demonstrated 
its  infrequency;  in  one  instance  the  writer  observed  a  red-cell  count  of 
2,000,000.  Increase  in  the  red  cells  (polycythemia  rubra)  and  in  the 
hemoglobin  results  from  concentration  of  the  blood,  due  to  vomiting 
and  diarrhea.  Lymphocytosis  is  ominous,  (c)  The  lymph  nodes,  Peyer's 
patches,  spleen,  thyroid,  thymus  and  pineal  glands  are  often  enlarged, 
probably  vicariously,  (d)  Emaciation  and  cachexia  are  terminal  conditions. 
Edema  of  the  ankles  is  infrequent  even  toward  the  end.  Characteristic 
metabolic  changes  are  not  found;  acetonuria  is  occasional  and  terminal 
albuminuria  may  develop.  The  temperature  is  most  often  normal  or 
subnormal  and  a  subjective  chilliness  is  experienced. 

Clinical  Course. — The  cardinal  symptoms  progress  slowly,  with  occa- 
sional intermissions,  and  in  nearly  all  cases  death  results  within  two 
years;  the  terminal  symptoms  are  often  violent,  viz.,  delirium,  convulsions, 
incoercible  vomiting  and  diarrhea,  small  pupils,  pseudomeningitic  or 
peritonitic  symptoms  and  finally  collapse  and  coma.  Variations  include: 
(a)  Acute  cases  resembling  typhoid,  or  acute  poisoning;  (6)  chronic  cases 
lasting  ten  to  thirteen  years;  (c)  sudden  death  before  pigmentation 
develops;  {d)  the  course  modified  by  pulmonary  or  intestinal  tuberculosis. 

Diagnosis. — Diagnosis  is  based  on  the  prostration,  cardiac,  psychical 
and  physical;  digestive  disorders,  vomiting,  diarrhea  and  neuralgia; 
pigmentation;  and  the  chronic  lethal  course. 


704  DISEASES  OF  THE  SUPRARENAL  GLANDS 

A  tuberculin  reaction  may  occur  from  tuberculosis  in  other  tissues. 
Adrenal  tumors  may  cause  metastases  in  the  brain  or  (like  tumors  of 
the  thyroid,  prostate  and  mammae)  in  the  long  bones,  skull  and  spine. 
According  to  Griinbaum  adrenal  extract,  gr.  iij,  t.  i.  d.,  for  three  days 
raises  the  blood-pressure  10  mm.  if  adrenal  insufficiency  exists. 

Differentiation. — Pigmentation  also  occurs  in  (a)  poisoning  by 
silver  (argyria),  in  which  the  reduced  metal  forms  a  gray  deposit  in  the 
extracellular  tissue  of  the  skin,  sweat  glands,  conjunctivae  and  nail-beds; 
by  arsenic,  which  seldom  stains  the  mucosae;  and  in  pellagra,  which  is 
exempt  from  mucous  membrane  pigmentation,  (b)  Chronic  icterus, 
cyanosis  (sometimes  pigmenting  the  oral  mucosa),  various  physiological 
pigmentations,  dirt  and  parasites,  as  in  tramps  (vagabondism),  (c) 
Abdominal  diseases;  dyspepsia,  gastric  ulcer,  tumor  (cancer,  lymphomata 
and  Hodgkin's  disease),  hypertrophic  cirrhosis  and  hemochromatosis 
(hepatic  and  pancreatic  cirrhosis,  diabetes  and  skin  pigmentation, 
diahete  bronze),  (d)  Pelvic  conditions;  pregnancy,  uterine  and  ovarian 
tumors  (after  the  removal  of  which  pigmentation  may  regress),  (e) 
Phthisis,  malaria,  melanosarcoma  of  the  skin,  or  exophthalmic  goitre. 
In  these  conditions,  pigmentation  of  the  oral  mucosa  is  rare. 

Treatment. — 1.  Supporting. — Absolute  rest  is  imperative  because  of 
exhaustion  and  proneness  to  lethal  syncope.  Alcoholic  stimulation  is 
poorly  tolerated.  Careful  feeding  is  necessary  because  of  the  sensitive- 
ness of  the  stomach  and  bowels. 

2.  Symptomatic.^ — Narcotics  for  pain,  gastric  sedatives  for  vomiting 
(«.  Gastritis),  opiates  for  diarrhea  {v.  Enteritis)  should  be  adminis- 
tered; strong  cathartics  are  always  contra-indicated;  one  case  in  the 
Cook  County  Hospital  died  suddenly  after  taking  a  dram  of  compound 
jalap  powder. 

3.  Organotherapy. — Of  Adam's  105  cases  treated  by  adrenal  extract 
by  mouth,  one-third  were  benefited  and  one-sixth  recovered.  The  med- 
ullary portion  of  the  gland  is  best.  It  may  increase  the  vascular  and 
muscular  vigor  or  even  lessen  pigmentation.  Some  advocate  adrenalin 
chloride,  5j  of  1  to  1000  hypodermically  on  alternate  days.  Some 
advanced   cases   are   unfavorably   affected. 

Other  affections  of  the  suprarenal  glands  are  of  slight  clinical  interest. 
(a)  Developmentally  the  glands  are  sometimes  absent  or  hypoplastic, 
chiefly  with  other  defects,  as  encephalocele.  (6)  Hypertrophy  in  one 
gland  may  compensate  for  hypoplasia  in  the  other.  Supernumerary 
glands  are  not  uncommon,  (c)  Atrophy  is  usual  in  advanced  age.  {d) 
Degenerations  embrace  the  parenchymatous,  fatty,  hyaline  and  amyloid 
types,  (e)  Circulatory  disorders  are  embolism,  thrombosis  and  hemorrhage 
which  latter  may  occur  in  trauma  in  the  newborn,  tumors,  inflammation 
and  the  hemorrhagic  diathesis.  (/)  Inflammation,  acute  and  chronic, 
is  uncommon,  {g)  Granidomata,  chiefly  syphilitic  and  tuberculous,  are 
rarely  primary,  {h)  Tumors,  e.  g.,  carcinoma  and  sarcoma,  are  chiefly 
of  anatomical  importance.  In  23  operations  on  hypernephroma 
the  mortality  was  50  per  cent.,  recurrence  developed  in  21  per  cent, 
and  29  per  cent,  recovered,     (i)  Echinococcus  is  extremely  infrequent. 


EMBOLISM  AND  ABSCESS  705 


DISEASES   OF   THE   SPLEEN. 

Structurally  and  physiologically,  the  spleen  resembles  the  lymph 
nodes,  which  vicariously  hypertrophy  after  splenectomy.  It  is  not  proved 
indispensable  to  life  nor  productive  of  an  internal  secretion.  During 
fetal  and  perhaps  adult  life  it  is  concerned  in  erythrocytogenesis.  In 
health  it  destroys  old  red  blood  cells  and  in  certain  diseases  its  hemolytic 
activity  is  pronounced.  In  immunization,  phagocytosis  and  perhaps 
some    chemical    factors    are    conspicuous. 

ACUTE  SPLENIC  TUMOR. 

This  occurs  (a)  in  acute  infections,  due  to  the  local  action  of  micro- 
organisms and  their  toxins  or  to  toxemic  paralysis  of  the  splanchnic 
nerve ;  it  is  most  common  in  typhoid,  malaria,  recurrent  fever  and  septic 
conditions;  (b)  in  acute,  usually  portal  stasis;  and  (c)  in  embolism  (v.  i.). 
Symptoms  are  infrequent;  pain  usually  indicates  perisplenitis.  On 
objective  examination:  (a)  The  spleen  may  sometimes  be  seen  during 
deep  inspiration.  (6)  Palpation  alone  is  reliable;  by  the  bimanual  method 
and  with  the  examiner  sitting  at  the  right  side  of  the  patient  the  edge 
of  the  spleen  comes  in  contact  with  the  fingers  and  slips  sharply  down 
below  them;  splenic  crenations  are  seldom  palpable.  A  palpable  spleen 
indicates  enlargement  or  less  often,  downward  dislocation  by  pleurisy, 
pneumothorax  or  thoracic  tumor,  (c)  Percussion,  valuable  in  outlining 
the  upper  splenic  level,  is  unreliable  in  determining  the  lower  border. 

CHRONIC  SPLENIC  TUMOR. 

Chronic  enlargement  is  symptomatic  of  (a)  chronic  infections,  as 
malaria,  tuberculosis  and  syphilis,  (h)  continued  portal  stasis,  (c)  repeated 
embolism,  (d)  blood  affections,  as  leukemia,  pseudoleukemia  or  splenic 
anemia,  and  (e)  amyloidosis,  neoplasms,  cysts,  polycythemia,  arthritis 
deformans,  chronic  acetanilide  poisoning,  etc. 

EMBOLISM  AND  ABSCESS. 

Embolism  of  the  spleen  ranks  second  in  frequency  to  kidney  em- 
bolism because  of  its  wide  arteries  and  slow  current.  It  usually  develops 
in  the  course  of  acute  endocarditis  or  chronic  valvular  lesions  and  seldom 
follows  local  lesions,  as  splenic  vein  thrombosis.  The  symptoms  vary 
as  the  embolus  is  simple  or  infective;  sudden  chill,  fever,  pain  in  the  side, 
acute  splenic  tumor  and  perisplenitic  friction  may  develop,  which  with  a 
cause  or  embolic  symptoms  in  other  organs,  justify  a  diagnosis  of  embolism. 
Frequently  no  distinctive  symptoms  occur.    Treatment  is  symptomatic. 

Abscess  from  embolism,  trauma  or  invasion  by  contiguity,  occurred 
in  9  per  cent,  of  430  cases  of  pyemia  (Paget).  It  is  largest  in  non-embolic 
cases;  embolic  abscesses  are  small  and  multiple.  Symptoms  are:  (a) 
those  of  the  cause,  which  may  mask  the  lesion;  (b)  of  embolism;  (c) 

45 


706  DISEASES  OF   THE  SPLEEN 

of  splenic  tumor,  perisplenitis,  friction  or  pain;  (d)  of  rupture  into  the 
pleura,  kidney  or  peritoneum;  (e)  aspiration  determines  the  diagnosis 
and  treatment  is  surgical  evacuation. 

PERISPLENITIS. 

This  affection  may  be  primary  or  secondary,  simple  or  suppurative, 
an  isolated  lesion  or  part  of  a  chronic  peritonitis  (see  "Icing  Liver," 
Chronic  ]^erihepatitis).  It  usually  accompanies  the  various  splenic 
affections  enumerated.  Without  local  peritonitic  friction,  pain  or 
tenderness  its  diagnosis  is  impossible.    There  is  no  therapy. 

AMYLOID  SPLEEN. 

Its  etiology  is  considered  under  Amyloid  Liver  and  Kidney.  Patho- 
logically, its  two  types  are  (a)  the  sago  spleen,  in  which  there  are 
amyloid  deposits  in  the  vessels  of  the  Malpighian  tufts,  and  (b)  the  more 
important,  diffuse  amyloid  infiltration,  diagnosticated  by  (i)  its  etiology, 
(ii)  large  size,  hardness,  smoothness  and  thick  edge,  and  (iii)  coincident 
amyloidosis  of  the  liver  and  kidneys. 

RUPTURE  OF  THE  SPLEEN. 

Rupture  may  be  traumatic  or  spontaneous;  the  latter  variety  has 
been  observed  in  embolism,  malaria,  typhoid,  leukemia  and  pregnancy. 
It  is  more  common  in  tropical  than  temperate  climates.  Aspiration  and 
even  palpation  have  occasioned  rupture.  The  treatment  is  surgical; 
104  splenectomies  for  rupture  are  reported,  with  29  per  cent,  mortality 
(Hortz). 

MOVABLE  OR  FLOATING  SPLEEN. 

Lien  mobile  is  due  (a)  to  the  same  factors  observed  in  enteroptosis, 
with  which  it  may  be  associated,  and  (6)  enlargement  and  increased 
weight  of  the  spleen. 

Symptoms.— Symptoms  are  often  absent.  Pain  or  a  dragging  sen- 
sation is  frequent,  which  is  either  local  or  radiates  to  the  thorax,  left 
shoulder  or  legs,  similar  to  that  observed  in  neurotics  or  women  with 
pelvic  disease.  There  may  be  headache,  psychical  alteration,  dyspepsia, 
menstrual  anomialies  and  paresthesias.  Objectively:  (a)  The  most  impor- 
tant sign  is  'palyatory  detection  of  the  spleen  in  an  abnormal  location,  most 
often  in  the  left  ilio-inguinal  region  but  also  below  the  left  costal  arch, 
near  the  navel,  in  a  hernial  sac,  in  the  pelvis  or  above  the  pubes.  Its 
hilum  usually  points  upward.  The  form,  notches  and  possibly  the  pulsat- 
ing vessels  are  those  of  the  spleen.  It  is  usually  enlarged,  from  causal 
hypertrophy  or  later  congestion;  torsion  of  its  pedicle  may  lead  to 
atrophy,  softening,  gangrene  or  even  liberation  of  the  spleen  as  a  free 
body.  As  a  rule  it  can  be  replaced  and  its  position  changes  with  posture; 
perisplenitis,  causing  a  friction-rub,  may  result  in  firm  adhesions  to  the 
colon,  bladder  or  uterus,  thereby  causing  insuperable  diagnostic  difficulty; 


GOITRE  707 

ill  such  cases  the  spleen  ceases  to  "wander."  ih)  The  spleen  is  absent 
from  its  normal  location,  the  splenic  area  being  replaced  by  tympany 
from  the  colon  (which  changes  to  dulness  when  water  is  introduced  into 
the  colon),  (c)  Pressure  symptoms  include  intestinal,  pyloric,  vesical  and 
rectal  compression. 

Diagnosis.^ — The  author  knows  of  three  laparotomies  performed  for 
supposed  uterine  or  renal  disease  in  which  abundant  adhesions  rendered 
differentiation  impossible.  On  the  other  hand,  a  hard,  immovable 
suprapubic  tumor  was  correctly  diagnosticated  as  leukemic  spleen  by 
the  adenopathy  and  blood  findings. 

Treatment. — (a)  Bandages  are  difficult  to  apply,  though  sometimes 
of  benefit,  (b)  The  spleen  may  be  replaced  by  operation  and  well  packed 
around  with  gauze;  the  resulting  adhesions  often  retain  the  viscus. 
(c)  Splenopexis  (Rydygier)  may  be  performed,  the  spleen  being  sewed 
in  place  or  deposited  in  a  peritoneal  pocket,  (d)  Splenectomy  may  be 
performed  as  a  last  resort. 

PRIMARY  SPLENOMEGALY. 

Reference  has  been  made  to  Banti's  disease  and  splenic  anemia  (pp.  571 
and  690),  splenomegaly  with  acholuric  jaundice  (p.  590),  pernicious 
anemia,  hepatic  cirrhosis,  etc. 

Gauchee's  splenomegaly  {primary  endothelioma),  of  which  16  cases 
are  reported,  is  characterized  anatomically  by  peculiar  large,  round  and 
multinucleated  cells  in  the  hemopoietic  system  (marrow,  spleen,  lymphad- 
enoid  structures,  liver).  Its  cause  is  disputed  (malignancy,  endogenous, 
splenic  toxemia,  etc.).  Besides  the  splenic  tumor,  the  clinical  symptoms 
are  a  yellowish-brown  discoloration  of  the  skin,  conjunctival  thickening, 
persistent  leukopenia,  mild  anemia,  hemorrhagic  tendencies,  develop- 
ment early  in  life,  chronic  course  and  familial  incidence.  As  in  Banti's 
disease,  splenectomy  is  indicated. 

Tumors  and  Cysts. — New  groT^'ths  are  very  infrequent.  They  are 
more  often  secondary  than  primary.  They  include  carcinoma,  sarcoma, 
enchondroma,  fibroma  and  lymphangioma.  They  are  rarely  differen- 
tiated from  splenic  anemia  and  like  affections. 

Echinococcvs  cysts  (q.  v.)  are  usually  found  with  concomitant  cysts  in 
the  liver.  One  dermoid  cyst  is  reported  (Andral,  1829).  Only  38  non- 
parasitic cysts  are  found  in  the  literature. 

Gramilomata  (see  Tuberculosis  and  Syphilis). 


DISEASES  OF  THE  ^rHYKOID  GLAND. 

GOITRE. 

Definition. — Hypertrophy  of  the  thyroid  gland.  Sporadic  cases  are 
common  in  Europe  and  America.  Goitre  occurs  endemically  in  Switzer- 
land and  Italy,  from  the  drinking  water.  It  is  usually  acquired  and  Is 
seldom   congenital. 


708  DISEASES  OF  THE  THYROID  GLAND 

There  are  three  main  forms:  (a)  The  ijarenchymatous  type,  with  for- 
mation of  colloid  material  in  the  hyperplastic  follicles;  (6)  the  cystic; 
and  (c)  vascular  type,  with  dilatation  of  the  bloodvessels,  which  form 
borders  closely  on  those  physiological  variations  observed  at  puberty, 
in  defloration,  pregnancy,  chlorosis  and  psychical  trauma. 

Symptoms. — 1.  The  thyroid  enlargement  may  be  diffuse,  as  in  the  soft, 
symmetrical,  vascular  form,  or  partial  or  nodose,  implicating  but  one 
lobe  or  the  isthmus.     In  most  cases  there  are  only  local  findings. 

2.  Compression  symptoms  are  not  common.  The  carotid  artery  and 
jugular  vein  are  pushed  to  one  side  and  the  sternomastoids  become 
thin.  The  tracheal  lumen  may  be  shaped  like  a  sword  scabbard;  dyspnea, 
bronchiectasis  and  dilatation  of  the  right  ventricle  follow  stenosis  of  the 
air  passages.  Laryngeal  paralysis  occurs  in  over  10  per  cent.,  and 
in  25  per  cent,  of  cases  in  which  there  is  tracheal  stenosis.  Goitres  may 
grow  in  a  retrosternal  or  retroclavicular  direction  (5  to  10  per  cent.), 
compressing  the  vagus,  sympathetic  nerves  and  vena  cava.  A  goitre 
may  disappear  into  the  chest  with  each  inspiration  {goitre  en  dedans), 
or  become  incarcerated  there. 

3.  An  aberrant  or  accessory  thyroid  may  occasionally  form  a  tumor 
anywhere  from  the  tongue  to  the  aorta,  from  the  spine  to  the  anterior 
chest  wall,  in  the  retropharyngeal  or  retro-esophageal  tissues  (causing 
dysphagia  or  dysarthria),  in  the  trachea,  larynx,  root  of  the  tongue, 
pleura  or  mediastinum;  it  may  compress  an  entire  lung;  75  benign, 
16  malignant  and  3  cystic  and  calcarious  growths  are  recorded  in 
retrosternal  accessory  thyroids;  there  are  in  the  literature  14  intratracheal 
accessory  thyroids. 

4.  Sudden  death  may  occur  from  pressure  on  the  vagus  or  trachea, 
spasm  or  edema  of  the  glottis,  sudden  hyperemia  of  the  gland,  hemor- 
rhage dissecting  into  the  chest  or  status  lymphaticus. 

Diagnosis. — Confusion  is  possible  with  tumors,  as  carcinoma,  adenoma, 
echinococcus  cj^sts  (25  reported  cases)  and  sarcoma  (100  reports). 
In  83  per  cent,  of  cases  cancer  develops  from  a  preexisting  goitre;  early 
metastases  are  especially  common  and  characteristic;  only  10  per  cent, 
recovered  among  110  operations  (Madelung).  In  20  cases  recorded, 
metastases  throughout  the  body  occurred /ro7?i  benign  tumors  of  the  thyroid 
(chondroma  or  myxoma).  Thyroid  inflammation  {strumitis)  is  usually 
metastatic  or  traumatic,  rarely  primary;  it  may  occur  in  sound  or  goitrous 
glands;  it  is  most  often  due  to  the  streptococcus  but  may  be  caused  by 
the  colon,  typhoid,  pneumonia  or  other  organisms. 

Treatment. — In  regions  where  goitre  is  prevalent  the  drinking  water 
should  be  boiled.  Medical  treatment  is  of  uncertain  value.  Iodine  may 
be  used  by  injection  (Maunoir,  1825).  Potassium  iodide  (Coindet, 
1820)  is  beneficial  in  some  subacute  cases,  according  to  Bruns,  in  75 
per  cent.;  Kraus  found  it  particularly  beneficial  in  the  vascular  type, 
with  moderate  tachycardia  and  full  arteries.  The  .r-rays  and  thyroid 
extract  are  occasionally  beneficial.  Surgical  treatment  is  indicated  in 
large  or  growing  goitres;  in  Kocher's  5000  cases,  1  death  occurred  in 
each  600  operations. 


EXOPHTHALMIC  GOITRE  709 


EXOPHTHALMIC  GOITRE   (HYPERTHYROIDISM). 

Definition. — A  malady  due  to  excessive  activity  of  the  thyroid  gland 
and  characterized  by  exophthalmos,  enlarged  thyroid,  tachycardia  and 
tremor.  It  was  first  described  in  England  by  Parry  (1786)  and  Graves 
(1835)  and  later  in  Germany  by  Basedow  (1840). 

Etiology. — 1.  The  cause  is  overactivity  or  perversion  of  thyroid  secretion 
(Mobius)  which  contrasts  sharply  with  myxedema: 

Exophthalmic  Goitre. vs. Myxedema. 

(a)  Hypertrophy  of  gland;  excessive  inter-       Atrophy;    deficient  (hypothyrea)  or  absent 

nal  secretion  (hyperthyrea) .  secretion  (athyrea). 

(b)  Increased  nervous  excitability.  Dulness,  apathy,  cretinism. 

(c)  Vascular    erythrism;      flushed,     moist,       Skin  dry,  thick  and  cool,  and  pulse  slow. 

warm  skin;    rapid  pulse. 

(d)  Increased    diuresis    and    active   metab-       Decreased. 

olism. 

(e)  Thyroid    extract    increases    symptoms ;       Thyroid  extract  improves  or  cures. 

it  may  produce  goitre,   tachycardia, 

tremor,  even  exophthalmos. 
(/)    Surgical  (partial)  excision  relieves,  and       Some  cases  result  from  removal  of  thyroid. 

often  cures.  Transplantation  of  new  gland  improves 

or  cures. 
(g)   Exophthalmic  goitre  (glandular  hypertrophy  with  hyperthyroidism)  may  occasionally 

become  myxedema  (hypothyroidism  from  glandular  atrophy). 

2.  Other  etiological  explanations  are  less  plausible,  as  vasomotor  neurosis 
or  lesions  in  the  corpus  restiforme  of  the  medulla. 

3.  Exciting  factors  are:  (a)  Sex;  80-95  per  cent,  are  women;  fibroids, 
pregnancy  and  puberty  are  sometimes  promoting  factors,  (b)  Age; 
most  cases  occur  between  the  twentieth  and  thirtieth  years.  Barrett 
(1904)  could  collect  only  42  cases  in  persons  under  fifteen  years,  (c) 
Psychical  trauma,  as  fear,  and  concussion,  anemia,  phthisis,  neuro- 
pathic family  tendencies,  other  neuroses  or  psychoses  favor  its  develop- 
ment, (d)  After  thyroidectomy  postoperative  hyperthyroidism  is  not 
rare. 

Symptoms. — 1.  Cardinal  Symptoms. — (a)  Tachycardia  is  the  earliest 
symptom.  The  pulse  ranges  from  100  to  120  (140  or  even  200);  it 
varies  from  time  to  time.  It  is  associated  with  other  cardiovascular 
symptoms,  as  (i)  increased  cardiac  action,  manifested  by  a  diffuse 
cardiac  impulse,  sharp  tones  sometimes  heard  at  a  distance  of  several 
feet  and  hypertrophy  of  the  left  ventricle  eventuating  in  dilatation; 
(ii)  a  functional  systolic  murmur  over  the  apex;  (iii)  palpitation,  usually 
antedating  tachycardia;  (iv)  vascular  symptoms;  a  pulse  weaker  than 
the  apex-beat;  active  arterial  pulsation  in  the  carotids  and  abdominal 
aorta;  capillary  pulsation  in  the  fingers,  forehead  or  even  in  the  retina, 
palate,  liver  and  spleen;  even  the  peripheral  veins  may  pulsate;  and 
(v)  irregular  failing  heart  action  occurs  late  and  in  severe  cases.  Hemor- 
rhages are  not  uncommon. 

(b)  Exophthalmos,  usually  a  later  symptom  than  tachycardia,  is  present 
in  90  per  cent,  of  cases  and  results  from  dilatation  of  the  orbital  vessels. 
The  protrusion  of  the  eyeballs  and  the  staring,  fixed  expression  are  very 


710  DISEASES  OF   THE   THYROID  GLAND 

characteristic  (exophthalmos  may  also  occur  in  extreme  myopia,  tumors 
of  the  orbit,  nephritis,  and  sympathetic  irritation).  The  condition  is 
generally  bilateral,  though  often  unequal;  the  author  saw  unilateral 
exophthalmos  with  homolateral  goitre.  The  eyelids  are  unable  to  cover 
the  eye-ball  entirely  and  a  rim  of  the  white  sclera  shows  about  the  iris. 
The  protrusion  may  even  amount  to  dislocation  of  the  bulb,  perhaps 
with  corneal  ulceration  and  loss  of  the  eye  by  panophthalmitis.  The 
associated  eye-symptoms  are :  (i)  von  Graefe's  sign,  the  failure  of  the  upper 
lid  to  follow  the  eye-ball  when  it  is  rolled  downward,  is  present  in  at 
least  33  per  cent,  and  is  of  considerable  diagnostic  value,  though  present 
also  in  Thomsen's  disease,  (ii)  Stelhvacfs  sic/n,  which  is  rarely  absent,  is 
widening  of  the  interpalpebral  fissure  (Dalrymple)  with  infrequent 
winking  (Stellwag) ;  it  also  occurs  in  mania  and  in  old  age.  (iii)  Mohius's 
sign  is  weakness  of  the  internal  recti,  when  the  eyes  converge;  it 
occurs  also  in  other  conditions,  as  paretic  dementia,  (iv)  Becker's 
sign  consists  of  pulsation  of  the  retinal  vessels,  (v)  In  Joffroy's  sign 
the  patient's  forehead  remains  smooth  (instead  of  becoming  wrinkled) 
when  he  glances  upward  with  the  head  bent  somewhat  downward. 
(vi)  Gifford's  sign  is  the  difficulty  in  everting  the  upper  lid;  (vii)  Jellinek 
and  Rosin  describe  edema  and  pigmentation  of  the  upper  lid.  Kocher 
noted  a  spasm  of  the  lid  in  eliciting  v.  Graefe's  sign.  Eye-muscle 
paralyses  and  retinal  or  pupillary  changes  are  infrequent. 

(c)  The  goitre  is  rarely  an  initial  symptom  and  usually  develops  later 
and  remittently.  It  is  present  in  100  per  cent,  (i)  It  typically  is  vascular. 
Acute  thyroidism  may  develop  in  thyroiditis,  chronic  cystic  goitre  or 
thyroid  malignancy.  The  goitre  is  smaller  than  the  ordinary  bronchocele; 
it  is  diffuse  or  oftener  more  developed  on  the  right  side  (an  accentuation 
of  physiological  proportions),  shows  a  vascular,  rough  surface  and  is  dry, 
gray  and  granular  on  section  (instead  of  the  normal  amber-red  color); 
microscopically  the  alveoli  are  not  rounded,  full  of  colloid  matter  or 
lined  with  cubical  epithelium,  but  are  extremely  irregular  in  size  and  form, 
ramifying  and  encroached  upon  by  epithelial  proliferations  and  the  epithe- 
lium becomes  columnar;  in  extreme  cases  there  is  epithelial  desquama- 
tion; the  scanty  colloid  matter  stains  faintly  and  lymphoid  tissue  de- 
velops; in  the  later  stages  some  fibrous  tissue  may  develop,  (ii)  It  is 
usually  soft,  elastic,  variable  in  size,  pulsating  on  inspection,  thrilling 
on  palpation  and  revealing  on  auscultation  a  loud,  systolic  bruit  or  a 
double  murmur,  which  Guttmann  considers  pathognomonic.  The  goitre 
is  retrosterna,l  in  4  per  cent. 

{d)  Tremor  is  present  to  some  degree  in  most  cases  and  is  conspicuous 
in  50  per  cent.  It  is  characteristically  fine,  regular  and  rapid,  numbering 
8  or  9  vibrations  to  the  second.  It  affects  the  wrist  more  than  the  fingers ; 
sometimes  it  affects  the  trunk, 

2.  Accessory  Symptoms. — (a)  Nervous  symptoms.  Cerebral  symp- 
toms are  usual,  as  headache,  impaired  memory,  insomnia,  irritability 
or  depression.  Mania  is  sometimes  observed  in  the  fatal  cases.  "  Giving 
way  of  the  legs"  and  slight  inspiratory  increase  in  the  chest  measurement 
(Bryson's  sign)  are  expressions  of  weakness  of  the  muscles,  whose  strength 
is  reduced  to  one-third  or  one-fifth  of  normal  (Miiller).    The  reflexes  are 


EXOPHTHALMIC  GOITRE  711 

often  increased.  Rheumatic  pains  may  be  noted.  Vasomotor  symptoms 
are  common,  as  reddening  of  the  face,  subjective  warmth,  dry  mouth, 
sweats  of  a  pecuHar,  penetrating  odor,  or  intermittent  swelUng  of  the 
joints.  (6)  JRcspiratory  symptoms  inckide  dyspnea  and  dry  cough, 
perhaps  simulating  phthisis,  (c)  Digestive  symptoms:  Severe  nervous 
vomiting,  abdominal  crises  and  diarrhea  may  simulate  organic  disease; 
their  persistence  is  ominous,  (d)  Cutaneous  symptoms:  Pigmentation 
may  be  extreme.  Vasomotor  edema,  urticaria,  itching  and  falling  of 
the  hair  may  also  occur.  A  peculiar  fulness  above  the  clavicles  may 
develop,  sometimes  with  pain  in  the  neck.  The  electrical  resistance  of 
the  skin  is  decreased,  perhaps  to  one-fifth  of  the  normal;  it  is  probably 
occasioned  by  profuse  sweating  and  has  no  pathognomonic  importance.- 
(e)  Constitutional  symptoms:  Emaciation  and  anemia  are  common, 
especially  in  blondes.  ^Metabolism  is  increased,  evidenced  by  the  nitrog- 
enous excretion,  increased  diuresis  and  elevation  of  temperature; 
these  symptoms  may  be  intermittent.  Thompson  describes  fever  and 
symptoms  resembling  ulcerative  endocarditis.  Amenorrhea,  albumin- 
uria, glycosuria,  persistence  of  the  thymus  gland  (in  80  per  cent.)  and 
the  occasional  hyperplasia  of  the  spleen  are  difficult  to  explain.  The 
lymphocytes  and  eosinophiles  are  increased,  leukopenia  is  frequent  and 
coagulation  is  slowed. 

Diagnosis. — The  diagnosis  is  unequivocal  when  the  cardinal  symptoms 
are  present,  reinforced  by  the  secondary  symptoms.  Atypical  forms 
{formes  frustes)  may  cause  confusion.  The  affection  is  often  incorrectly 
diagnosticated  in  young  girls  at  puberty,  in  whom  thyroid  turgescence, 
moderate  tachycardia  and  vascular  excitability  occur  without  particular 
significance.  Incipient  tuberculosis,  carcinosis  and  neurasthenia  may  be 
simulated. 

Course  and  Prognosis. — (a)  The  onset  is  usually  insidious  and  the 
course  chronic  and  remittent.  Chronic  cases  sometimes  begin  rather 
acutely.  Acute  cases  are  unusual  but  usually  fatal;  they  occur  chiefly 
in  men;  Lloyd  records  a  case  which  was  fatal  in  three  days.  The  author 
has  seen  3  cases  in  which  death  occurred  in  two  weeks,  ih)  Death 
occurs  in  12  per  cent,  of  cases,  commonly  due  to  cardiac  failure,  (c)  The 
outlook  is  best  in  the  less  typical  (rudimentary)  forms,  {d)  Complete 
recovery  is  rare,  though  20  to  50  per  cent,  of  cases  improve,  (e)  Unfavor- 
able prognostics  are  its  occurrence  in  the  very  young  and  in  men, 
emaciation,  extreme  tachycardia,  persistent  vomiting  or  diarrhea,  fever, 
lymphatism  and  intercurrent  myxedema. 

Treatment. — 1.  General.^  i??^^  and  a  quiet  life  at  a  moderate  ele- 
vation or  at  the  sea-side  are  very  beneficial.  Travel,  sojourn  at  resorts, 
gymnastics  and  excitement  are  injurious.  A  simple  diet  and  interdiction 
of  alcohol,  coft'ee,  tea  and  tobacco  are  essential. 

2.  Drugs. — Drugs  are  disappointing;  digitalis,  strophanthus  and  spar- 
tein  fail  to  slow  the  heart.  Belladonna,  in  large  physiological  doses,  is 
recommended  by  Go wers ;  the  annoying  palpitation  and  abdominal  throb- 
bing are  most  relie\'ed  by  it.  Ergotin,  quinine,  salicylates,  arsenic  and 
strychnine  are  of  uncertain  value,  but  the  latter  seems  rather  more 
beneficial;  iron  is  useful  only  in  chlorotic  girls  but  in  men  it  aggravates 


712  DISEASES  OF   THE   THYROID  GLAND 

digestive  and  vasomotor  disturbances.     Constant  application  of  an  ice- 
bag  to  the  heart  reUeves  palpitation  and  somewhat  slows  the  heart  rate. 

3.  Electricity. — Galvanization  is  recommended  by  Erb,  who  uses 
the  anode  over  the  cervical  spine  and  the  kathode  over  various  periph- 
eral areas.  X-rays  are  beneficial  but  render  operation  difficult  by  the 
adhesions  produced. 

4.  Organotherapy. — Thyroid  extract  and  iodides  aggravate  the  symp- 
toms. Thymus  extract  is  uncertain.  Adrenalin  clysters  may  check 
diarrhea.  Baumann  demonstrated  that  the  thyroid  gland  contained  an 
iodine  body  which  Ross  proved  was  the  main  functional  constituent 
of  the  organ.  The  active  element  neutralizes  toxins  (failing  in  which 
myxedema  results),  and  if  not  itself  neutralisied,  Basedow's  disease 
results;  to  neutralize  hyperthyroidism  serum  of  thyroidectomized  animals 
was  suggested. 

5.  Thyroidectomy. — In  Kocher's  371  operations,  only  3.5  per  cent, 
died;  2  cases  died  in  the  last  153  operations;  83  per  cent,  were  cured. 
Kocher  considers  (a)  the  blood-pressure,  size  of  the  heart  and  tachycardia; 
(b)  he  hesitates  to  operate  if  there  is  great  nervousness,  intoxication 
or  absence  of  lymphocytosis,  and  (c)  if  the  gland  is  very  large,  pulsating 
or  vascular.  Sudden  operative  death  has  been  ascribed  to  the  narcosis, 
fiooding  of  the  blood  with  thyroid  products  or  enlarged  thymus  (which 
Capelle  found  in  four-fifths  of  60  autopsies) .  The  mortality  is  much  lower 
when  Graves's  disease  develops  from  an  old  goitre  (secondary  form) .  The 
Mayos  prefer  local  anesthesia.  Kocher  prefers  trying  the  .x-rays  first 
and  then  ligating  the  thyroid  arteries  (after  which  tetany  may  occur) 
and  later  performing  partial  thyroidectomy;  the  danger  of  a  "heart" 
death  is  avoided  by  early  operation.  The  mortality  of  operation,  for  any 
indication,  in  an  exophthalmic  subject,  is  increased  15  per  cent. 

MYXEDEMA. 

Definition. — A  chronic  disease,  characterized  by  (a)  loss  of  thyroid 
function  (athyrea),  (6)  myxedema  (an  edematous  change  in  the  sub- 
cutaneous tissue),  (c)  cachexia  or  (d)  cretinism  (mental  failure).  It  was 
described  by  Gull  (1873),  Ord  (1877),  Charcot,  Bourneville  and  d'Olier. 

Etiology. — The  thyroid  may  be  aplastic,  hypoplastic,  cirrhotic  from 
an  infective  sclerosing  thyroiditis  (syphilis,  tuberculosis,  rheumatism 
or  erysipelas),  hypertrophied  (goitre)  or  removed  by  operation,  but  in  all 
cases  the  thyroid  function  (internal  secretion  or  antitoxic  action)  is 
suspended  or  lost.  The  symptoms  vary  as  to  cause  and  combination, 
whence  (i)  cretinism,  (ii)  adult  myxedema  and  (iii)  operative  myxedema 
will  be  considered  separately. 

CRETINISM. 

Cretinism  may  be  congenital,  in  which  instance  life  is  not  long  pro- 
tracted; it  usually  develops  near  the  time  of  weaning  (infantile  form);  it 
may  develop  between  the  fourth  year  and  puberty  (juvenile  form). 
The  endemic  form  occurs  in  regions  where  goitre  is  prevalent,  in  Switzer- 


MYXEDEMA   OF  ADULTS  713 

land,  Italy,  France,  Great  Britain,  Spain  and  Sweden;  when  both 
parents  are  goitrous,  the  child  is  invariably  a  cretin,  is  myxedematous 
and  may  also  have  goitre.  The  sporadic  form  may  develop  from  thyroid 
aplasia,  sclerosing  thyroiditis  or  from  goitre.  In  1905,  100  cases  were 
collected  in  America  (Howard). 

Symptoms. — In  the  last  part  of  the  first  or  in  the  second  year  of  life, 
retardation  of  mental  and  physical  development  is  apparent.  The  head 
is  disproportionately  large,  the  fontanelles  persist,  the  forehead  is  nar- 
row and  the  base  of  the  skull  is  shortened.  The  face  is  turgid,  pale  and 
imbecile,  the  lids  are  swollen,  as  are  the  nose,  the  protruding  tongue  and 
pouting  lips.  Dentition  is  retarded  and  caries  is  frequent.  The  skin 
loses  its  tone  and  is  dry,  and  the  hair  is  thin.  The  neck  is  short,  which 
condition  is  accentuated  by  supraclavicular  deposits  of  fat.  The  abdo- 
men is  large  and  pendulous;  umbilical  hernia  is  very  frequent.  The 
body  is  dwarfed  and  the  extremities  are  short,  stumpy  and  weak  or 
helpless.  Metabolism  is  slow,  the  gaseous  interchange  being  reduced 
to  60  to  50  per  cent,  of  the  normal. 

Diagnosis. — (a)  The  mental  alteration  is  marked,  though  mild  com- 
pared with  the  grimaces,  grinding  of  the  teeth  and  compulsory  move- 
ments caused  by  gross  lesions  of  the  brain,  (b)  In  hyperplasia  of  the  bone 
cartilages  (chondrodystrophia  foetalis)  there  are  great  enlargement  of  the 
head  and  joints,  dwarfing  of  the  body  and  shortness  of  the  extremities 
(micromelia),  but  no  essential  mental  change;  court  fools  were  probably 
of  this  type,     (c)  Infantilism  (v.  i.). 


MYXEDEMA   OF   ADULTS. 

Symptoms. — ^Myxedema  spontaneum  adultorum,  or  cachexie  pachy- 
dermique  (Charcot)  is  characterized  bv  (1)  thyroid  atrophy,  (2)  myxedema 
(pachydermia),  (3)  intellectual  and  physical  weakness  and  (4)  certain 
accessory  symptoms.  It  is  most  frequent  in  England  and  France.  Most 
cases  occur  between  thirty  and  fifty  years  of  age. 

1.  Thyroid  Atrophy. — This  is  less  a  clinical  than  a  histological  con- 
dition, as  evidenced  by  the  lack  of  function  sometimes  observed  in  gross 
enlargement  of  the  gland  (one-seventh  of  the  cases).  Eighty-six  per  cent, 
occur  in  women  and  it  is  possibly  related  to  the  uterine  functions  or  to 
the  physiological  congestive,  thyroid  enlargement  observed  in  women. 
It  may  be  hereditary  or  familial,  perhaps  associated  with  exophthalmic 
goitre. 

2.  Myxedema. — Mucin  fibrils  and  nuclei — like  granulation  tissue — 
have  been  found  in  the  skin  and  subcutaneous  tissues.  These  structures 
are  inelastic,  semigelatinous  and  semiedematous,  but  do  not  pit  upon 
pressure;  the  skin  is  pale,  waxy,  dry,  rough,  firm  and  its  electrical 
resistance  is  increased;  the  hair  and  teeth  may  fall  out  and  the  nails 
thicken  and  break.  The  loss  of  the  outer  half  of  the  eyebrow  is  described 
by  French  writers.  The  facies  is  somnolent,  coarse  and  swollen,  and  the 
features  are  individually  changed,  rather  resembling  those  of  a  cretin; 
the  cheeks  are  patchy  red,  pendulous  and  tremble  like  jelly  and  the 


711  DISEASES  OF   THE   THYROID  GLAXD 

tongue  is  big.  The  supraclavicular  tissue  is  enlarged  in  lumps  and  rolls, 
though  this  is  also  observed  in  healthy  persons  fVerneuirs  pseudolipo- 
mata).  S.  Kidi  observed  a  painfid  swelling  over  the  clavicle  alone,  which 
rather  resembled  keloid.  The  hands  and  feet  are  infiltrated.  The 
swellings  may  change  rapidly.  The  oral  mucous  membrane  is  dry  and 
thick,  sometimes  also  the  pharynx,  larynx  and  e\'en  the  rectum. 

3.  Mental  ^YEAK^^:ss. — Intellectual  and  physical  weakness  is  appar- 
ent. Charcot  compares  the  somnolence  to  hibernation.  Headache  is 
common.  The  patient  is  apathetic,  irritable,  weak  in  memory  and  slow 
in  thought,  speech  and  movement;  sometimes  delirium  and  mania  pre- 
cede the  ultimate  dementia.  The  gait  is  clumsy  ("hippopotamus  gait") 
and  muscular  fatigue  follov\-s  moderate  exertion. 

4.  Other  St^iptoms. — The  accessory  s\Tnptoms  are  variable,  as 
arteriosclerosis,  palpitation;  small,  sluggish  pupils,  tremor,  vertigo. 
night  terrors,  sensitiveness  to  cold;  indigestion  and  constipation;  anemia, 
leukopenia,  lymphocj'tosis  and  rapid  coagidation;  amenorrhea;  scanty 
urine  with  Httle  urea  and  low  specific  gra\'ityj  sometimes  albuminuria 
and  less  often  glycosuria;  hemorrhages,  especially  from  the  uterus; 
and  subnormal  temperatiu-e.  The  thymus  is  usually  enlarged,  sometimes 
the  hj-pophysis  and  adrenals. 

Course. — The  course  is  chronically  progressive  and  covers  ten  to  twenty 
years.  Remissions  may  occur  in  warm  weather,  by  a  change  to  a  milder 
climate  or  during  pregnancy.  In  the  last  stage,  the  m\-xedema  often  dis- 
appears. Transient  cases  of  acute  mA'xedema  have  been  observed.  Osier 
reported  an  acute  case  with  melena,  mania,  glycosuria,  tachycardia  and 
death  in  six  months.  Sudden  death  is  occasional,  but  most  patients  die 
of  intercurrent  tuberculosis  or  acute  infections. 


CACHEXIA   THYREOPRIVA    OR   OPERATFTE   MYXEDEMA. 

Horsley  reported  m\'xedema,  apathy  and  coma  in  monkey's  after 
complete  thyroidectomy;  when  kept  warm  the  monkeys  did  not  mani- 
fest m^'xedema,  but  a  species  of  cretinism.  Cachexia  follows  extirpjation 
in  man  and  herbivora;  con\Tilsions  develop  in  carnivora,  since  the 
antitoxic  elements  of  the  th^Toid  are  not  present  to  neutralize  the  nuclein 
of  ingested  meat.  The  toxemia  strumipriva  is  accompanied  by  anemia, 
leukocytosis  and  degeneration  in  the  bloodvessels.  Kocher  and  Reverdin 
observed  cachexia  strumipriva  in  70  per  cent,  of  cases,  more  often  after 
the  complete  than  after  the  partial  operation,  and  von  Eiselsberg  reported 
it  in  about  23  per  cent,  of  complete  excisions.  Accessory  th\Toids  (r. 
Goitre j  may  avert  this  operative  complication.  The  author  knows  of 
two  instances  in  which  removal  of  an  accessory  lingual  thyroid  (under 
a  mistaken  diagnosis)  caused  mjrxedema.  Schiff,  von  Eiselsberg,  and 
Bircher  cured  operative  m^-xedema  by  transplantation  of  a  th\Toid. 
Unfortunately,  the  function  of  the  transplanted  gland  is  seldom  main- 
tained. 

Treatment  of  Myxedema,  Cretinism  and  Cachexia  Thyreopriva. — 
For  these  allied   conditions  we  possess  in  th\Toid  extract    rGlandulfe 


TETANY  715 

tliyroidepe  siccse)  one  of  the  few  actual  specifics  of  medicine;  and  most 
cases  can  be  cured — in  a  sense  we  seldom  employ  this  term.  jNIurray 
first  used  thyroid  extract  hypodermically  and  his  first  case  is  alive, 
after  twenty-fi\'e  years;  the  equalh'  successful  administration  by  mouth 
was  advocated  by  Horwitz,  Mackenzie  and  E.  L.  Fox.  The  powdered 
extract  should  be  prepared  from  the  glands  of  young  sheep,  for  the  thy- 
roid atrophies  in  older  animals.  Beginning  with  gr.  ij,  t.  i.  d.,  the  dose 
may  be  increased  to  gr.  v.  In  a  short  time  the  evidences  of  increased 
metabolism  appear,  as  loss  of  weight,  increased  diuresis,  increased  urea 
and  elevation  of  bodily  temperature;  normal  growth  is  stimulated, 
myxedema  and  cretinism  disappear,  the  pulse  becomes  full  and  lively, 
the  skin  moistens  and  regains  its  lustre  and  in  every  regard  the  results 
are  magical.  In  some  instances  toxic  eft'ects  (hyperthyroidism)  are 
apparent,  as  tachycardia,  nervousness,  delirium,  dyspnea,  palpitation, 
flushing,  sweating,  tremor,  less  often  tonic  spasms,  severe  pains  and 
rarely  exophthalmos,  softening  of  the  bones,  or  even  death;  these  symp- 
toms are  seemingly  more  frequent  in  myocarditic  and  arteriosclerotic 
subjects;  arsenic  lessens  the  liability  of  hyperthyroidism,  which  after 
all  is  an  infrequent  result.  Larger  doses  may  be  given  in  winter  than  in 
summer.  At  first  large  doses  are  indicated  and  later,  after  relief  is  ob- 
tained, smaller  doses  should  be  given,  averaging  gr.  j  or  whatever  size 
experience  in  the  individual  case  may  determine.  Relapses  are  common 
after  withdrawal  of  the  extract  and  in  most  cases  it  becomes  rather  a 
food  than  medication.  Change  of  climate,  warm  baths  and  milk  or  a 
salt-free  diet  are  of  decided  benefit. 


DISEASES  OF  THE  PARATHYEOID  GLANDS. 

TETANY. 

Definition. — Tetany,  first  described  by  Steinheim  (1830)  and  Dance 
(1831)  and  named  by  Corvisart  (1852)  consists  chiefly  of  (a)  peculiar 
tonic,  intermittent,  bilateral,  painful  spasms,  mostly  in  the  extremities, 
without  involvement  of  the  sensorium  and  (b)  increased  mechanical  and 
electrical  excitability  of  the  nerves.  The  only  known  diseases  of  the 
parathyroids  are  hemorrhage,  tuberculosis  and  surgical  ablation.  The 
parathyroid  hormone  normally  restrains  the  excitability  of  the  ganglion 
cells,  possibly  by  promoting  calcium  assimilation;  it  antagonizes  the 
thyroid  gland. 

Etiology. — (a)  Tetany  occurs  endemically ,  especially  in  Vienna,  Heidel- 
berg, Berlin  and  Syria,  and  during  March  and  April.  It  is  rare  in  America 
(115  cases,  Howard),  England  and  Italy;  though  once  frequent  (1830- 
1860),  it  is  now  uncommon  in  Paris.  In  the  Vienna  outbreaks  46  per 
cent,  of  cases  occurred  in  shoemakers  and  24  per  cent,  in  tailors;  83 
per  cent,  occur  between  sixteen  and  twenty-five  years  of  age.  It  may 
develop  in  an  entire  family,     {h)   Digestive  affeeii(j)is  may  produce  it,  as 


716  DISEASES  OF   THE  PARATHYROID  GLANDS 

dilatation  (Kiissmaul,  1871),  ulcer  or  cancer  of  the  stomach  or  duodenum, 
often  with  pyloric  obstruction;  auto-intoxication  plus  parathyroid 
insufficiency  affects  the  nerve  cells.  Only  80  cases  of  gastric  tetany  are 
on  record,  (c)  Rickets  is  causal  in  90  to  96  per  cent.  (Cassel)  of  the 
infantile  types;  Heubner  classifies  them  as  spasmophilia,  tetany,  laryngo- 
spasm  and  infantile  convulsions,  (d)  Tetania  parathyreopriva  is  a  type 
which  follows  thyroid  operations.  Gley  (1831)  was  the  first  to  connect 
tetany  with  extirpation  of  the  parathyroid  glands,  first  specifically  described 
by  Sandstrom  (1880).  Vassali  and  Generali  maintained  that  absence  or 
ablation  of  the  parathyroid  glands  causes  tetany  (without  cachexia). 
Thyroidectomy  should  be  carefully  done  in  order  to  spare  the  para- 
thyroids located  alongside  the  lateral  lobes,  (e)  Tetany  occurs  also  in  the 
acute  infections,  sepsis,  nephritis,  intoxications  with  ergot,  morphine  or 
lead.  There  are  recorded  only  32  cases  of  the  puerperal  form.  Of  the 
6  cases  which  the  author  has  seen  in  this  country  2  occurred  with  florid, 
secondary  syphilis,  1  after  an  adenoid  operation  and  3  with  gartrectasis. 
It  may  develop  with  other  nervous  diseases.  In  a  few  cases  there  has 
been  cloudiness  with  swelling  of  the  anterior  horns. 

Symptoms. — 1.  Muscular  Contracture. — The  earliest  and  chief 
symptom  is  the  muscular  contracture,  which  usually  commences  in  the 
hand,  with  stiffness,  numbness  and  pain,  and  culminates  in  a  tonic, 
symmetrical,  painful  contracture.  The  muscles  of  the  hand  are  hard; 
the  attitude  is  that  of  the  accoucheur's  hand,  the  hand  in  writing  or  that 
observed  in  paralysis  agitans;  it  is  produced  by  contraction  of  the 
ulnar  flexors;  less  often  it  resembles  the  clenched  hand  of  old  hemi- 
plegic  contracture,  and  the  nails  even  enter  the  palm;  rarely  the  fingers 
are  tonically  spread  apart.  Except  in  light  forms,  the  spasm  cannot 
be  overcome  by  force.  The  foot  is  affected  less  often  than  the  hand  and 
the  spasm  draws  the  foot  into  the  equinovarus  position,  with  the  toes 
fiexed  and  the  sole  hollow.  The  spasm  is  usually  limited  to  these  parts, 
lasts  from  minutes  to  hours  or  even  days,  disappears  and  then  recurs. 
In  rarer  and  more  severe  cases  the  parts  above  the  elbows  and  knees 
may  participate,  with  adduction  of  the  arms  and  thighs,  cramping  of 
the  face  (risus  sardonicus  and  trismus),  neck,  chest,  tongue,  diaphragm 
and  ocular  muscles,  with  diplopia,  spasticity  of  the  sphincters,  dysuria,  etc. 

liaryngismus  stridulus  (Clark,  1815)  is  common  in  infantile  rickets, 
in  which  clonic  contractures  also  occur.  Pineles  describes  laryngospasm 
following  parathyroid  extirpation. 

2.  Trousseau's  Sign. — This  consists  in  producing  the  spasm  by 
pressure  over  the  nerves,  for  example,  just  above  the  elbow  or  over  the 
peroneal  nerve,  for  a  few  seconds  or  minutes.  It  is  patJiognomonic. 
Schlesinger's  sign;  pressure  on  the  sciatic  nerve  or  flexion  of  the  thigh 
with  extension  of  the  knee  elicits  a  talipes  equinovarus. 

3.  Erb's  Sign. — There  is  increased  electrical  irritability  of  the  motor 
nerves  to  the  galvanic  current  with  early  anodal  closing  and  cathodal 
opening  tetanus.  Anodal  opening  tetanus  is  found  in  this  disease  alone. 
There  is  also  increased  electrical  irritability  of  the  sensory  nerves  (Hoff- 
mann) and  of  the  nerves  of  special  sense  (Chvostek,  Jr.),  to  faradic  and 
galvanic  currents. 


TETANY  717 

4.  Chvostek's  Sign. — Increased  mechanical  irritahility  of  the  motor 
nerves  is  observed  on  tapping  or  pressing  on  the  facial,  median,  uhiar 
or  other  nerves,  which  produces  contraction  of  the  muscles  supplied  by 
them.  It  is  quite  constant  but  may  be  absent  in  children  and  is  not 
pathognomonic,  having  been  found  in  normal  persons,  bulbar  paralysis, 
neuroses  and  facial  paralysis.  The  muscles  themselves  are  not  over- 
excitable. 

5.  Other  Symptoms. — The  sensorium  is  usually  clear,  except  in  rare 
cases  with  pyloric  stenosis.  The  special  senses  and  reflexes  are  normal; 
optic  neuritis  is  extremely  rare.  Headache  and  malaise  are  frequent. 
In  contrast  to  the  pain  and  paresthesia,  objective  sensory  findings  are 
absent.  In  rare  cases  epileptiform  seizures  are  seen.  The  temperature 
is  elevated  in  15  per  cent,  of  cases.  In  rare  cases,  there  may  be  dis- 
turbances of  the  intermediary  metabolism  of  albumin;  hypothyroidism, 
trophic,  vasomotor  and  secretory  disturbances  may  occur,  as  edema, 
polyuria,  glycosuria  or  falling  out  of  the  hair  (visceral  tetany). 

Diagnosis. — The  diagnosis  in  typical  cases  is  most  easy  from  the 
cardinal  signs — the  peculiar  spasms.  Trousseau's,  Erb's  and  Chvostek's 
signs.  In  epilepsy  these  signs  are  absent  and  the  aura,  the  cry,  falling, 
tonic  and  clonic  convulsions,  biting  of  tongue  and  involuntary  urina- 
tion are  characteristic.  Hysteria  mimics  everything,  but  the  cardinal 
symptoms,  except  the  spasms,  cannot  be  reproduced;  certain  reported 
epidemics  of  tetany,  as  at  Gentilly,  were  clearly  hysterical.  The  other 
cardinal  signs  easily  separate  tetany  from  the  occupation  neuroses  and 
acroparesthesia  {v.  i.) ;  meningitis  and  brain  tumor  are  distinguished  on 
careful  examination. 

Prognosis. — Death  may  occur  from  dilated  stomach  or  laryngospasm. 
Frankl-Hochwart  concludes  that  the  prognosis  is  worse  than  is  usually 
stated;  20  per  cent,  of  his  cases  died,  20  remained  well  and  the  balance 
had  recurrences  and  serious  disabilities. 

Treatment. — The  treatment  varies  with  the  cause,  (a)  Rest  and  quiet 
are  indicated  on  general  principles,  although  tetany  is  little  influenced 
by  excitement.  Massage,  strychnine  and  electricity  should  be  avoided. 
Change  of  occupation  and  location  is  advisable  in  the  endemic  form. 
(6)  In  the  digestive  form,  washing  out  the  stomach  and  bowels  may  induce 
severe  spasms.  These  cases  are  obstinate  and  the  spontaneous  mortality 
in  gastric  tetany  is  75  per  cent.;  with  operation  this  figure  is  reduced 
(see  page  507).  (c)  In  the  rhachitic  form,  carbohydrates,  phosphorus  and 
substitution  of  human  for  cow's  milk  are  efficient.  Inhalations  of  chloro- 
form in  some  cases  irritate  the  sensitive  larynx,  (d)  In  tetania  parathy- 
reopriva  the  mortality  is  80  per  cent.;  parathyroid  grafting  or  feeding 
is  helpful,  {e)  Cases  following  acvte  infections  usually  run  a  spontaneously 
short  course;  those  in  pregnancy  rarely  indicate  abortion;  in  nursing 
women,  weaning  gives  prompt  relief;  for  intoxications  there  are  obvious 
indications.  Drugs  are  of  little  value  except  calcium  salts,  gr.  xv;  chloral 
influences  the  motor  nerves,  but  is  inferior  to  the  bromides,  as  is  also 
morphine. 


718  DISEASES  OF  THE  THYMUS  GLAND 


DISEASES  OF  THE  THYMUS  GLAND. 

The  thymic  functions  are  unknown.  It  is  thought  that  the  thymus  is 
concerned  in  neutrahzing  infection,  and  in  certain  vegetative  functions,  as 
the  growth  of  bone.  There  is  an  intimate,  though  obscure,  relation 
between  the  thymus,  thyroid,  pituitary  body,  parathyroids,  testes, 
ovaries,  brain  and  bone-marrow.  The  thymus  wastes  as  the  testicles 
and  ovaries  develop.  Thymic  extract  causes  a  fall  in  blood-pressure, 
cardiac  acceleration  and,  in  large  doses,  fatal  collapse.  Some  class  it  as 
a  ductless  gland.  The  gland  is  epithelial  in  origin,  but  becomes  lymphoid 
in  structure.  Its  secretion  in  the  first  two  years  of  life  is  milky  and 
contains  iodine,  cells  and  a  molecular  substance.  It  weighs  12  gm.  at 
birth;    after  puberty  it  wastes. 

(a)  Hemorrhages  into  the  thymus  may  be  found  in  congenital  syphilis 
and  asphyxia  of  the  newborn,  (b)  Thymic  cysts  are  in  50  per  cent, 
merely  accentuation  of  the  normal  findings,  in  which  the  lymphoid  ele- 
ments overgrow  into  the  convolutions  of  the  gland,  (c)  Abscess  of  the 
thymus,  described  by  Dubois  (1850),  is  often  mistaken  for  softened 
gummata,  cysts  and  postmortem  softening,  (d)  The  most  frequent 
tumors  are  sarcoma  and  lymphosarcoma.  Less  frequent  are  dermoids 
and  granulomata.  (e)  Persistence  of  the  gland  after  puberty  is  described; 
the  term  is  ill-chosen,  as  the  gland  normally  persists  into  adult  life.  (/) 
Some  cases  of  "persistent  thymus"  are  hypertrophy  or  hyperplasia,  which 
is  the  most  common  thymic  lesion.  Microscopically,  we  find  lymphoid 
hyperplasia,  Hassal's  concentric  epithelial  corpuscles,  eosinophiles  and 
even  myelocytes.  ^  (i)  Physical  signs.  Dulness  of  more  than  1  cm.  to 
each  side  of  the  sternum  is  pathological;  it  is  greater  to  the  left  and 
shifts  on  retraction  of  the  head.  The  gland  may  be  palpated  in  the 
jugulum  or  seen  by  the  fluoroscope  like  a  cap  on  the  heart.  The  gland 
may  weigh  150  gm.  (ii)  Plater  (1614)  associated  enlargement  of  the 
thymus  with  sudden  death.  Grawitz  and  Jacobi  described  thymic  hyper- 
plasia which  caused  sudden  dyspnea,  usually  in  infants,  followed  by  early 
death;  the  gland  presses  on  the  vagus,  cava  or  trachea  or  causes  laryngo- 
spasm.  These  cases  are  thought  to  be  lymphatism  (v.  i.).  (iii)  In  thymic 
asthma  (Kopp,  1830),  also  known  as  Millar's  asthma,  the  stridor,  caused 
by  thymic  compression  of  the  trachea,  is  pronounced,  progressive  and 
usually  fatal  from  asphyxia.  The  enlarged  gland  may  actually  flatten 
the  trachea  (Summa  and  Benecke),  as  the  distance  between  the  sternum 
and  spine  is  but  little  more  than  an  inch  and  compression  in  this  region 
is  critical.  It  may  be  seen  by  bronchoscopy.  In  48  operations,  about 
two-thirds  recovered  (Veau  and  Olivier),  (iv)  Hyperplasia  is  frequently 
found  in  Graves's  disease,  status  lymphaticus,  myxedema,  syphilis, 
acromegaly,  epilepsy,  myasthenia  gravis  and  atrophy  of  the  splenic, 
lymphatic  or  myeloid  structures.  Besides  operation,  the  .r-rays  are 
excellent. 


DISEASES  OF   THE  HYPOPHYSIS  719 

LYMPHATISM    (STATUS   LYMPHATICUS). 

The  constitutio  lymphatica  or  status  thymicus  is  a  condition  in  which 
there  is  hyperplasia  of  the  various  lymphoid  and  kindred  tissues  and  a 
tendency  to  sudden  death. 

The  affection  is  rare  and  occurs  most  often  in  women  and  children. 
Felix  Plates  (1614)  observed  it  as  a  familial  affection. 

Symptoms. — I.  There  is  lymphoid  hyperplasia.  The  lymph  glands  of 
the  chest  and  abdomen  are  more  often  involved  than  the  external  glands. 
The  tonsils,  nasopharyngeal,  lingual  and  intestinal  lymphadenoid  tissues 
are  frequently  hyperplastic.  Moderate  splenic  enlargement  is  usual,  the 
thymus  is  swollen  and  the  hone-marrow  often  reddish.  Leukopenia, 
lymphocytosis  and  eosinophilia  may  be  found. 

II.  Associated  findings  may  include  thyroid  enlargement,  tetany  and 
laryngismus.  Siess  and  Stoerk  give  the  following  symptomatology:  (1) 
Atypical  arrangement  of  the  hair;  (2)  abnormal  length  of  the  extremities; 
(3)  scaphoid  scapulae;  (4)  a  wide  pelvis  in  males,  narrow  in  women;  (5) 
adiposity  of  the  reverse  type,  in  the  lower  half  of  the  body  in  males, 
upper  half  in  females;  (6)  poor  development  of  the  breasts;  (7)  general 
glandular  hyperplasia;  (8)  small  but  elongated  heart  associated  with  a 
strong  apex-beat  and  an  accentuated  aortic  second  sound;  (9)  low 
blood-pressure;  (10)  psychoneurotic  manifestations;  (11)  vagotonia;  (12) 
infantile  type  of  epiglottis. 

III.  Sudden  death  is  often  the  first  evidence  of  the  condition  and  may 
occur  without  seemingly  adequate  cause.  It  has  occurred  during  or 
after  anesthesia,  especially  with  chloroform.  In  one  case  a  patient  with 
enlarged  glands  died  suddenly  after  receiving  but  20  drops  of  chloroform. 
Operations  with  local  anesthesia  have  also  been  fatal.  Administration 
of  antitoxin  has  caused  death,  as  in  the  well-known  case  in  Professor 
Langerhans's  family.  It  may  occur  while  bathing  or  after  falling  in  the 
water.  Sudden  deaths  during  convalescence  from  acute  infectiojis  or 
some  collapses  during  hydrotherapeutic  treatment  may  be  attributed  to 
the  lymphatic  constitution  (Escherich).  Children  with  eczema  may  die 
suddenly;  lymphatism  causes  75  per  cent,  of  these  deaths.  It  is  said  to 
be  due  to  cardiac  excitability  (Kundrat),  to  lessened  physiological 
resistance  with  a  tendency  to  cardiac  paralysis  (Paltauf),  respiratory 
paralysis  (Meltzer)  or  lymphotoxism  (Blumer). 

The  .T-rays  may  induce  regression  in  the  hyperplastic  tissues. 


DISEASES  OF  THE  HYPOPHYSIS. 

The  pituitary  body  consists  of  two  lobes;  the  anterior,  the  larger,  is  of 
epithelial  buccal  origin  and  probably  discharges  its  hormone  into  the 
blood,  influencing  growth  and  sexual  development;  the  smaller  posterior 
lobe,  partly  of  epithelial  and  partly  of  nervous  origin,  seemingly  empties 
its    secretion    into    the    cerebrospinal    fluid,    increasing    blood-pressure 


720  DISEASES  OF   THE  HYPOPHYSIS 

(pituitarin)  and  influencing  diuresis  and  carbohydrate  and  fat  metab- 
olism. 

Hyperpituitarism,  analogous  to  Graves's  disease^as  in  hypophyseal 
tumors  or  hyperplasia — is  an  overfunctioning,  perhaps  due  to  chromo- 
phile  activity.  In  early  life,  before  the  epiphyses  ossify,  gigantism  results ; 
if  later,  acromegaly.  Emaciation,  vascular  degeneration,  calcium  reten- 
tion, thyroid  activity  (stimulated  by  the  anterior  lobe)  or  adrenal  stimu- 
lation (from  posterior  lobe)  and  lowering  of  the  assimilation  limit  of 
carbohydrates  may  be  observed. 

Hypopituitarism  or  deficient  internal  secretion  is  analogous  to  myx- 
edema; when  it  operates  in  life,  it  induces  dwarfism  or  infantilism,  obesity, 
hypoplastic  sexual  organs  and  secondary  sexual  characters  (Frohlich's 
type),  diabetes  insipidus  and  great  tolerance  of  carbohydrates;  deficient 
secretion  in  later  life  induces  reversive  sexual  infantilism;  often  there 
are  dry  skin,  subnormal  temperature  and  pulse,  and  drowsiness. 

Dyspituitarism  combines  the  above  types,  to  some  degree,  just  as 
symptoms  of  Graves's  disease  and  myxedema  may  occur  simultaneously 
or  successively. 

ACROMEGALY. 

Acromegaly  (large  extremities)  described  by  Marie  (1886),  is  a  dys- 
trophy marked  clinically  by  overgrowth  of  the  bones,  tissues  of  the 
face,  hands  and  feet  and  by  other  symptoms  of  hyperpituitarism. 

Etiology. — In  1902,  Woods-Hutchinson  collected  262  cases ;  in  77  autop- 
sies the  hypophysis  was  obviously  diseased  in  73.  The  process  may  be 
hyperplasia  or  adenoma,  less  commonly  sarcoma,  colloid  degeneration, 
fibrosis,  softening  or  hemorrhage.  Benda  holds  that  acromegaly  is  due 
to  excessive  activity  of  the  chromophile  cells  in  the  anterior  lobe.  Ac- 
cording to  Sternberg,  the  sexes  are  about  equally  affected,  and  in  50  per 
cent,  the  affection  begins  between  twenty  and  thirty,  in  75  per  cent, 
between  twenty  and  forty  and  in  14  per  cent,  under  twenty  years  of  age. 

Symptoms. — 1.  Acromegaly. — Enlargement  of  the  extremities  is 
usually  the  first  clear  symptom,  but  is  preceded  by  paresthesise  and 
pains  in  the  extremities,  often  extreme  and  due  to  expansion,  (a)  A 
remarkable  change  occurs  in  the  face;  the  superciliary  ridges  protrude, 
the  maxillae  enlarge  and  the  nose,  ears,  lips,  tongue  and  chin  attain  mas- 
sive proportions.  The  general  contour  of  the  face  is  hexagonal.  The 
teeth  separate  and  the  tongue  sometimes  protrudes  beyond  them.  The 
eyes  by  contrast  appear  small.  Pathologically,  the  change  in  the  bone 
is  simple  hypertrophy,  with  increase  in  the  vascular  furrows,  widening 
of  some  foramina  (with  narrowing  of  others),  some  roughening 
and  localized  protuberances  which  are  not  osteophytes;  the  skull  is 
thicker  and  larger,  especially  the  sphenoid,  superciliary  ridges,  mastoid 
and  occipital  protuberances;  the  orbit  may  be  narrowed  by  ethmoid 
bulging  and  the  sinuses  and  sella  turcica  are  increased  as  shown  by  the 
.T-rays.  {h)  The  hands  and  feet  are  greatly  but  symmetrically  hyper- 
trophied.  The  fingers  and  toes  show  either  the  long  or  the  thick  type; 
they  are  square  at  their  ends — the  "spade-like  fingers."  The  palms  and 
soles  become  flattened.    The  .r-rays  show  simple  hypertrophy  of  the  peri- 


ACROMEGALY  ^  721 

osteal,  subperiosteal  and  soft  tissues;  in  some  cases  the  soft  parts  are 
more  hyperplastic  than  the  bones.  A  common  statement  in  the  history 
is  that  the  patient  "must  each  year  buy  larger-sized  hats,  gloves  or  shoes." 
The  nails  are  thin  and  small.  The  antithesis  of  acromegaly  is  micro- 
melia.  (c)  The  changes  in  the  trunk  are  less  conspicuous.  The  sternum 
is  increased  anteroposteriorly  and  the  ribs  and  clavicles  are  thickened. 
The  anteroposterior  diameter  of  the  thorax  is  increased,  the  head  is 
held  backward  and  the  dorsal  kyphosis  is  rather  characteristic.  The 
muscular  weakness  and  lean  arms  and  legs  contrast  sharply  with  the  first 
impression  of  strength  imparted  by  the  massive  face  and  extremities. 
The  breathing  is  largely  abdominal,  (d)  The  skin  is  hyperplastic  and  also 
the  mucous  membrane  of  the  nose,  tongue,  pharynx  and  larynx.  The 
enlarged  larynx  may  explain  the  deep,  rough,  monotonous  voice.  Hyper- 
trichosis is  common. 

2.  Nervous  Manifestations. — (a)  Symptoms  of  brain  tumor  (hypo- 
physis) are  common,  as  headache,  vertigo,  mental  alteration,  vomiting, 
periodic  loss  of  consciousness  and  eye  symptoms  in  52.5  per  cent.,  hemi- 
anopsia, optic  atrophy  (40  per  cent.),  paralysis,  anosmia,  auditory  disturb- 
ance and  exophthalmos,  (b)  Changes  in  character,  anxiety,  apathy  and 
insomnia  which  deepens  into  terminal  somnolence,  are  common;  severe 
pains,  paresthesia,  acroparesthesia  and  subjective  warmth  are  frequent. 

3.  Constitutional  Symptoms. — (a)  Glycosuria  occurs  in  40  per  cent. 
Sometimes  polyuria  occurs  without  glycosuria,  (b)  Profuse  sweats  are 
common,  even  with  glycosuria;  the  skin  is  sometimes  pigmented;  obesity 
is  common,  (c)  Sexual  disturbance  is  the  rule,  as  amenorrhea  often 
preceded  by  dysmenorrhea;  in  men  impotence  is  not  unusual;  the 
external  genitalia  are  often  hypertrophied,  the  internal  infantile,  (d) 
The  heart  is  often  dilated  and  hypertrophied  from  the  concomitant  arterio- 
sclerosis, deformed  chest  and  rarely  from  actual  overgrowth  (cardio- 
megaly).  The  vessels  are  wide  and  thick.  Splanchnomegaly  may  be 
observed  (intestines,  tonsils,  spleen,  thymus  and  thyroid).  In  most  cases 
the  lymph  nodes,  particularly  the  cervical,  are  palpably  enlarged. 

Course  and  Prognosis. — (a)  Acromegalic  subjects  seek  advice  for  the 
enlargement  of  the  extremities  or  tonsils,  sweats,  pain,  eye  symptoms 
or  polyuria;  (6)  remissions  are  common,  the  constitutional  symptoms 
and,  to  a  slight  extent,  the  enlargements  subside;  on  the  other  hand,  a 
fitful  advance  may  be  noted,  (c)  The  average  course  is  chronic,  covering 
ten  to  twenty  years,  though  relatively  benign  cases  occur,  lasting  thirty 
or  even  fifty  years,  and  acute  malignant  cases  are  known,  which  are  due 
to  malignant  adenomata,  (d)  Death  is  inevitable;  it  may  result  sud- 
denly or  from  gradual  marasmus,  diabetic  coma,  intercurrent  infection, 
cardiac  insufficiency  or  pyelonephritis. 

Diagnosis. — Charcot  held  that  physicians  in  general  see  and  diagnos- 
ticate only  what  they  have  seen  and  learned  to  diagnosticate;  the 
diagnosis  is  made  at  a  glance  by  one  who  has  seen  a  single  case;  undue 
regard  to  a  single  symptom,  as  the  skin  changes,  amenorrhea  or  glyco- 
suria, may  cause  error. 

Differentiation. — 1.  In  the  cranium  p)rogenium,  the  hyperplastic 
lower  jaw  protrudes  and  its  teeth  are  directed  forward;  the  upper  jaw 
46 


722  DISEASES  OF  THE  HYPOPHYSIS 

is  hypoplastic;    it  may  occur  in  acromegaly,  cretinism,  healthy  individ- 
uals, degeneracy  and  idiocy. 

2.  Gigantism  occurs  in  over  20  per  cent,  of  acromegaly,  particularly 
when  acromegaly  develops  early  in  life.  Forty  per  cent,  of  giants  are 
acromegalic  (Sternberg).  Gigantism  implies  symmetry  of  overgrowth; 
there  are  normal  "giants"  and  giants  with  acromegaly,  leontiasis  (v.  i.), 
facial  hemihypertrophy,  etc. 

3.  Diffuse  hyperostosis  (Starr,  Putnam,  Prince)  occurs  in  the  young, 
involves  all  the  skull  bones,  but  seldom  the  extremities  or  spine;  exoph- 
thalmos, blindness,  deafness,  bilateral  facial  palsy,  dysphagia,  dyspnea 
and  other  basilar  symptoms  are  noted,  which  culminate  fatally  in  stupor, 
idiocy,  epileptiform  convulsions  and  paralysis  of  the  extremities.  A 
subtype  (leontiasis  ossea,  Dana)  occurs  in  the  form  of  tumor-like 
protuberances  on  the  skull  and  other  bones.  Prince  (1902)  collected  20 
cases  from  the  literature.  He  maintains  that  it  is  a  form  of  osteitis 
deformans. 

4.  Osteitis  deformans  (Paget's  disease)  is  a  combined  rarefying  and 
hypertrophic  osteitis.  It  begins  slowly  in  subjects  over  forty  years  old, 
with  pains  and  deformity  of  the  thighs,  legs  and  spine;  the  legs  bow 
widely  outward  and  somewhat  forward,  the  cervical  and  upper  dorsal 
spine  becomes  kyphotic,  the  thorax  narrows  transversely  and  widens 
anteroposteriorly,  the  abdomen  is  diamond-shaped  and  crossed  by  a  sul- 
cus and  the  head  hangs  forward.  The  soft  parts  do  not  hypertrophy  as 
in  acromegaly,  the  face  is  rarely  involved,  the  head  is  larger  above  than 
below  and  the  arms  are  little  altered.  Clopton  (1906)  found  75  cases  on 
record. 

5.  Hypertrophic  osteo-arthropathy,  known  since  the  time  of  Hippoc- 
rates, was  especially  described  by  Bamberger  and  Marie,  in  1889.  The 
ends  of  the  fingers  and  perhaps  the  toes  become  clubbed  or  "drumstick" 
in  appearance.  While  the  nails  are  thin  and  small  in  acromegaly,  in 
hypertrophic  osteo-arthropathy  they  are  large,  thick,  wide  and  curved 
downward.  The  alteration  typically  involves  the  terminal  phalanges, 
but  also  in  severe  cases  the  ends  of  the  ulna,  radius,  tibia  and  fibula. 
The  pathology  is  a  toxemic,  chronic  periostitis,  with  hypertrophy  and 
osteophytic  growth.  The  most  common  cause  is  chronic  lung  disease 
(chronic  phthisis,  bronchiectasis,  emphysema  or  fibrosis),  whence  Marie's 
name  of  osteo-arthropathie  hypertrophiante  pneumonique;  it  may  develop 
in  congenital  heart  disease,  aneurysm  or,  less  frequently,  in  hepatic 
cirrhosis,  gastric  dilatation,  syphilis,  cystitis  or  various  other  infections. 

Treatment. — The  treatment  of  acromegaly  is  symptomatic.  Extract 
of  the  hypophysis  has  been  given  and  in  a  few  cases  with  temporary 
success.    Operation  seldom  helps. 

INFANTILISM. 

The  persistence  beyond  puberty  of  the  physical  and  mental  characters 
of  childhood. 

I.  The  Frbhlich  Type,  dystrophia  adiposogenitalis,  is  hypopituitarism 
— obesity,  persistence  of,  or  reversion  to,  the  secondary  sexual  characters 


INFANTILISM  723 

of  childhood,  hypotrichosis,  poor  mammary  or  testicular  development, 
gracile  figure,  lack  of  the  masculine  voice  and  hypoplasia  of  the  sexual 
organs. 

II.  The  Brissaud  type,  referable  to  hypopituitarism  (or  hypothyroidism, 
Brissaud),  presents  a  "round  face,  lips  projecting  and  plump,  small  nose, 
smooth  face,  clear  skin,  fine  hair,  eyebrows  and  eyelashes  scant,  eyes 
prominent,  large,  round  cheeks,  infantile  face  and  head,  skeleton  under- 
developed, neck  short  and  chubby,  body  long  and  cylindrical,  abdomen 
prominent,  limbs,  round  and  large,  a  layer  of  fat  over  the  whole  body, 
infantile  pelvis,  lumbar  lordosis,  rudimentary  sexual  organs,  no  hair 
except  on  head,  high-pitched  voice,  thyroid  small,  mind  slow,  retarda- 
tion of  ossification,  and  absence  or  retardation  of  second  dentition." 

ni.  The  Lorain  type  is  as  follows:  "Small  stature,  delicately  formed, 
slender  skeleton,  skin  soft  and  pale,  large  shoulders,  lower  extremities 
long  and  slender,  trunk  relatively  small,  infantile  sternum  and  pelvis, 
epiphyses  normally  united,  no  fat  increase,  abdomen  normal,  finely 
chiselled  face,  voice  high,  neck  long,  genital  atrophy,  absence  of  or 
slight  secondary  sexual  characteristics." 

IV.  Herter's  Intestinal  Infantilism. — -The  child  stops  growing  as  it  stops 
gaining  in  weight;  the  mental  development  is  fair.  Marked  abdo- 
minal distention  is  common,  often  with  dilatation  of  the  abdominal 
veins.  There  is  a  moderate  anemia,  a  very  characteristic  fatigue, 
looseness  of  the  bowels  with  occasional  attacks  of  diarrhea,  often 
with  fatty  stools,  an  excessive  appetite  and  thirst,  an  increased 
secretion  of  urine,  and  cold  hands  and  feet.  There  is  an  absence  of  the 
ordinary  intestinal  flora  of  the  intestines  of  young  children.  The  pre- 
vailing organisms  are  the  Bacillus  bifidus.  Bacillus  acidophilus  and 
Bacillus  infantilis.  There  is  a  rise  in  the  ethereal  sulphates,  indican, 
phenol  and  aromatic  oxyacids. 

V.  Other  types  include  malnutrition,  myxedema,  lues,  congenital  heart 
lesions,  etc.  Gilford  describes  micromegaly,  ateliosis  (continuous  youth 
and  premature  old  age),  or  progeria.  A  pancreatic  form,  due  to  deficient 
pancreatic  secretion,  is  associated  with  recurring  severe  diarrhea  in 
children. 


SECTION  VIII. 

CONSTITUTIONAL  DISEASES, 


DIABETES    MELLITUS. 

Definition. — A  disease  of  metabolism  characterized  (a)  by  a  permanent 
lessened  capacity  of  the  organs  fixing,  storing  and  consuming  (jrape-siigar; 
(b)  by  excess  of  sugar  in  the  blood  (hyperglycemia),  resulting  in  (c)  grape- 
sugar  in  the  lU'ine  (glycosuria);  (d)  acid-intoxication;  and  (e)  causal 
changes  in  the  pancreas. 

Willis  (1674)  differentiated  between  diabetes  mellitus  and  diabetes 
insipidus  and  Dobson  (1776),  of  Liverpool,  fully  described  the  symptoms; 
Aretseus  (150  a.d.)  used  the  term  diabetes. 

The  liver,  the  reservoir  for  carbohydrates,  contains  up  to  14  per  cent, 
glycogen.  It  collects  carbohydrates  from  the  portal  vein,  stores  them 
as  glycogen  and  again  imparts  them  to  the  blood  as  grape-sugar,  for  use 
in  the  tissues.  The  muscles  also  manufacture  glycogen  from  the  grape- 
sugar  of  the  blood.  Glycogen  may  also  be  produced  from  the  albumins 
and  possibly  from  fats.  When  there  is  a  temporary  carbohydrate  short- 
age, the  reserve  store  of  glycogen  is  drawn  upon.  Fat  is  converted  in  the 
liver  into  sugar  when  neither  the  carbohydrates  nor  the  albumins  suffice 
to  maintain  the  normal  proportion  of  sugar  in  the  blood.  The  fate  of 
carboh}'drates  when  ingested  in  excess  is:  (a)  glycogen  storage  (up  to 
400  gm.);  (h)  conversion  into  fat;  (c)  glycosuria  from  hyperglycemia, 
when  sugar  in  the  blood  exceeds  0.2  per  cent.;  this  ''alimentary  glyco- 
suria" is  physiological  and  occurs  when  the  blood-sugar  exceeds  the 
assimilation  limit.  Alimentary  glycosuria  is  tested  by  giving  100  gm. 
of  grape-sugar,  after  a  light  breakfast  of  bread  and  coffee.  If  more  than 
1  per  cent,  of  sugar  appears  in  the  urine  or  if  2  or  3  per  cent,  of  the  entire 
amount  administered  is  found,  it  indicates  diabetes  rather  than  glycosuria. 
Most  absorbed  sugar  goes  to  the  liver,  but  some  absorbed  by  the  l^^m- 
phatics  appears  in  the  urine,  whence  its  presence  is  not  necessarily  a  sign 
of  diabetes;  in  liver  cirrhosis,  sugar  may  reach  the  blood  by  the  col- 
lateral circulation.  Traces  of  sugar  (0.01  to  0.02  per  cent.)  are  normally 
present  in  the  urine,  but  are  not  detected  by  the  usual  tests. 

Etiology. — 1.  The  pancreas  (q.  v.)  has  long  been  considered  an  etiolog- 
ical factor.  Opie  (1900)  discovered  atrophic  changes  in  the  cells  of  the 
islands  of  Langerhans  which  produce  an  internal  secretion,  regulating  or 
inhibiting  the  conversion  of  glycogen  into  sugar.  Weichelbaum  found 
"  Langerhans's  insufficiency"  in  all  of  183  cases,  as  hydropic  changes  in 


726  CONSTITUTIONAL  DISEASES 

younger  subjects  or  as  sclerotic,  atrophic  or  hyaline  changes,  in  arterio- 
sclerotic or  obese  cases.  This  internal  secretion  from  Langerhans's  islands 
is  wholly  distinct  from  the  external  secretion  of  the  pancreatic  juice  voided 
into  the  intestine,  (a)  Total  pancreatic  extirpation  in  animals  and  man 
produces  glycosuria;  (6)  after  partial  extirpation  and  suture  of  the 
remaining  portion  to  the  abdominal  wall,  diabetes  fails  to  appear,  but 
develops  if  this  portion  is  later  removed;  {c)  when  a  tenth  part  is  left, 
glycosuria  occurs  only  after  the  ingestion  of  carbohydrates;  (d)  sub- 
sequent destruction  of  the  remaining  portion  of  the  gland  produces  a 
severe  form;  (e)  when  more  than  one-tenth  of  the  functionating  gland  is 
left  behind  no  diabetes  ordinarily  results;  (/)  diabetes  does  not  occur 
in  simple  ligature  of  the  pancreatic  duct,  excluding  its  juice  from  the 
intestine,  nor  when  the  fluid  escapes  through  a  cutaneous  fistula,  whence 
the  argument  for  an  internal  secretion  (Minkowski  and  v.  Mehring); 
(g)  Cohnheim  suggests  that  a  pro-enzyme  secreted  by  the  pancreas,  joins 
another  ferment  secreted  by  the  muscles  and  that  the  united  ferments 
break  down  the  sugar  molecules  to  produce  heat  and  energy. 

2.  Other  Ductless  Glands. — The  adrenals  stimulate  the  conversion  of 
glycogen  into  sugar,  mobilizing  the  sugar,  and  antagonizing  the  pancreatic 
action;  adrenalin  injected  intramuscularly  causes  transient  glycosuria, 
acting  on  the  peripheral  sympathetic.  Adrenalectomy  is  followed  by 
hypoglycemia;  in  Addison's  disease  the  tolerance  for  sugar  is  high  and 
it  is  impossible  to  produce  adrenalin  glycosuria.  The  hypophysis  is 
antagonistic  to  the  pancreas  and  is  associated  with  adrenal  hyper- 
function  and  thyroid  hypofunction;  in  acromegaly  glycosuria  is  common; 
in  dystrophia  adiposogenitalis  high  carbohydrate  tolerance  is  noted. 
The  parathyroids  inhibit  thyroid  action;  after  parathyroidectomy  sugar 
tolerance  is  reduced  and  adrenalin  glycosuria  readily  effected.  The  thyroid 
antagonizes  pancreatic  activity,  but  stimulates  adrenal  activity.  After 
thyroidectomy  and  in  myxedema,  there  is  hyperf unction  of  the  pancreas; 
sugar  tolerance  increases  and  adrenalin  causes  no  glycosuria.  Thyroid 
feeding  and  Basedow's  disease  produce  glycosuria. 

3.  Neurogenous  diabetes  occurs  through  the  sympathetic  and  chromaf- 
fin systems,  controlling  the  various  ductless  glands.  Claude  Bernard's 
well-known  puncture  of  the  fourth  ventricle  (piqure  glycosuria,  1844), 
may  possibly  lessen  via,  the  sympathetic  the  power  of  the  liver  to  hold 
glycogen.  Apoplexy,  tabes,  brain  tumors,  multiple  sclerosis,  meningitis 
syphilis,  softening  of  the  brain,  diseases  of  the  cord,  vagus  and  sym- 
pathetic system  may  induce  glycosuria.  Hoffmann  distinguishes  between 
(a)  neurogenous  diabetes,  which  occurs  chiefly  in  men,  with  no  tendency  to 
furuncles,  carbuncles  or  cataract,  with  no  connection  with  gout,  and  is 
temporary;  and  (b)  diabetes  of  the  obese,  which  occurs  in  either  sex,  often 
produces  carbuncles,  is  often  connected  with  gout  and  is  very  chronic. 

4.  Obesity  embraces  cases  with  ordinary  diabetes,  obesity  without 
glycosuria  (masked  diabetes)  and  obesity  with  consecutive  glycosuria. 

5.  Gout,  arteriosclerosis,  liver  lesions  (cirrhosis)  and  possibly  acute 
infections  have  apparent  relations  with  diabetes.  Renal  diabetes  (glyco- 
suria without  excessive  sugar  in  the  blood)  may  develop  in  nephritis, 
renal  hemorrhage,  chyluria,  etc.    Lactosuria  may  occur  in  late  pregnancy, 


DIABETES  MELLITUS  727 

the  puerperiiim  and  nurslings;  von  Xoorden's  hypothesis  is  that  in  the 
"puerperal  state  the  capacity  of  the  tissues  for  breaking  up  milk-sugar 
is  diminished,  an  instance  of  adaptation  to  an  end  in  that  the  cells  of  the 
mother  refuse  a  material  which  is  preeminently  suited  to  the  nutritive 
wants  of  the  nursling." 

6.  Predisposing  factors  are  (a)  sex;  men  (3:2)  are  especially  subject 
to  diabetes;  (b)  age;  its  frequency  is  as  follows:  In  persons  from  thirty 
to  forty  years,  18  per  cent.;  forty  to  fifty  years,  25  per  cent.;  fifty  to 
sixty  years,  30  per  cent.;  in  Stern's  collection  of  117  infantile  cases  1 
was  apparently  congenital,  (c)  Heredity:  A  family  history  of  obesity, 
consanguinity,  neuropathic  taint  or  gout  is  especially  significant;  cases 
are  reported  in  which  the  grandfather  was  diabetic,  the  son  gouty  and 
the  grandson  diabetic  (alternating  diabetes),  (d)  Race:  Diabetes  is 
comparatively  rare  in  the  colored  race  and  is  especially  common  in  Jews. 
(e)  Occupation:  Diabetes  is  more  often  seen  in  private  than  in  hospital 
practice.  Wealth  and  culture  increase  tenfold  the  predisposition  to 
diabetes.  It  is  frequently  found  in  scientists,  laT\yers,  musicians,  poets, 
teachers,  statesmen,  merchants,  ■  speculators  and  in  those  leading  a 
luxurious  or  self-indulgent  existence  with  sedentary  habits;  it  also  results 
from  overwork,  excitement,  overeating  and  overdrinking. 

Symptoms. — I.  Hyperglycemia. — The  blood-sugar  rises  to  0.1  to  1.6 
per  cent.,  either  because  the  diabetic  cannot  store  or  oxydize  sugar  or 
because  sugar  is  formed  in  excess. 

II.  The  Urixe. —  Glycosuria  is  the  leading  symptom  of  diabetes. 
A  daily  excretion  of  5  to  12  grams  is  not  uncommon;  the  maximum 
amount  recorded  is  1500  gm.;  the  largest  quantity  of  sugar  is  voided 
late  in  the  morning  or  after  6  p.m.  A  percentage  of  from  1  to  4  is 
common,  8  or  9  per  cent,  is  rare  and  the  maximum  is  20  per  cent, 
(personal  observation).  The  diabetic's  capacity  to  consume  sugar  is 
considered  under  Therapy.  Muscular  exercise  usually  decreases  it.  It 
is  often  increased  by  psychic  disturbances  and  may  be  suspended  during 
an  acute  intercurrent  infection,  especially  tj-phoid;  chronic  diseases 
with  fever,  especially  pulmonary  tuberculosis,  have  less  influence.  It  may 
be  reduced  or  absent  in  the  final  stages  of  diabetes,  diabetic  coma  and 
w^hen  granular  nephritis  develops.  Gouty  diabetics  as  a  rule  pass  no 
sugar  during  an  attack  of  gout  (diabetes  alternans). 

Tests  for  Sugar. — (a)  For  Fehling's  test,  two  solutions  are  kept  sepa- 
rate; one  contains  copper  sulphate  and  the  other  sodium  and  potassium 
tartrate  and  sodium  hydrate.  Equal  parts  of  these  solutions  are  heated, 
but  not  boiled,  and  the  urine  is  added  drop  by  drop.  The  volume  of 
urine  should  never  exceed  that  of  the  solution.  Reduction  of  the  blue 
copper  solution  to  the  yellowish-red  suboxide  of  copper  indicates  sugar. 
Chloral,  phenacetin,  chloroform,  formalin,  morphine,  uroleukinic  and 
homogentisinic  acids  (the  probable  causes  of  alkaptonuria),  glycuronic 
acid,  cascara,  rhubarb  and  salicylates  may  also  reduce  Fehling's  solution, 
particularly  after  boiling.  In  doubtful  cases  (b)  the  fermentation  test 
may  be  used;  yeast  is  shaken  thoroughly  with  a  quantity  of  urine,  the 
air  allowed  to  bubble  up  and  the  mixture  placed  in  a  saccharometer — 
a  tube  closed  at  the  top  and  graduated  for  estimation  of  percentages. 


728  CONSTITUTIONAL  DISEASES 

The  sugar,  fermenting,  is  measured  by  the  amount  of  carbon  dioxide 
formed.  A  control  test  should  be  made,  (c)  The  polarization  test  shows 
dextrorotary  reaction.  (d)  The  very  delicate  phenylhydrazin  test  may 
be  used,  (e)  In  Robert's  test,  the  sugar  percentage  equals  the  difference 
between  the  specific  gravitv  before  and  after  fermentation,  multiplied 
by  0.23. 

Quantity  and  Specific  Gravity. — The  urine  is  acid  even  after  fermenta- 
tion (lactic  acid)  and  has  a  sweet  taste.  The  quantity  of  urine  secreted 
during  the  night  is  "  less  than  that  secreted  in  the  daytime,  whereas 
in  other  polyurias  frequently  f  to  f  of  the  urine  is  secreted  during  the 
night.  A  secretion  of  ten  quarts  is  not  rare  and  17  and  28  quarts  are  re- 
corded. Higher  figures  suggest  simulation,  patients  having  been  known 
to  add  sugar  to  the  urine.  In  part,  polyuria  results  from  the  inability  of 
the  kidneys  to  concentrate  the  urine.  PoUakiuria  (frequency  of  urination) 
is  common.  The  urine  is  pale;  if  dark  and  if  uratic  deposits  are  present, 
the  prognosis  is  good.  Foam  often  remains  long  on  its  surface  and  the 
sediment  is  scant  or  absent.  Prout  dated  the  onset  of  diabetes  when 
the  urine  ceased  having  a  turbid,  uratic  deposit. 

Amount  in 
litres  or  quarts.  Specific  gravity.  Sugar. 

1 . 5  to    2 . 5 1 .  025  to  1 .  030 2  to  3  per  cent. 

2 . 5  to    4 1 .  030  to  1 .  036 3  to  5  per  cent. 

4      to    6 1 .  032  to  1 .  046 4  to  7  per  cent. 

6       to  10 1.036  to  1.040 6  to  9  per  cent. 

The  average  specific  gravity-  is  1.030  to  1.040,  it  is  rarely  more  than 
1.050,  and  the  highest  record  is  1.074;  very  high  specific  gravity  suggests 
fraud;  the  lowest  records  are  1.003  and  1.002.  If  under  a  meat  diet  the 
urine  becomes  entirely  or  nearly  free  from  sugar,  the  quantity  approaches 
normal;  the  specific  gravity  remains  high  because  the  urine  is  rich  in 
meat  end-products.  There  is  no  absolute  parallelism  between  the  per- 
centage of  sugar  and  the  specific  gravity.  In  some  cases,  though  there 
is  a  large  percentage  of  sugar,  only  a  pint  or  a  pint  and  a  half  of  urine  is 
excreted,  described  by  Peter  Frank  a  century  ago  as  "diabetes  decipiens." 
Crystals  of  sugar  may  be  seen  on  the  shoes,  clothing  or  in  the  vessel. 

Nitrogenous  Constituents.- — Diabetics  usually  excrete  15  to  20  gm. 
or  more  of  nitrogen  daily  (the  normal  being  10  to  15  gm.);  the  urea 
may  reach  even  60  to  150  gm.,  (metabolism  being  increased  15  per  cent. 
in  severe  tj^es);  larger  figures  are  reached  in  no  other  disease;  the  con- 
dition is  pathological  when  the  amount  of  nitrogen  in  the  urine  exceeds 
that  in  the  food. 

Ammonium,  normally  0.5  or  1  gm.  per  diem,  may  increase  to  3,  6  or 
even  12  gm.,  and  may  constitute  10  to  20  per  cent,  of  the  total  nitrogen 
output  (instead  of  the  normal  3  to  5  per  cent.);  over  5  gm.  indicate  a 
severe  type,  probably  with  death  within  a  year,  especially  in  subjects 
over  fifty  years  of  age;  the  highest  figures  are  seen  exclusively  in  diabetic 
coma.  The  organism  excretes  increased  ammonia  to  neutralize  acidosis. 
Creatinin  may  reach  1  or  2  gm.  per  diem.    The  uric  acid  is  nearly  normal. 

Acetonuria,  or  ketonuria,  indicates  the  presence  in  the  blood  of  /S-oxy- 
butyric  and  diacetic  acids.     This  acidosis  results  from  either   (i)   an 


PLATE  XIX 


Crystals  of  Phenyl-glucosazone.     (Musser.) 
(Oc.  4,  Obj.  D.)     Drawn  by  J.  D.  Z.  Chase. 


DIABETES  MELLITUS  729 

entirely  abnormal  type  of  metabolism  or  (ii)  intermediate  substances, 
which  the  diseased  organism  cannot  split  up  into  normal  end-products 
(water  and  CO2),  thus  robbing  the  body  of  native  alkali  and  decreasing 
the  power  of  the  blood  to  take  up  CO2.  These  acid  sustances  are  derived 
from  the  fatty  acids  and  possibly  from  protein,  ^-oxyhutyric  acid  is 
absent  in  diabetics  in  good  physical  condition  and  not  infrequently  also 
in  those  who  are  suffering  from  marked  loss  of  albumin.  The  urine 
and  breath  may  be  odorless  or  may  smell  like  chloroform,  fruit  or  wine. 
The  daily  excretion  varies  from  a  few  grams  to  50  to  even  100  to  180  gm. 
Its  abnormal  excretion  once  begun,  is  uninterrupted  and  constantly 
tends  to  increase.  It  is  of  the  gravest  prognostic  significance  because  in 
most  cases,  at  the  end  of  days,  weeks  or  months,  fatal  diabetic  coma 
develops.  An  excretion  of  more  than  30  gm.  indicates  imminent  coma, 
/3-oxybutyric  acid  is  thought  by  some  to  be  the  parent  substance  of  ace- 
tone and  diacetic  acid.  Acetone  and  diacetone  are  present  in  the  urine 
in  diabetes,  fevers,  cancer,  inanition  or  auto-intoxications  and  indicate 
malnutrition.  When  the  amount  of  acetone  progressively  rises  from 
1  gm.  upward,  the  outlook  is  unfavorable,  its  normal  daily  output  being 
0.01  to  0.03  gm.  Acidosis  may  be  measured  by  the  amount  of  ammonium 
excreted  or,  more  roughly,  by  the  amount  of  sodium  bicarbonate  neces- 
sary to  render  the  urine  alkaline.^ 

Albuminuria  is  found  in  35  per  cent,  of  cases;  it  is  slight  and  is  due 
(a)  to  cystitis,  pyelitis,  intercurrent  diseases  as  gangrene  or  infection, 
pulmonary  tuberculosis  or  without  relation  to  diabeteSj  as  in  the  arterio- 
sclerotic and  gouty  types  of  diabetes,  liver  cirrhosis,  etc. ;  (6)  to  circu- 
latory disturbances,  and  (c)  in  uncomplicated  diabetes  it  may  be  due  to 
the  action  of  the  sugar,  /3-oxybutyric  and  other  acids  and  toxins  on  the 
kidneys;  albuminuria  is  a  frequent  forerunner  of  diabetic  coma  (de- 
creased renal  permeability  with  retention  in  the  blood  of  toxins). 
Diabetes  may  develop  into  chronic  interstitial  nephritis  and  the  sugar 
then  disappears. 

Sodium  chloride,  sulphuric  and  phosphoric  acids  and  the  ethereal 
phosphates  are  abundant,  caused  by  the  amount  of  food  ingested.  Much 
lime  is  excreted,  which  suggests  osseous  waste. 

Pneumaturia. — The  butyric  acid  bacillus,  the  Bacillus  coli,  yeast 
fungus  and  other  bacteria  may  cause  fermentation  in  the  bladder,  pro- 
ducing gas.    Lipuria  has  been  observed. 

III.  Direct  Consequences  of  the  Glycosuria  and  Polyuria. — 
(a)  The  exaggerated  thirst  (polydipsia)  is  secondary  to  the  polyuria.  (6) 
Nutrition:  For  each  gram  of  sugar  in  the  urine  four  calories  are  lost  to 
the  tissues,  and  for  each  gram  of  /3-oxybutyric  acid,  five  calories.  There- 
fore the  nutritive  requirements  are  great,  the  appetite  is  excessive  (poly- 
phagia) and  in  severe  cases  emaciation  and  fatigue  are  pronounced. 
Increase  in  weight  may  follow  reduction  in  the  sugar.  The  temperature 
in  uncomplicated  cases  is  subnormal  from  inanition. 

1  L.  Blum  finds  that  from  5  to  10  grams  of  sod.  bicarbonate  are  sufficient  to  render  the 
normal  urine  alkaline,  while  with  mild  acidosis  20  grams  are  necessary.  With  an  acidosis 
of  moderate  intensity  from  20  to  30  grams  are  required,  in  severe  cases  of  acidosis  50,  and 
in  diabetic  coma  150  grams  or  more  are  necessary  to  make  the  urine  alkaline. 


730  CONSTITUTIONAL  DISEASES 

IV.  Complications. — Complications  and  other  symptoms  result  from 
various  causes :  (a)  excess  sugar  in  the  blood,  (&)  malnutrition  and  lowered 
physiological  resistance;  both  conditions  predispose  to  (c)  infection, 
particularly  by  the  Bacillus  tuberculosis,  (d)  acidosis  and  other  ill-under- 
stood degenerations  and  toxemias. 

1.  Nervous. — (a)  Intellectual  depression,  headache  and  neurasthenic 
symptoms  are  common ;  psychoses  are  infrequent.  In  rare  instances  focal 
symptoms  develop  without  anatomical  findings.  (6)  Diabetic  coma  occurs 
in  20  per  cent,  and  causes  half  the  deaths  in  diabetes;  it  is  most  frequent 
in  youth  and  in  acute  and  severe  types;  Naunyn  holds  that  it  is  favored 
by  a  strict  antidiabetic  diet.  All  coma  in  diabetes  is  not  diabetic;  patients 
may  succumb  (i)  to  cerebral  apoplexy,  embolism,  thrombosis,  sepsis  or 
uremia;  (ii)  to  heart  failure,  which  may  cause  sudden  death,  or  coma  with 
death  after  a  short  time  or  (iii)  diabetic  coma  proper,  due  to  acidosis  and 
closely  resembling  experimental  acid  poisoning.  Most  writers  believe 
that  i8-oxybutyric  acid  is  causal,  though  in  three  of  the  author's  cases  it 
was  not  present  in  the  urine.  Coma  is  imminent  when  the  daily  output 
of  ammonium  exceeds  3  gm.  It  may  occur  suddenly  without  obvious 
cause  or  may  follow  exertion,  excesses,  excitement  or  gastro-intestinal 
disorders.  In  some  cases  there  are  prodromal  headache,  stupor,  restless 
anxiety  or  symptoms  resembling  acute  alcoholism.  The  pupils  are 
dilated,  the  reflexes  abolished,  the  small  pulse  averages  110  and  the  tem- 
perature is  usually  subnormal.  Convulsions  are  most  uncommon.  The 
breath  has  the  wine-like  acetone  odor.  The  breathing  is  characteristic; 
inspiration  is  deep,  long-drawn  and  energetic  and  expiration  is  short 
and  slightly  sighing;  in  this,  Kussma^id's  dyspnea  (1876),  the  inspiratory 
energy  contrasts  strongly  with  the  general  bodily  weakness;  respiration 
is  generally  somewhat  accelerated;  there  is  no  stridor  nor,  at  the  onset, 
cyanosis.  The  albuminous  urine  contains  innumerable  short,  broad, 
granular  casts  (Kiilz) ;  a  few  drops  of  ferric  chloride  give  the  Burgundy 
wine  color;  sugar  is  present,  though  it  may  disappear  as  the  coma 
develops.  Partial  consciousness  may  return,  but,  with  few  exceptions, 
death  occurs  within  a  few  hours  to  two  days,  with  subnormal  temperature, 
slowed  respiration  and  cardiac  weakness.  The  autopsy  reveals  no  con- 
stant brain  changes,  (c)  Toxemic  degeneration  in  the  posterior  columns 
of  the  cord  may  develop,  {d)  Neuralgia  is  common  and  may  indicate 
incipient  neuritis  or  may  appear  and  disappear  varying  with  the  amount 
of  sugar  in  the  blood  and  urine.  It  is  often  an  early  symptom;  it  is 
more  often  bilateral,  most  frequently  affects  the  sciatic  nerves  and  is  a 
most  obstinately  recurrent  symptom.  Neuritis  occurs  in  severe  forms  of 
diabetes  and  in  its  later  stages.  Neuritis  may  involve  the  cranial  nerves, 
mostly  the  abducens,  or  with  greater  frequency  the  spinal  nerves;  the 
lower  are  affected  more  often  than  the  upper  extremities  and,  like  diabetic 
neuralgia,  bilateral  involvement  of  the  crural  or  sciatic  nerves  is  the  most 
common  type.  Its  symptoms  are  those  of  neuritis  or  polyneuritis,  as 
paralysis,  obstinate  pain,  painful  paresthesia  in  the  legs,  muscular 
cramps,  abolished  patellar  reflexes,  reaction  of  degeneration  and  trophic 
disturbances,  as  falling  of  the  hair  and  nails,  glossy  skin,  herpes  or  per- 
forating ulcer  of  the  foot  {mal  perforant).    In  severe  cases  tabes  is  simu- 


DIABETES  MELLITUS  731 

lated,  pseudotabes  diabetica,  described  by  Fischer  (1886)  (see  Multiple 
Neuritis),  {e)  Special  senses.  Retinal  disease  (Jager,  1856)  occurs  under 
four  forms:  (i)  albuminuric  retinitis;  (ii)  retinitis  centralis  punctata  with 
characteristic  shining  bilateral  spots,  with  hemorrhagic  points;  (iii) 
the  ordinary  hemorrhagic  type  (see  Plate  IV,  Fig.  1);  (iv)  lipemia  retin- 
alis,  in  which  the  vessels  appear  white  and  red.  It  occurs  in  19  per 
cent.  Neuroretinitis  and  retrobulbar  neuritis  with  consecutive  atrophy 
are  progressive  and  occur  more  frequently  in  severe  cases.  Twenty  per 
cent,  of  diabetics  with  retinitis  die  within  one  year  and  60  per  cent,  live 
over  two  years  (Nettleship). 

Amblyopia  and  amaurosis  often  first  induce  the  patient  to  seek  medi- 
cal advice.  Paralysis  of  the  ocular  muscles  occurs  in  7  per  cent,  of  cases; 
accommodation  paralysis  is  the  most  frequent  type,  and  then  that  of  the 
external  rectus;  the  most  probable  cause  is  neuritis.  Cataract  occurs 
in  4  per  cent.  Aural  complications  include  external  furuncles  and  otitis 
media,  with  a  tendency  to  hemorrhage  and  mastoiditis. 

2.  Circulatory. — (a)  The  blood  may  become  concentrated,  for  much 
water  is  required  to  eliminate  the  sugar;  the  blood-sugar  is  increased. 
Fat  in  the  blood  (lipemia)  is  a  frequent  finding;  what  appears  to  be  fat 
is  sometimes  albumin  or  cholesterin  in  combination  with  fatty  acids; 
Fischer  in  1  case  found  18  per  cent,  of  fat.  In  lipemia,  acidosis  is  always 
present,  although  acidosis  may  develop  without  lipemia.  Bremer's  test 
is  based  on  changes  in  the  hemoglobin;  thick  smears  of  blood  are  made 
on  a  slide,  heated  and  treated  with  1  per  cent.  Congo  red  solution  for  two 
minutes.  Diabetic  blood  will  not  stain.  Williamson's  test  is  based  on  the 
fact  that  diabetic  blood  decolorizes  a  weak  alkaline  solution  of  methyl  blue. 
Acidosis  (v.  s.).  (6)  The  arteries  are  frequently  sclerosed  and  cause  car- 
diac hypertrophy  or  dilatation,  angina  pectoris,  cardiac  asthma,  hemi- 
plegia, albuminuria,  senile  gangrene  and  intermittent  claudication,  (c) 
The  heart  may  be  altered  variously  (v.  s.).  Hypertrophy  occurs  in  about 
10  per  cent,  and  is  less  ominous  than  atrophy,  which  occurs  in  uncom- 
plicated diabetes  of  the  young.  Heart  failure  may  occur  after  moderate 
exercise  or  may  develop  precipitately,  ending  in  coma  or  asphyxia  and 
classified  as  an  acidosis  sign  by  Erdmann.  Von  Noorden  observed  5 
sudden  deaths  in  140  fatal  cases.  The  pulse  is  accelerated  and  its  tension 
reduced.     Dropsy  is  uncommon. 

3.  Respiratory. — (a)  Tuberculosis  is  most  frequent  in  the  poor  classes 
and  in  the  young,  but  much  less  so  in  older,  obese  and  gouty  subjects; 
25  per  cent,  of  diabetics  contract  tuberculosis.  Hemoptysis  is  very  rare; 
the  sputum  is  abundant;  in  the  secondary  necrosis,  to  which  all  diabetics 
are  prone,  the  marked  clinical  and  pathological  lung  findings  may  sharply 
contrast  with  the  few  tubercle  bacilli  in  the  sputum.  The  course  is  rapidly 
fatal,  (b)  Gangrene  is  much  less  common  than  tuberculosis;  it  is  char- 
acterized by  fever,  pulmonary  hemorrhage,  purulent  sputum  and  fetor 
which  is  less  conspicuous  than  in  other  forms  of  pulmonary  gangrene. 
(c)  Intercurrent  pneumonia  is  usually  fatal. 

4.  Digestive. — (a)  The  mouth  is  dry  and  acid  from  decomposition  of 
sugar;  the  saliva  is  scanty;  stomatitis  and  gingivitis  are  common  and 
the  growth  of  aphthse  is  promoted  by  the  acid  reaction  of  the  mouth, 


732  CONSTITUTIONAL  DISEASES 

though  preventable  by  cleanliness.  The  teeth  may  decay  from  alveolar 
periostitis,  or  drop  out  from  trophoneurotic  changes,  (fe)  The  stomach  is 
affected  with  remarkable  infrequency,  considering  the  oral  findings  and 
the  poh'phagia.  Anorexia  is  uncommon,  though  the  patient  maA'  refuse 
fatty  and  nitrogenous  foods.  The  stomach  is  usually  dilated,  (c)  The 
bowels  are  generally  costive.  Gastro-intestinal  catarrh  sometimes  seems 
to  precipitate  coma,  but  it  may  be  mereh'  an  associated  symptom. 
Severe  abdominal  crises  may  simulate  tabes  or  surgical  conditions  (cord 
degeneration),  (d)  The  liver  is  usually  enlarged  and  sometimes  tender; 
it  is  rose-colored,  transparent,  homogeneous;  fatty  changes  in  Kupffer's 
stellate  cells  and  peculiar  refractile  bands  along  the  capillaries  are  con- 
stant (Rossle).  Gall-stones  are  concomitants  in  10  per  cent,  of  cases,  but 
they  have  no  intrinsic  relationship  to  diabetes.  Hanot  and  Chauffard 
described  a  pigmentary  cirrhosis  in  diabetes  (diabete  bronze)  which  prob- 
ably develops  in  the  following  sequence:  (i)  hemolysis,  (ii)  pigment 
deposit  in  the  liver,  pancreas  and  skin  from  the  altered  blood  (hemo- 
chromatosis), (iii)  chronic  interstitial  inflammation,  chronic  hepatic 
cirrhosis  and  (iv)  chronic  pancreatitis,  causing  diabetes  (see  pages  572 
and  603). 

5.  Genito-urinary . — (a)  Albuminuria  may  be  present  (see  Urine). 
The  kidneys  are  hypertrophied  and  hyperemic;  various  degenerations 
may  be  noted,  including  Ehrlich's  glycogenic  degeneration.  Interstitial 
nephritis  may  follow  and  replace  diabetes,  chiefly  in  gouty  and  corpulent 
individuals,  (b)  Cystitis  is  common;  the  urine  may  ferment  in  the 
bladder,  just  as  it  decomposes  in  the  urinal;  this  may  lead  to  pyelone- 
phritis or  pneumaturia  (i).  .5.).  Cystitis  may  cause  temporary  disappear- 
ance of  the  glycosuria,  (c)  In  the  female,  menstruation  may  be  dis- 
turbed or  suspended.  The  sexual  inclination  is  usually  lessened  in  severe 
cases,  but  may  be  increased  from  genital  pruritus  (v.  ?'.).  Conception 
may  occur  even  in  advanced  cases,  but  in  33  per  cent,  there  is  spontan- 
eous abortion  or  premature  deli^'ery.  In  severe  diabetes  interruption  of 
pregnancy  is  indicated.  In  Offergeld's  series,  the  maternal  mortality 
was  30  per  cent,  from  coma  (collapse,  infection)  and,  in  all,  50  per  cent, 
within  two  and  one-half  years,  and  the  child's  mortality  was  66  per  cent. 
either  in  utero  or  within  ten  days.  Fungous  development  about  the 
labia  and  vagina  is  promoted  by  lessened  general  resistance  and  local 
contact  with  the  saccharine  urine,  particularly  in  careless  subjects; 
pruritus  pudendorum,  vulvitis,  vaginitis,  urethritis,  furunculosis  and  even 
gangrene  may  develop,  (d)  In  the  male,  impotence  results  from  spinal 
degeneration.  Phimosis,  balanitis,  erosions  near  the  urethra,  urethritis, 
itching  at  the  meatus  causing  tenesmus,  curious  nodes  on  the  corpora 
cavernosa,  furuncles  and  necrosis  may  first  engage  the  physician's  atten- 
tion.   Genital  symptoms  in  men  are  less  conspicuous  than  in  women. 

6.  Cutaneous. — The  skin  is  dry  and  harsh  when  there  is  much  polyuria 
and  emaciation.  Itching  is  caused  by  toxemia  irritating  the  cutaneous 
nerves,  as  in  uremic  and  cholemic  pruritus.  Skin  eruptions  include 
pityriasis,  erythema,  eczema,  bullse,  acne,  purpura  and  herpes.  Infec- 
tion is  favored  by  reduced  physiological  resistance  and  hyperglycemia; 
furunculosis   (15  per  cent.),   due  largely  to  the   staphylococcus,   ma\- 


DIABETES  MELLITUS  733 

initiate  lymphangitis,  phlegmon  or  gangrene;  erysipelas  is  promoted 
by  reduced  resistance.  Gangrene  is  most  frequent  in  late  or  middle  life, 
and  in  mild  cases;  it  usually  begins  on  the  toes  and  extends  upward,  as 
dry  or  moist  gangrene;  it  results  from  obliterating  endarteritis  or  the 
ordinary  plaque-like  atheroma.  Unfortunately  gangrene  is  usually  pro- 
gressive. Wounds  in  diabetics  heal  better  than  in  pre-antiseptic  times, 
but  delayed  healing,  infection  and  gangrene  are  still  frequent.  Enlarge- 
ment of  the  lymphatic  glands  is  seldom  absent  in  severe  forms  with 
emaciation. 

Course  and  Prognosis. — The  onset  may  be  acute  and  the  course  short, 
covering  weeks,  or  protracted  and  remittent,  covering  twenty  years  or 
more;  80  per  cent,  lose  their  tolerance  of  carbohydrates  within  ten 
years.  Comphcations  modify  the  duration  and  outcome.  In  von  Noor- 
den's  summary  of  the  prognostic  signs,  favorable  signs  are:  (a)  onset 
late  in  hfe;  (b)  long  duration,  with  no  grave  complications  or  emacia- 
tion; (c)  traumatic  or  {d)  syphilitic  origin;  (e)  the  occurrence  of  mild 
forms  of  diabetes  in  the  family  of  the  patient;  (/)  precedent  and  co- 
existent obesity;  (g)  coexistent  uric  acid  diathesis;  (h)  marked  oscilla- 
tions and  increasing  tolerance  of  carbohydrates;  (i)  circumstances  which 
permit  of  dietetic  and  hygienic  prescriptions.  Unfavorable  prognostics 
are:  (a)  onset  in  early  life;  (b)  great  loss  of  strength,  despite  a  brief  dura- 
tion of  the  diabetes;  (c)  a  history  of  severe  forms  in  the  family;  (d)  early 
appearance  of  grave  complications;  (e)  a  high  degree  of  glycosuria,  with 
complete  intolerance  of  carbohydrates;  (/)  excretion  of  fi-oxybutyric 
acid;  coma;  {g)  circumstances  frustrating  dietetic  treatment  or  avoid- 
ance of  bodily  and  mental  overwork. 

Diagnosis. — Only  when  the  urine  in  every  case  is  examined  as  a  routine 
procedure,  can  the  lighter  cases,  amenable  to  treatment,  be  discovered. 
In  many  cases  the  thirst,  polyuria,  emaciation,  itching  and  the  complica- 
tions yer  se  are  suggestive.  Pentosuria;  19  familial  or  hereditary  cases  are 
recorded.  Pentose  reduces  Fehling's  solution,  even  after  fermentation 
of  the  urine. 

Treatment. — 1.  Diet. — Regulation  of  diet,  dating  from  Rollo  (1797), 
is  the  most  essential  point.  The  carbohydrates  normally  supply  nearly 
half  the  bodily  requirements  for  food  and  energy.  The  diabetic  loses  a 
large  part  by  their  escape  through  the  kidneys,  which  entails  a  waste 
of  digestive  energy,  irritation  of  the  tissues  by  the  unused  sugar  and  a 
growing  decrease  of  the  tolerance  of  the  tissues  for  it,  A  man  weighing 
70  kilograms  (150  lbs.)  requires  a  diet  representing  2500  calories,  i.  e., 
roughly,  35  calories  for  each  kilogram.  The  dietary  must  therefore  regard 
not  merely  the  symptom,  glycosuria,  but  the  maintenance  of  body  weight 
and  energy.  The  therapeutic  aim  is  to  limit  the  carbohydrates  and 
replace  them  with  albumin  and  fat,  increase  the  tolerance  for  carbo- 
hydrates and  supply  sufficient  calories. 

General  Outlines  of  Dietary. — Explicit  written  directions  should  be 
given  each  patient.  All  diabetics  may  eat  the  following  foods:  meat:  beef, 
veal,  mutton,  game,  tongue,  lung,  heart,  brain,  marrow,  sweetbreads, 
fatty  liver,  peptones,  gelatin  and  meat  jellies;  fish:  caviar,  cod-liver  oil, 
clams,  oysters,  lobsters  and  crabs;  eggs  (10  to  20  per  cent,  of  fat) ;  animal 


734  CONSTITUTIONAL  DISEASES 

and  vegetable  fais,  bacon,  suet,  olive  oil,  cocoa  butter;  butter  con- 
tains 85  per  cent,  fat,  and  should  be  used  on  meats,  eggs  or  spinach  or 
melted  in  milk;  rich  cream;  all  cheeses  (3  to  30  per  cent,  fat),  especially 
Swiss  varieties;  vegetahles:  cress,  tomatoes,  cabbage,  cauliflower,  sprouts, 
artichokes,  mushrooms,  truffles,  olives,  onions,  garlic,  celery  leaves, 
lettuce,  cucumbers  and  radishes;  of  fruits,  only  whortle-berries,  young 
raspberries  and  green  gooseberries  should  be  eaten,  though  fruit-sugar 
(levulose)  is  better  tolerated  than  starch  or  cane-sugar.  Desserts  (suffles) 
of  eggs,  gelatin  and  lemon;  tea,  coffee,  Rademann's  diabetic  cocoa  and 
von  Hoevel's  saccharine  chocolate  may  be  taken. 

Of  the  calories  necessary  in  health,  1800  are  supplied  by  carbo- 
hydrates; these  must  be  replaced  by  protein  and  fat;  protein  cannot  be 
greatly  increased,  at  the  most  500  gm.  of  cooked  meat  (700  gm.  raw 
meat)=  one  pound  flean  meat  =  500,  and  fat  meat=  1000  calories).  Fat 
must  make  up  the  balance. 

To  some  cases  we  allow  after  determining  the  limit  of  tolerance, 
beans  and  peas;  turnips,  carrots,  celery  bulbs,  wax  beans;  radishes; 
walnuts,  hazel-nuts,  almonds  (no  chestnuts) ;  apples,  pears,  apricots, 
peaches,  berries;  cooked  apples,  plums,  pears,  peaches,  cherries  and 
milk;  some  diabetics  tolerate  levulose,  cane-sugar  or  honey,  in  small 
amounts  and  intermittently.     (See  Food  Values,  pages  53  and  54). 

Gradual  withdraival  of  carbohydrates  is  tolerated  better  than  abrupt 
restriction.  Glutin  flours  differ  but  little  from  ordinary  flours  in  their 
percentage  of  starch.  Aleuronat  or  so}"  bean  flour  contains  7  per  cent, 
of  starch.  Fat  is  best  absorbed  when  some  carbohydrates  are  given 
with  it.  If  some  starch  can  be  given  Mosse  prefers  potatoes,  which  are 
more  easily  assimilated  and  contain  but  20  per  cent,  of  starch  (bread 
contains  55  per  cent.).  Saccharin  should  be  used  in  place  of  sugar, 
gr.  iss  daily;  it  is  280  times  as  sweet  and  is  antifermentative,  but  an 
excess  may  occasion  dyspepsia.  Naunyn  advised  an  occasional  fast-day, 
and  Austin  Flint  kept  his  cases  in  bed  and  without  food  from  Saturday 
night  until  ^Monday  morning.  As  the  disease  is  eventually  progressive, 
a  schematic  diet  should  not  be  insisted  upon;  reasonable  restriction,  with 
occasional  dietetic  treats  is  less  often  violated  by  the  diabetic,  who  is 
always  hungry  for  bread  and  potatoes.  The  patient's  weight,  color  and 
strength  are  of  more  significance  than  the  urine,  remembering  that  there 
is  little  or  no  carbohydrate  metabolism,  increased  protein  and  perverted 
fat  metabolism.  Alcohol  aids  in  the  absorption  of  fat,  prevents  tissue 
waste  and  contributes  energy  and  heat;  not  over  30-70  gm.  should  be 
given;  it  is  contra-indicated  in  obvious  hepatic  disease  and  sweet  or 
white  wines  and  beer  are  injurious. 

Treatment  of  indindiial  forms  is  conducted  by  determining  the  limit  of 
tolerance;  the  percentage  of  sugar  on  a  general  diet  is  found,  then  the 
amount  on  a  sugar-free  diet  and  finally  the  amount  of  carbohydrate  which 
can  be  given  without  gh'cosuria  ensuing,  (a)  Mild  forms  of  glycosuria; 
in  elderly  persons  it  is  not  necessary  to  determine  with  great  accuracy 
the  sugar  tolerance  (about  100  gm.  bread).  The  patient  may  eat  bread, 
potatoes  and  vegetables,  for  the  quantity  of  sugar  in  the  urine  is  usually 
insignificant  (1  or  2  per  cent.).     The  older  the  patient  and  the  more 


DIABETES  MELLITUS  735 

corpulent,  the  more  caution  necessary  in  reducing  the  body  weight;  fatty 
foods  should  be  increased — butter  used  freely  on  bread,  potatoes,  vege- 
tables and  meat;  and  bacon,  eggs,  fatty  cheese,  light  wine,  coffee,  tea  and 
carbonated  water  are  also  given.  In  young  persons,  carbohydrates  should 
be  given  with  great  caution,  as  carelessness  in  diet  is  more  frequent  and 
the  glycosuria  more  often  progressive.  The  patient  may  not  tolerate, 
e.  g.,  90  gm.  bread  yet  pass  no  sugar  on  80  gm.  bread  plus  20  gm.,  potato, 
300  gm.  milk  and  20  gm.  oatmeal.  The  limits  of  tolerance  for  carbo- 
hydrates should  be  closely  watched.  All  carbohydrates  must  be  for- 
bidden excepting  bread  and  potatoes,  in  addition  to  which  the  patient 
should  have  butter,  16  pats  (each  9  gm.  =  80  calories)  with  bread,  cheese 
and  potatoes  (480  calories);  2  eggs  (150  calories);  olive  oil  6  table- 
spoonfuls  (750  calories)  with  salad,  cucumbers,  etc.  (90  calories); 
30  gm.  of  fatty  cheese  (115  calories);  1  quart  of  milk  (590  calories); 
and  one  ounce  of  alcohol;  and  meats  {v.  s.).  ih)  Moderately  severe  forms 
embrace  cases  in  which  the  excretion  of  sugar  is  reduced  to  1  or  2 
per  cent,  only  by  total  abstinence  from  carbohydrates.  The  rise  or  fall 
of  the  tolerance  limit  should  be  watched  every  month,  and  every  few 
months  all  carbohydrates  must  be  withdrawn  for  three  weeks.  The 
diet  must  contain  much  fat;  butter,  3  ounces  (gm.  110  =  800  calories), 
must  be  weighed  out  every  morning  and  eaten  on  bread,  vegetables,  meat, 
fish,  etc.,  either  in  solid  form  or  melted.  Olive  oil  should  be  taken  on 
salad  (lettuce,  chicory,  cress,  cucumbers,  tomatoes,  red  cabbage),  and 
as  mayonnaise  dressing  for  salad,  cold  meat,  fish,  lobster,  etc.  Bacon, 
5  eggs  and  one  ounce  of  brandy  (280  calories)  should  be  given.  In  addi- 
tion the  patient  receives  meats  and  some  articles  mentioned  in  the 
conditional  list,  (c)  In  severe  forms,  despite  a  continued  rigid  diet,  sugar 
and  acetone  are  constantly  excreted.  These  cases  usually  occur  with 
emaciation,  complications  and  a  fatal  issue  after  a  few  months  or  a  year. 
Careful  dietetic  treatment  may  retard  the  progress  of  the  disease,  prevent 
complications  and  delay  the  fatal  issue  {v.  i.  Acidosis). 

2.  General  Treatment. — (a)  Exercise  lessens  glycosuria  and  is 
permissible  in  mild  cases,  guarded  m  severe  cases  and  interdicted  in 
acidosis;  fatal  s^Ticope  and  diabetic  coma  may  follow  exhausting  exertion. 
{h)  The  mouth  and  skin  require  special  attention.  Cleanliness  averts 
in  large  part  gingivitis,  furunculosis  and  genital  complications.  Frequent 
warm  (not  cold)  baths  and  change  of  underwear,  gentle  brushing  of  the 
teeth  and  soothing  salves  for  eczema,  and  similar  eruptions  are  imperative. 
(c)  Diabetics  for  the  most  part  should  be  kept  at  home  and  at  work,  for 
they  often  become  restless  and  desire  to  travel.  A  prolonged  stay  in  a 
quiet  place  is  better.  Sea  bathing  and  exposure  to  cold  and  dampness 
increase  glycosuria,  {d)  Suggestive  treatment  and  optimism  are  needed  with 
depressed  subjects,  (e)  Mineral  springs  are  suitable  only  for  mild  cases; 
Carlsbad  and  other  spas  are  contra-indicated  in  severe,  youthful,  very 
aged,  reduced  and  nephritic  cases.  (/)  The  mode  of  life  should  be  quiet 
and  worry  avoided. 

3.  Treatment  of  Acidosis. — If  the  patient  has  been  on  a  mixed  diet, 
the  carbohydrates  are  gradually  reduced;  if  he  has  been  carefully  dieted, 
the  protein  is  reduced,   and  vegetables,   carbohydrates,  oatmeal  and 


736  CONSTITUTIONAL  DISEASES 

alkalies  are  indicated.  Often  glycosuria  and  ketonuria  are  refractory, 
till  protein  is  reduced  to  200-150  gm.;  vegetable  is  better  than  animal 
protein.  The  fatty  acids  of  metabolism  are  burned  in  the  fire  of  car- 
bohydrates; alcohol  is  thus  valuable  and  also  oatmeal,  which  is  poor 
in  protein  and  stimulates  sugar  combustion,  especially  when  preceded  or 
followed  for  a  couple  of  days  by  a  green  vegetable  diet  or  actual  starving. 
Oatmeal,  250  gm.,  boiled  in  Oiij  of  water  and  strained  while  hot  is  mixed 
with  butter  250  gm.  and  8  eggs;  200  gm.  are  given  every  three  hours, 
as  gruel  or  fried,  with  which  coffee,  tea  or  brandy  is  allowed.  It  may 
induce  diarrhea,  but  increases  sugar  tolerance.  Its  favorable  action  is 
lacking  when  given  steadily  with  meat,  or  in  mild  cases  or  after  several 
trials.  Levulose  may  operate  equally  well.  Sod.  bicarb,  and  citrate 
neutralize  ketones  and  facilitate  their  renal  elimination;  a  teaspoonful 
is  given  every  three  hours  by  mouth  if  swallowing  is  possible,  4  table- 
spoonfuls  in  water  (Oij)  by  rectum  (drop  method)  or  in  impending  coma, 
a  5  per  cent,  solution  intravenously,  after  phlebotomy  if  there  is  hyper- 
tension; subcutaneous  injection  may  cause  sloughing.  Coma  (acidosis, 
protein  poisoning,  dehydration)  indicates  large  quantities  of  water.  Like 
salt,  the  alkalies  may  be  retained,  causing  increase  in  weight  or  eveii 
pulmonary  edema.  Levulose  (10  per  cent.)  may  be  given  by  mouth, 
subcutaneously,  intravenously  or  by  rectum,  lessening  acidosis  and  not 
augmenting  glycosuria. 

4.  Treatment  of  Types. — (a)  Minimal  or  transitory  glycosuria  should 
be  regarded  as  diabetes  and  dietetic  carelessness  avoided,  not  giving  over 
150gm.  of  bread  daily.  (&)  Neurogenous  diahetes;  nervous  conditions  are 
more  potent  than  diet,  excitement  increasing  and  rest  decreasing  the 
sugar,  which  often  amounts  to  6  per  cent,  with  1500  c.c.  urine;  strict 
diet  is  poorly  stood;  bromides,  opium  or  acetanilide  may  be  indicated 
but  opium  alone  exerts  an  appreciable  influence  upon  the  glycosuria 
(Dobson  1776);  it  affects  the  severe  more  than  the  light  type,  i.  e., 
it  decreases  the  transformation  of  albumins  into  sugar,  but  does 
not  control  the  transformation  of  starch  into  sugar;  the  average 
dose  may  be  gradually  increased  without  the  patient  exhibitilig  toxic 
symptoms  or  sufi^ering  from  its  reduction  afterward.  Codeine,  gr,  j-x, 
is  less  effective  than  opium;  it  may  be  combined  with  sodium  bromide 
5ss.  Neuralgia  (q.  v.)  and  neuritis  should  be  treated  dietetically  and  by 
salicylates,  (c)  Renal  diabetes  is  rare;  hyperglycemia  is  absent  and 
diet  is  without  influence,  the  patient  even  standing  100  gm.  glucose. 
(d)  Tuberculosis  is  serious  and  allows  of  only  moderate  dietetic  restriction; 
if  incipient,  the  diet  may  be  rigid,  (e)  Gangrene  should  be  treated 
expectantly  until  there  is  a  possible  halt  in  the  process  and  definite 
demarcation;  positive  rules  of  treatment  are  laid  down  with  difficulty.  If 
there  is  no  acidosis,  diet  is  usually  efficacious;  if  acidosis,  surgery  is  indi- 
cated (after  oatmeal,  alcohol,  alkalies  and  much  water) ;  advanced  diabetics 
stand  operative  shock  and  anesthesia  poorly  and  most  die  from  rapid 
syncope  or  dyspneic  coma.  Other  operations  may  be  performed,  when 
indicated  as  absolutely  necessary  life-saving  procedures  and  only,  if 
possible,  after  strict  dieting.  Boils  and  furuncles  are  excised,  not 
incised.      (/)    In    arteriosclerotics   and   lithemics,   protein   should   not 


DIABETES  INSIPIDUS  737 

exceed  100  gm.  Sudden  carbohydrate  reduction  should  be  avoided  in 
obesity.  Uremia  and  decompensation  contra-indicate  strict  diets  and 
constipation,  drastic  purges. 

DIABETES  INSIPIDUS. 

Definition. — A  chronic  malady  characterized  by  large  amounts  of  urine 
of  low  specific  gravity.  Willis  (1674)  differentiated  between  diabetes 
niellitus  and  insipidus  (without  taste,  i.  e.,  non-saccharine);  55  cases 
occurred  in  113,600  in  the  Berlin  Charite. 

Etiology. — Two  groups  of  cases  are  observed :  (a)  the  idiopathic  (nervous 
or  vasomotor)  and  (b)  the  symptomatic,  which  occur  in  (i)  brain  disease, 
especially  basal  syphilis  and  less  often  traumatism,  basilar  meningitis, 
apoplexy,  lesions  of  the  hypophysis,  medulla,  fourth  ventricle,  middle 
cerebellar  lobe  or  corp.  trapezoides,  etc.  (ii)  It  may  result  from  ab- 
dominal diseases,  aneurysms,  tumors,  kidneys  (losing  their  power  to 
concentrate  the  urine)  or  tuberculous  peritonitis,  (iii)  Malnutrition 
with  tuberculous,  diabetic,  syphilitic  or  gouty  ancestry,  acute  infec- 
tions and  alcoholism  are  numbered  among  its  possible  causes.  Weil 
collected  36  cases  among  individuals  of  four  generations,  all  of  whom 
enjoyed  good  health.  Rare  congenital  cases  are  recorded.  Most  cases 
occur  in  males;  10  per  cent,  are  under  five  years  old,  14  per  cent,  under 
ten  and  45  per  cent,  were  between  ten  and  twenty-five  years  of  age. 

Symptoms. — The  onset  is  usually  gradual,  though  abrupt  symptoms 
have  followed  fright,  (a)  The  urine  is  greatly  increased,  20  to  40  pints 
daily,  even  90  pints  and  more  at  night  than  by  day;  less  urine  is  excreted 
than  water  ingested.  It  is  passed  rapidly  (tachyuria).  Its  specific 
gravity  ranges  between  1000.5  and  1005.  It  is  pale  and  sometimes  the 
urea,  chlorides  and  phosphates  are  increased,  being  washed  out  from 
the  tissue.  Albumin,  sugar  and  inosite  are  very  uncommon.  (6)  Poly- 
dipsia is  secondary,  though  perhaps  the  earliest  symptom  noticed.  In 
one  case,  a  physician  with  brain  syphilis,  2  gallons  of  water  were  drunk 
each  night  between  10  p.m.  and  7  a.m.  (<?)  The  skin  is  dry;  carbuncles 
are  rare.  The  saliva  is  decreased.  Phenomenal  polyphagia  marks  some 
cases.  Headache,  irritability,  increased  knee-jerks,  impotence  and 
severe  lumbar  pain  radiating  into  the  legs,  are  quite  frequent.  Nutrition 
is  often  good  in  the  idiopathic  cases  and  no  unusual  metabolic  findings 
are  noted ;  in  the  symptomatic  variety  the  nutrition  depends  on  the  causal 
disease;  in  children  growth  may  be  retarded.  The  temperature  is  low 
and  chilling  occurs  readily.  Aside  from  causal  lesions,  there  is  no  constant 
autopsy  finding  except  hypertrophy  of  the  kidneys  from  increased 
activity,  and  sometimes  dilatation  of  the  bladder  and  renal  pelvis. 

Diagnosis. — Differentiation  is  required  from  (a)  diabetes  mellitiis,  with 
which  it  has  no  common  symptoms  except  polyuria  and  polydipsia; 
there  is  no  glycosuria,  acidosis,  gangrene,  carbuncles  or  neuritis;  (b) 
from  interstitial  nephritis,  in  which  the  specific  gravity  is  higher,  the 
urine  is  less  abundant,  is  albuminous  and  contains  casts,  and  which  is 
associated  with  cardiovascular,  retinal  and  uremic  manifestations;  (c) 
from  privmry  polydipsia,  which  is  exceedingly  rare;  and  {d)  from  transi- 
47 


738  CONSTITUTIONAL  DISEASES 

tory  'polyuria,  distinguished  by  its  course  or  etiology,  as  recent  fever, 
hysteria,  etc. 

Prognosis. — The  prognosis  is  more  favorable  in  idiopathic  forms. 
Less  than  one-half  of  the  patients  recover,  though  death  results  less 
frequently  from  the  disease  itself  (save  cerebral  or  abdominal  tumors) 
than  from  intercurrent  infections,  notably  pulmonary  tuberculosis. 

Treatment. — Aside  from  antisyphilitic  therapy,  drugs  are  of  little 
use.  Iodides  improve  some  non-syphilitic  cases.  Salt  or  water  restriction 
may  work  benefit.  Opium  may  be  useful  and  large  doses  are  often  well 
tolerated.  Ergot  (fluidextract  TTlxx,  t.  i.  d.),  sodium  bromide  (5ss, 
t.  i.  d.)  and  acetanilide  (gr.  v-x,  t.  i.  d.)  are  recommended.  Talquist 
advocates  a  vegetable  diet. 

GOUT. 

Definition. — An  obscure  metabolic  disease,  characterized  by  acute 
periodic  or  chronic  inflammation  of  the  joints  with  uratic  deposits. 

Mentioned  by  Hippocrates,  gout  was  clearly  described  by  Sydenham 
(1683),  who  suffered  from  the  affection  for  forty  years.  Forbes  (1792) 
and  Wallaston  (1797)  recognized  its  uratic  nature. 

Etiology. — 1.  The  actual  cause  is  unknown.  Garrod  (1848)  held  that 
uric  acid  accumulated  periodically  in  the  blood  before  the  gouty  seizure. 
His,  Vogel  and  Magnus  Levy  maintain  that  in  gouty  subjects  it  is 
increased  all  the  time,  and  that  the  urine  contains  less  uric  acid  before 
and  more  during  and  after  the  seizure.  Pfeiffer  holds  that  it  is  really  less 
a  question  of  its  amount  than  of  its  insolubility  or  form.  The  endogenous 
uric  acid  (which  constitutes  90  per  cent,  of  the  purin  bodies)  is  derived 
from  the  nucleins  of  the  body  tissues  and  the  exogenous  uric  acid  from 
the  food  nucleins.  The  subject  is  still  much  involved  but  it  appears 
that  the  uric  acid  elimination  (perhaps  from  reduced  renal  action)  is  at 
fault  rather  than  any  increased  formation  or  suboxidation  of  the  acid. 

2.  Predisposing  factors,  (a)  Heredity  is  a  factor  in  60  per  cent.;  trans- 
mission is  more  common  by  the  father  than  mother  and  to  the  vounger 
rather  than  the  older  children.  (6)  Mode  of  life;  lack  of  exercise,  over- 
eating, meat  diet  and  alcoholism  are  potent  factors.  The  old  verse 
read  that  "Wine  was  the  father.  Eating  the  mother,  and  Venus  the 
midwife"  of  gout.  Though  gout  often  affects  the  well-to-do  (arthritis 
divitum)  and  arthritis  deformans  the  poor  (arthritis  pauperum),  gout 
is  not  uncommon  among  the  lower  classes.  Heavy  ales  and  beers  are 
more  injurious  than  whisky  and  light  wine.  Gout  may  occur  in  temperate 
individuals.  Obesity,  diabetes,  arteriosclerosis  and  calculous  tendencies 
are  concomitant  rather  than  causal  conditions,  (c)  Lead  poisoning  is 
observed  in  15  per  cent,  of  cases,  particularly  in  England;  saturnine 
nephritis  may  explain  it.  {d)  Men  are  particularly  prone  to  gout  (1  to 
13  or  25).  {e)  Age:  Gout  begins  between  thirty  and  forty  years  in  38 
per  cent.,  thirty  and  fifty  in  60  per  cent.,  and  before  the  seventeenth 
year,  less  than  1  per  cent.;  Gairdner  observed  1  case  in  a  nursling. 
(/)  England  leads  in  frequency  of  its  occurrence.  Li  the  United  States 
it  is  rare,  though  Futcher  shows  that  the  cases  in  Baltimore  and  London 
hospitals  stood  as  2  to  3.    Few  cases  seek  hospital  treatment. 


GOUT  739 

Symptoms. — These  may  be  considered  under  two  captions,  (1)  acute, 
and  (2)  irregular,  chronic  and  visceral  gout. 

1.  Acute  (regular,  sthenic  or)  typical  gout  usually  appears  without 
prodromes,  though  sometimes  an  attack  is  heralded  by  digestive  disorder 
(pyrosis,  gastralgia),  cerebral  congestion,  vertigo,  tinnitus,  irritability, 
paresthesia,  cramps  or  pain  in  the  muscles  or  dark  lateritious  urine. 
The  paroxysm  is  remarkably  characteristic,  (a)  Local  findings:  The 
patient  is  awakened  one  to  three  hours  after  midnight  by  an  agonizing 
pain  in  the  metatarsophalangeal  joint  of  the  large  toe  {podagra),  described 
as  crushing  by  a  vise  or  burning  by  a  hot  iron.  Localization  in  the  toe 
(95  per  cent.,  Garrod)  is  practically  diagnostic  of  gout;  the  skin  becomes 
red,  tense,  slightly  edematous  and  exquisitely  sensitive;  the  shorter  the 
attack  the  severer  are  the  symptoms.  Serum  exudes  into  the  joint. 
The  pain  abates  toward  morning,  but  the  inflammation  increases.  Each 
early  morning  sees  a  repetition  of  the  pain  for  three  to  five  or  less  often 
six  to  seven  days;  the  paroxysmal  pain  and  the  local  findings  then 
gradually  subside;  in  two-thirds  of  the  cases,  the  skin  desquamates 
over  the  joint.  Later  attacks  involve  the  thumb,  knee  and  other 
joints,  less  commonly  than  in  chronic  gout  {v.  i.).  The  pathological 
changes  probably  develop  in  this  sequence:  (i)  local  stasis  (inflammation), 
(ii)  uratic  deposit;  (iii)  necrosis;  the  ordinary  urates  (biurate  of  sodium 
in  conjunction  with  sodium  phosphate)  do  not  cause  such  local  reaction, 
but  the  biurate  alone,  even  in  most  dilute  solutions  (0.004),  produces 
inflammation;  residual  swellings  (acute  gouty  tophi)  consist  of  this 
biurate  precipitated  by  the  carbonates  of  the  blood  and  tissues.  Con- 
valescence is  complete  in  ten  days,  often  with  greatly  improved  spirits 
and  health.  During  the  seizure  (6)  constitutional  symptoms  are  present, 
as  the  temperature,  100.5°  or  101°;  the  pulse  is  slow  and  hard,  sometimes 
arrhythmic  and  seldom  exceeds  100.  The  heart  may  palpitate.  Slight 
leukocytosis,  nausea,  vomiting,  epigastric  cramping  and  eructations  are 
not  uncommon.  The  urine  is  dark,  decreased,  acid  and  higher  in  specific 
gravity;  Bain  and  Futcher  find  the  uric  and  phosphoric  acids,  both 
derived  from  disintegration  of  nuclein,  fall  below  normal  in  the  quiescent 
period  and  increase  during  the  attack. 

Subsequent  acute  seizures  are  likely  to  occur,  notably  in  the  spring  and 
fall,  precipitated  by  excesses  in  alcohol  or  eating,  trauma,  exertion  or 
excitement;  in  one  case  it  would  occur  within  fifteen  minutes  from 
a  glass  of  champagne. 

Retrocedent  or  suppressed  gout  was  once  thought  to  develop  when  an 
acute  paroxysm  abated  "too  rapidly";  many  of  its  symptoms  are 
doubtless  coincident  arteriosclerosis  or  uremia  {v.  i.). 

2.  Chronic,  irregular,  atypical  gout  generally  follows  acute  attacks 
which  increase  in  frequency,  decrease  in  acuity  and  show  slight  tendency 
toward  resolution.  Sometimes  tophi  appear  to  begin  as  chronic  gout, 
particularly  in  the  aged,  cachectic  or  women  of  a  gouty  family,  all  of 
whom  lack  reactive  power  (asthenic  gout),  (a)  Local  findings:  There 
are  less  pain,  fever  and  redness  but  greater  and  more  permanent  swelling 
than  in  the  acute  form,  until  the  condition  eventually  becomes  chronic; 
the  "attacks"  may  be  rudimentary  and  remissions  alternate  with  exacer- 


740  CONSTITUTIONAL  DISEASES 

bations.  Tlie  lower  extremities  and  hands  are  most  often  affected;  it 
may  develop  in  the  thumb  (ckiagra),  knee  {gonagra),  elbow  {yechiagra) 
and  spine  {rhachisagra) ,  but  the  shoulder  is  very  seldom  and  the  hip 
almost  never  invaded.  In  some  cases  its  moving  from  joint  to  joint 
{lirarthntis  multiplex  seu  vaga)  may  cause  confusion  with  acute  rheuma- 
tism. Uratic  deposits  {tophi  arthritici)  form  in  the  cartilage  and  later 
in  the  capsule  and  ligaments,  and  the  swelling  never  recedes  essentially. 
These  prominences  and  the  attendant  fibrosis  lead  to  deformation,  sub- 
luxation, fluctuation,  crackling,  anyklosis  and  contractures.  The  proximal 
joints  of  the  fingers  may  point  to  the  radial  and  the  others  to  the  ulnar 
side.  Tophi  may  rupture,  evacuating  yellowish-white  urates,  though  in- 
completely, as  they  are  partly  diffused  through  the  tissues;  these  gouty 
ulcers  heal  tardily,  if  at  all,  for  their  basis  is  fibrous  and  indolent.  Tophi 
occur  also  on  the  ear  (25  per  cent.),  bursse,  tendons,  aponeuroses  (which 
may  explain  some  cases  of  Dupuytren's  palmar  contracture),  and  even 
in  the  skin,  eyelids,  nose,  larynx,  penis  or  scrotmn.  (h)  Visceral  gout 
includes  a  curious  mixture  of  real  gouty  complications  and  incongruous 
doubtful  symptoms  {arthritisme,  herpetisvie  and  the  "uric  acid  diathesis"). 

Complications. — Renal,  the  most  important  visceral  complications, 
sometimes  dominate  the  clinical  picture.  In  1440  cases,  Garrod  observed 
albuminuria  m  26.5  per  cent.,  more  often  in  advanced  than  in  early 
cases.  It  may  follow  the  metabolic  changes,  or  may  possibly  constitute 
a  primary  gout.  At  first  albuminuria  may  be  considered  toxic,  congestive 
or  arteriosclerotic,  but  later  the  renal,  cardiovascular  and  retinal  findings 
of  interstitial  nephritis  develop  with  all  its  accidents;  uratic  deposits 
occur  in  the  intertubular  tissue  and  in  15  per  cent,  in  the  secreting 
tissue  of  the  cortex  and  medulla,  or  as  calculi  in  the  renal  pelvis;  hema- 
turia, oxaluria  and  pyelitis  may  occur. 

A  rteriosclerosis  of  the  ordinary  type  is  promoted  by  metabolic  changes, 
alcoholism,  plumbism  and  nephritis;  with  nephritis,  it  causes  most 
of  the  so-called  visceral  symptoms,  as  the  cerebrospinal  (headache, 
vertigo,  congestion,  epileptiform  and  apoplectiform  attacks,  encephalo- 
malacia),  the  circulatory  (hypertrophy,  myocarditis,  angina,  valvular 
lesions,  phlebosclerosis) ,  the  respiratory  (stasis,  bronchitis,  asthma)  and 
retinitis. 

Eczema  (18  per  cent.),  scleritis  and  episcleritis  (with  circumscribed 
points  of  inflammation  and  sometimes  semimicroscopic  tophi),  neuralgia 
or  less  often,  lumbago,  sciatica  and  brachial  neuritis,  burning,  psoriasis- 
like patches  on  the  tongue,  digestive  symptoms  {v.  Prodromes)  and 
burning  in  the  eye-balls  are  probably  often  gouty.  On  the  other  hand, 
many  so-called  visceral  gouty  manifestations  are  neurotic,  paroxysmal 
(calculous  colic,  migraine  or  asthma)  and  other  conditions  common  in 
persons  not  suft'ering  from  gout. 

Diagnosis. — (a)  Acute  gout  is  most  typical  in  its  etiology,  history, 
acuity  and  localization.  In  a  few  cases  (urarthritis  multiplex),  a  diag- 
nosis of  acute  rheumatism  may  be  made;  fibrous  rheumatic  nodes  may 
be  confused  with  tophi,  but  if  the  possibility  of  gout  is  recognized  there 
is  usually  no  error,  (b)  Chronic  gout  is  suggested  by  a  history  of  acute 
attacks,  involvement  of  the  distal  joints  of  the  hands  and  feet,  unequal 


GOUT  741 

distention  and  thickening  of  the  soft  parts  and  often  by  its  association 
with  early  arteriosclerosis,  contracted  kidney,  obesity,  renal  calculus 
and  diabetes.  The  x-rays  sometimes  show  the  tophi  as  light  spots  and 
the  joints  smooth.  Visceral  gout  is  an  entity  only  when  it  develops  in 
a  patient  undoubtedly  gouty. 

Prognosis. — Gouty  patients  may  live  to  an  old  age,  but  with  a  tendency 
to  chronic  gout,  of  which  the  issues  are  (a)  uremia,  (6)  arteriosclerosis, 
as  coronary  disease  or  apoplexy  or  (c)  terminal  pericarditis,  pneumonia 
or  pleurisy,  induced  by  the  (d!)  gouty  marasmus.  In  general  the  out- 
look is  better  in  frank  than  in  irregular  gout  and  better  in  cases  which 
develop  after  forty  years  of  age. 

Treatment. — 1.  Acute  Paroxysm. — (a)  Absolute  rest  is  indicated. 
(&)  For  'pain,  the  use  of  colchicum  is  empirical  (Storck,  1763)  but  it  relieves 
pain  and  inflammation  and  acts  as  a  cholagogue  (5iss  of  the  vinum 
colchici  radicis  [not  seminis]  daily).  It  requires  care  in  nephritic  and 
marantic  subjects.  It  should  be  stopped  when  pain  is  alleviated  and 
diarrhea  intervenes.  Full  therapeutic  doses  produce  a  slow  pulse, 
vomiting,  pain  and  purging;  inversely  to  its  action  on  the  bowels,  there 
are  diaphoresis  and  diuresis.  It  is  eliminated  by  the  kidneys,  bowels 
and  skin.  After  toxic  doses,  retching,  serous  and  finally  hemorrhagic 
purging,  great  pain,  prostration,  paralysis  of  the  sensory  nerves,  motor 
cord  and  respiratory  centre  (the  usual  cause  of  death)  develop. 

If  colchicum  produces  no  effect,  sodium  salicylate  (5j~ij  daily) 
usually  relieves  the  pain  and  swelling  and  aids  in  solution  of  the  uric 
acid;  its  early  effect  is  greatest  and  it  usually  fails  after  the  third  day. 
Acetphenetidinum  (gr.  viij-x)  and  morphine  are  indicated  in  severe 
paroxysms.  In  prolonged  attacks,  potassium  iodide,  gr.  v  (given  with 
care  in  nephritis)  and  wine  of  colchicum  TUx  are  useful.  Atophan  (gr. 
vij,  t.  i.  d.,  for  4-5  days)  increases  the  uric  acid  output  three-  or  fourfold, 
more  efficiently  than  salicylates  and  is  less  irritant  to  the  stomach  when 
combined  with  alkalies,  (c)  The  diet,  according  to  Pfeiffer,  should  con- 
sist of  foods  which  "release  uric  acid  in  a  free  form,"  as  meal  soups, 
rice  and  other  carbohydrates;  meat,  eggs,  alcohol  and  lemonade  are 
withheld.  Plain  or  acid  water,  as  Seltzer  (not  alkaline  water  as  Vichy) 
and  hydrochloric  acid,  are  given  freely,  (d)  Local  measures  induce 
necrosis  and  tophi,  especially  vesicants,  the  ice-bag  and  massage;  warm 
applications  of  50  per  cent,  alcohol  or  lead-water  (tinctura  opii,  liquor 
plumbi  subacetatis  aa  5ij  and  water  §  j)  may  be  used. 

2.  Between  Attacks. — (a)  Regulation  of  diet  is  the  cardinal  indica- 
tion. Moderation  in  the  quantity  is  more  important  than  the  quality 
of  food.  Quantity:  a  full  diet  increases  the  uric  acid,  taxes  resorption 
which  is  usually  impaired  and  favors  acid  fermentations  which  engage 
the  diphosphates  and  carbonates  of  the  food  necessary  for  the  formation 
of  soluble  uric  acid  salts;  three  medium-sized  meals  are  allowed.  Quality: 
(i)  alcohol  is  absolutely  forbidden;  (ii)  water  may  be  given  freely  on  an 
empty  stomach,  (iii)  Moderate  amounts  of  fat  are  allowed,  (iv)  Fruits 
and  vegetables  increase  diuresis  and  their  malates  and  citrates  help  to 
dissolve  the  uric  salts,  (v)  Meats  are  allowed;  urea  seems  to  dissolve 
uric  acid  which  the  meat  does  not  increase  if  given  in  moderation  (meat 


742  CONSTITUTIONAL  DISEASES 

1  part,  vegetables  3  parts  of  the  diet).  Meat  is  essential  in  marantic 
cases.  There  is  no  difference  between  the  effect  of  light  and  dark  meats; 
those  rich  in  purin  (sweet-breads,  liver  and  kidneys)  are  avoided;  milk 
and  eggs  are  purin-free.  (vi)  Carbohydrates  should  be  largely  decreased, 
though  following  their  ingestion  the  uric  acid  (as  compared  T\dth  the  urea) 
increases  nearly  twofold.  In  severe  cases  the  purin  contents  of  peas, 
beans,  corn  or  oats,  contra-indicates  them,  (b)  Exercise  is  indispensable, 
avoiding  fatiguing  effort,  hurry  and  worry,  (c)  Medicinal  treatment  is 
secondary.  Alkalies  are  useless,  though  claimed  to  produce  an  increased 
output  of  uric  acid;  they  operate  only  by  preventing  decomposition  of 
the  neutral  (bi-)  sodium  phosphate  (the  chief  uric  solvent),  e.g.,  lithium 
carbonate,  sodium  bicarbonate  or  mineral  waters.  Luff  advises  guaiacum 
resin,  gr.  v-x,  t.  i.  d.  Piperazin,  lysidin,  urotropin,  urosin  and  sidonal 
are  inert. 

3.  Chroxic  Gout. — This  is  difficult  to  treat.  For  general  dietetic, 
hygienic  and  medicinal  measures,  see  above.  Colchicum  T\dne,  Vf[x, 
and  potassium  iodide,  gr.  v,  may  relieve  arthritis,  asthma,  neuralgia 
and  eczema.  Tonics,  principally  arsenic,  are  indicated  in  marantic 
forms.  Tophi  should  not  be  operated  on;  local  measures  are  useless, 
save  Bier's  stasis,  gentle  massage,  dry  heat  or  salicylate  salves  (ac. 
salicylic.  4,  lanolin  40,  and  oleum  terebinthinee  1  part). 

RICKETS. 

Definition. — A  metabolic  affection  of  early  infancy,  characterized 
chiefly  by  hyperemia  and  deficient  calcification  of  the  growing  bones. 
The  disease  was  first  well  described  by  Glisson  (1650).  The  name  is 
derived  from  an  old  English  word  meaning  "twisted,"  and  Glisson 
suggested  the  Greek  "rhachitis"  (vertebral  inflammation)  because  the 
spine  was  often  involved,  and  the  term  sounded  like  "rickets." 

Etiology. — ^All  theories  advanced,  such  as  abnormal  calcium  metab- 
olism, infection  or  reduced  activity  of  the  thymus,  are  insufficient. 
(a)  The  diet  is  of  prime  importance;  proprietary  foods,  condensed 
milk,  cow's  milk,  excess  of  carbohydrates,  prolonged  lactation  or 
nursing  during  pregnancy  are  probable  factors.  A  deficiency  in  animal 
fats  and  proteids  is  causative;  after  20  litters  of  lion  cubs  had  been  lost 
from  rickets  in  the  London  Zoological  Gardens,  Bland  Sutton  found 
that  a  diet  of  milk,  powdered  bone,  meat  and  cod-liver  oil  prevented  it. 
(6)  Unsanitary  surroundings  may  be  causal,  as  lack  of  fresh  air  and 
sunlight,  crowded  quarters  and  kindred  factors  observed  largely  among 
the  poor  classes  in  large  cities;  among  nurslings  Kassowitz  (Vienna) 
observed  it  in  89  per  cent,  and  Joucousky  (St.  Petersburg)  in  90  per  cent. ; 
in  the  United  States  it  is  most  frequent  among  negroes  and  Italians. 
Hereditary  syphilis  is  a  predisposing  factor,  (c)  Age.  In  over  600  cases 
Baginsky  did  not  observe  it  in  children  under  three  months  of  age;  his 
figures  show  7  per  cent,  in  children  between  three  and  six  months  and 
88  per  cent,  between  three  months  and  two  years.  The  occurrence 
of  congenital  rickets  is  usually  denied.  Rickets  which  develops  later, 
up  to  puberty,  is  called  rhachitis  tarda. 


RICKETS  743 

Symptoms. — An  experienced  observer  may  diagnosticate  the  gradual 
onset  from  the  prodromes,  as  the  irregular  or  tardy  dentition;  irritability, 
insomnia  and  throwing  off  of  the  bedclothes;  sweating  about  the  head 
and  neck;  bronchitis;  digestive  disturbances,  anorexia,  malnutrition, 
meteorism  or  diarrhea;  immobility,  the  child  crying  when  moved  or 
touched  and  general  hyperesthesia.  However,  a  positive  diagnosis  is 
not  justifiable  until  the  bone  symptoms  develop. 

1.  Bone  symptoms  are  most  marked  in  the  skull  and  thorax,  (a)  The 
skull  shows  the  earliest  changes,  generally  in  the  first  year  of  life.  The 
face  appears  small  and  the  head  large.  Nodes  of  bone  appear  on  the 
frontal  and  parietal  regions,  which  with  the  occipital  flattening  produce 
the  caput  quadratum  (tete  caree).  The  anterior  fontanelle  and  sutures 
(which  normally  close  at  the  fifteenth  or  eighteenth  month)  remain  open, 
even  until  the  fourth  year.  The  occiput  softens  (craniotabes)  in  40  per 
cent.,  near  the  lambdoid  suture;  the  occipital  protuberance  remains 
hard.  Craniotabes  may  less  frequently  occur  in  the  frontal  bones; 
besides  the  actual  bone  changes  (v.  i.),  the  pressure  of  the  pillow  and 
brain  further  its  development.  In  extreme  cases  the  peri-  and  endo- 
cranium  actually  touch,  and  in  moderate  degrees  the  skull  feels  "parch- 
ment-like." Though  it  occurs  also  in  syphilis,  craniotabes  is  rather 
characteristic,  with  the  tender  quadrate  head,  head  sweating,  thin 
occipital  hair  and  blue  scalp  veins.  The  frequent  systolic  murmur  heard 
over  the  greater  fontanelle  is  also  heard  in  other  affections  or  in  health 
and  is  said  to  occur  only  in  conjunction  with  a  similar  bruit  in  the 
carotids.  The  upper  jaw  becomes  long  and  narrow  and  the  lower  jaw 
hexagonal,  from  muscular  traction  on  the  soft  bones.  The  eruption  of 
the  teeth  is  delayed  until  the  second  or  even  the  third  year;  the  second 
teeth  are  crowded,  carious,  curved  and  eroded.  (6)  In  the  thorax,  the 
rhachitic  "rosary"  appears  toward  the  end  of  the  first  or  early  in  the 
second  year;  it  is  so-called  from  the  bead-like  succession  of  enlarged 
chondrocostal  joints — enlarged  epiphyses.  The  chest  is  altered  toward 
the  end  of  the  second  year,  due  to  the  softness  of  its  bones,  traction 
exerted  by  the  diaphragm,  atmospheric  pressure  and  sometimes  by 
external  influences,  as  holding  of  the  child  with  a  hand  on  the  chest. 
Louis's  angle  is  often  prominent,  and  the  sternum  juts  forward,  causing  the 
"chicken  breast"  (pectus  carinatum).  There  is  also  a  depression  outside 
of  the  costochondral  junctions  which  extends  outward  and  downward, 
and  is  accentuated  by  some  eversion  of  the  costal  arch.  The  thoracic 
deformity  promotes  respiratory  complications  and  dyspnea,  which  in 
turn  aggravate  it.  With  this  deformity  we  may  group  lumbar  kyphosis 
which  is  arcuate  and  not  angular,  the  thickened  or  bent  clavicles  and  the 
thickening  of  the  spine  or  edges  of  the  scapulae,  (c)  In  the  extremities, 
the  epiphyses,  particularly  of  the  ulna,  radius,  tibia  and  fibula,  are  enlarged, 
at  the  same  time  as  the  rosary,  craniotabes  and  wide  fontanelle.  The 
epiphyses  also  are  tender  and  painful  and  may  look  like  "  double  joints." 
Deformities  may  develop  from  muscular  traction  or  the  weight  of  the 
body ;  the  arms  may  incline  outward  and  forward  or  the  forearms  become 
convex  toward  their  extensor  surfaces.  The  thighs  sometimes  become 
convex  anteriorly  and  outwardly;  the  legs  bow  outward  or  less  often 


744  CONSTITUTIONAL  DISEASES 

forward,  especially  when  early  walking  is  encouraged.  Spiral  deformities 
are  less  frequent.  The  gait  is  waddling.  Green-stick  or  actual  fractures 
sometimes  occur,  (d)  The  flat  rhachitic  yelms  develops  by  the  weight 
of  the  body  pushing  the  sacrum  into  the  pelvis  and  the  counter-pressure 
of  the  thighs  narrowing  the  anterior  pelvis,  so  that  the  pelvic  aperture 
may  become  heart-shaped,  the  acetabula  lie  more  anteriorly  and  the 
iliac  crests  flare  outward,  {e)  Pathology.  Normal  bone  grows  in  length 
as  follows:  there  are  two  zones  in  the  epiphyseal  surface  facing  the  shaft; 
(i)  the  first  zone  is  nearest  the  shaft,  is  faintly  yellow  and  measures  2 
mm.;  it  is  the  zone  of  preliminary  calcification,  into  which  normally  the 
bloodvessels  grow  and  form  medullary  canals  by  absorbing  small  areas 
of  bone,  and  in  which  osteoblasts  appear  and  calcification  develops. 
In  rickets  the  calcification  is  imperfect  and  irregular  in  this  zone  and 
the  bloodvessels  grow  not  merely  into  these  calcified  areas  but  beyond 
them,  even  into  the  cartilage  area,  and  absorb  what  little  new  bone  is 
formed,  (ii)  The  second  zone  lies  outside  the  one  described,  is  sharply 
demarked  from  it,  is  normally  bluish,  measures  1  or  2  mm.  in  thickness 
and  is  known  as  the  hyperplastic  zone,  in  which  the  cartilage  cells  divide 
and  proliferate.  In  rickets  this  zone  becomes  larger,  proliferates 
irregularly  and  is  invaded  by  bloodvessels  and  irregular  foci  of  abortive 
calcification;  the  demarkation  between  the  first  and  second  zones  is 
ill-defined.  Normal  bones  grow  in  thickness  by  bony  increase  beneath 
the  periosteum.  In  rickets  this  layer  becomes  several  millimeters  thicker, 
irregular  and  nodose.  Normal  bone  develops  in  the  skull  and  face  in 
the  connective  tissue.  In  rickets  the  lime  salts  are  either  not  deposited, 
are  insufficiently  deposited  (craniotabes)  or  overdeposited  as  bosses 
(osteosclerosis).  The  essence  of  this  inflammation  or  dystropy  is  undue 
hyperemia  and  irregular,  deficient  calcification;  which  one  is  primary 
remains  a  disputed  point;  the  bones  may  contain  but  20  to  30  per  cent, 
of  the  normal  amount  of  lime  salts. 

2.  General  Symptoms. — (a)  Muscular  weakness  is  pronounced,  as 
evidenced  by  impaired  breathing,  the  tardy  efforts  to  hold  up  the  head 
and  disinclination  to  walk;  in  this  myopathia  rhachitica  there  is  a  great 
reduction  of  the  caliber  of  the  muscle  fibers,  much  nuclear  multiplica- 
tion and  increase  of  their  longitudinal  and  decrease  of  their  transverse 
striation.  (b)  Nutrition;  there  is  anemia,  sometimes  with  leukocytosis 
and  often  with  emaciation,  (c)  Nervous  system:  Mentality  is  unim- 
paired; rhachitic  patients  frequently  grind  their  teeth;  spasmodic 
conditions  are  not  infrequent,  as  generalized  convulsions,  tetany  and 
spasm  of  the  glottis,  (d)  Temperature  always  denotes  complications,  (e) 
Digestive  disturbances  are  common;  there  may  be  anorexia,  diarrhea, 
more  commonly  constipation  and  distention  of  the  abdomen,  from  enlarge- 
ment of  the  liver  and  spleen,  and  possibly  from  thoracic  changes.  The 
amount  of  chalk  in  the  feces  may  be  increased.  The  spleen  is  enlarged  in 
70  per  cent.,  and,  less  often  and  less  markedly,  the  liver.  (/)  Rickety 
children  catch  cold  easily  and  bronchitis  frequently  leads  to  atelectasis 
and  bronchopneumonia,  (g)  The  heart  may  be  luxated  from  the  altered 
thoracic  conformation,  which  frequently  causes  hypertrophy  of  the  right 
ventricle,    (h)  Eczema  is  common. 


RICKETS  745 

Course,  Complications  and  Prognosis. — (a)  TJie  onset  is  insidious  and 
the  clinical  course  covers  a  year  or  more.  (6)  Complications  include  but 
few  of  immediate  danger,  as  bronchitis,  pneumonia  and  spasm  of  the 
glottis.  Later  complications  include  the  contracted  rhachitic  pelvis  of 
obstetrical  importance,  kyphosis  and  pulmonary  tuberculosis,  which 
is  found  in  36  per  cent,  of  the  fatal  cases;  its  early  diagnosis  depends 
largely  upon  auscultation,  for  percussion  is  peculiarly  deceptive  when 
the  chest  is  deformed.  (c)  The  prognosis  is,  with  these  exceptions, 
excellent  as  to  life,  and  with  care,  as  to  deformity,  for  deformities 
may  regress. 

Diagnosis. — The  diagnosis  is  based  chiefly  upon  the  bone  changes. 
Errors  are  possible  from  precipitate  diagnosis,  based  on  the  prodromal 
phenomena,  (a)  Barloiv's  disease  (q.  v.),  misnamed  acute  rickets,  has 
no  connection  with  it.  (b)  Syphilis  predisposes  to  rickets  but  is  other- 
wise distinct  and  separate;  it  usually  develops  at  a  time  (first  to  sixth 
month)  when  rickets  is  most  uncommon  and  is  usually  stamped  by  other 
syphilitic  stigmata,  as  cutaneous  and  mucous  syphilides;  when  it  invades 
the  epiphyses,  the  femur  is  usually  its  seat,  and  between  the  cartilage 
and  bone,  the  wall-like,  very  tender,  painful  and  doughy  swelling  is  rather 
fusiform,  compared  with  the  rounder  rhachitic  nodes;  epiphyseolysis 
may  occur  in  syphilis,  but  never  in  rickets;  in  doubtful  cases  an  ex 
juvantibus  diagnosis  and  the  sero-test  may  be  made,  (c)  Vertebral  tuber- 
culosis is  easily  distinguished;  the  rhachitic  kyphosis  is  arcuate,  not 
angular. 

Treatment. — 1.  Hygiene. — Fresh  air  and  sunlight  produce  wonderful 
results,  particularly  in  the  country,  mountains  or  at  the  sea-side. 

2.  Dietetic. — In  nurslings  (who  seldom' develop  the  disease),  a  wet- 
nurse  may  entirely  cure  the  disease.  In  older  children  it  may  be  less  a 
question  of  food  than  of  digestion. 

3.  Medicinal. — No  specific  is  known,  but  phosphorus  is  more  impor- 
tant than  any  other  drug.  Under  its  use  the  child  becomes  easier  and 
brighter;  the  nervous  symptoms  abate,  as  insomnia,  convulsions,  tetany 
or  laryngospasm;  the  osseous  symptoms  are  improved,  bone  is  deposited 
and  dentition  occurs,  both  clinically  and  in  experiments.  Phosphorus 
itself  is  given  in  doses  of  gr.  2-^-^-1-^-5  in  piU  fonn  or  as  the  ol.  phospho- 
ratum  (1  per  cent,  solution)  Tn,j,  t.  i.  d.,  or  better,  in  1  per  cent,  cod-liver 
oil;  the  oil  or  emulsion  should  be  freshly  prepared,  for  both  deteriorate 
readily  on  exposure  to  light,  (Its  toxic  symptoms  are  fever,  thirst, 
anorexia  and  weakness;  vomiting  of  food,  mucus,  bile,  later  blood  and 
sometimes  phosphorescent  material;  abdominal  pain,  diarrhea  or  con- 
stipation, phosphorescent,  clay-colored  or  bloody  feces;  jaundice;  the 
liver  at  first  may  be  large,  but  becomes  small;  there  may  be  cholemia; 
albumin,  bile,  casts,  leucin  and  tyrosin  in  the  urine  and  hemorrhages 
from  the  uterus,  abortion  or  miscarriage  and  bleeding  from  other  sur- 
faces.) Cod-liver  oil  was  recommended  by  Bretonneau  in  1827;  if  it  is 
well  tolerated  by  the  stomach,  the  general  level  of  health  may  be 
elevated  by  its  use;  if  not,  cream  and  butter  should  be  given.  Iron 
is  a  good  tonic.  It  is  proved  that  a  sufficient  quantity  of  calcium 
salts  is  present  in  the  food. 


746  CONSTITUTIONAL  DISEASES 

4.  Orthopedic. — During  the  florid  stage  the  child  should  be  kept 
quiet  upon  a  firm  mattress  and  off  his  feet.  Later,  corrective  measures 
are  indicated  for  the  kyphosis  and  deformity  of  the  Hmbs. 

OBESITY. 

Etiology. — Obesity  (adiposity,  corpulence  or  polysarcia  adiposa)  is 
favored  (a)  by  heredity;  it  frequently  occurs  in  entire  families;  con- 
genital cases  are  known;  (h)  by  mode  of  life,  e.  g.,  lack  of  exercise,  over- 
eating and  alcohoHc  indulgence,  (c)  The  menopause  is  frequently  attended 
by  increase  in  weight,  (d)  Diseases  of  the  thyroid  or  hypophysis  or 
nervous  or  osseous  system;  and  gout,  diabetes,  anemia,  valvular  dis- 
ease and  emphysema,  which  act  rather  by  preventing  adequate  exercise 
than  by  deficient  oxygenation. 

Symptoms. — The  general  habitus  requires  no  description.  Fat  develops 
in  the  subcutaneous  tissues,  in  parts  where  it  is  normally  found,  as  in 
the  omentum  and  around  the  kidneys  and  it  may  cause  fatty  infiltration 
and  degeneration  of  all  internal  organs  excepting  the  brain  and  spleen; 
even  the  blood  may  contain  fat  (lipemia). 

1.  Cardiac. — The  heart  is  embarrassed  by  increased  resistance  to 
the  capillary  flow,  fatty  infiltration  of  the  myocardium,  and  fat  accu- 
mulation in  the  chest  wall,  omentum  and  mediastinum.  The  pulse  is 
more  often  frequent  than  slow.  Hypertrophy  may  occur.  Edema  is  not 
uncommon. 

2.  Respiratory. — The  breath  sounds  and  heart  tones  are  faint  and 
thoracic  percussion  is  difficult  because  of  the  subcutaneous  fat.  Bron- 
chitis is  common  and  probably  results  from  the  ready  sweats  and  conse- 
quent chilling.    Dyspnea  may  occur  on  exertion. 

•3.  Digestive. — Digestive  disturbances  may  develop.  The  large  liver 
is  less  frequently  fatty  than  congested  and  hypertrophic.  Constipation 
and  hemorrhoids  are  frequent. 

4.  Urinary. — The  urine  may  be  scanty  in  oxaluric,  lipuric,  lithuric, 
albuminuric  or  glycosuric  subjects.  Actual  impotence  is  not  uncommon, 
as  well  as  mechanical  obstacles  to  coitus. 

5.  Lessened  physiological  resistance  to  infections,  surgical  measures  or 
phlebotomy,  and  (6)  such  associated  affections  as  diabetes,  gout,  calculous 
disease  and  less  often  contracted  kidney,  arteriosclerosis  and  apoplexy 
may  be  noted. 

Treatment. — Treatment  is  (a)  that  of  the  fundamental  condition  and 
(fe)  dietetic.  The  various  "cures"  enumerated  possess  more  than  his- 
torical interest — (i)  Banting's  cure.  Banting,  a  merchant,  was  treated 
so  successfully  by  Wm.  Harvery  for  obesity  that  he  addressed  a  "  Letter 
to  the  Public  on  Obesity"  (1863).  This  diet,  largely  albuminous,  consisted 
of  fish,  meat,  eggs,  tea  without  sugar  or  milk,  vegetables,  fruit,  some  red 
wine  and  toast  without  butter.  It  may  cause  indigestion,  nervousness, 
palpitation  or  gout,  (ii)  Ebstein,  himself  a  sufferer,  proposed  (1872) 
a  diet  with  larger  proportions  of  fat;  his  diet  consisted  of  meat,  fish, 
eggs,  tea,  leguminous  vegetables,  fruit,  fats  and  butter,  but  restricted 
the  carbohydrates;  digestive  disorders  may  also  occur  under  this  system. 


ADIPOSIS  DOLOROSA  OR  DERCUM'S  DISEASE  747 

(iii)  Oertel  allowed  more  carbohydrates,  limited  the  fats  and  fluids  and 
insisted  upon  sweats  and  graduated  exercises.  From  the  following  it 
will  be  seen  that  all  these  methods  are  "starvation  cures"  The 
average  man  requires  118  gm.  of  nitrogen,  56  gm.  of  fat  and  500  gm. 
of  carbohydrates,  equaling  3054  calories. 

The  diet  of  Banting  contains  172  gm.  of  nitrogen,  8  gm.  of  fat,  and 
81  gm,  of  carbohydrates,  equaling  1112  calories. 

The  diet  of  Ebstein  contains  102  gm.  of  nitrogen,  85  gm.  of  fat,  and 
47  gm.  of  carbohydrates,  equaling  1401  calories. 

The  diet  of  Oertel  contains  183  gm.  of  nitrogen,  38  gm.  of  fat,  and  143 
gm.  of  carbohydrates,  equaling  1690  calories.  In  any  reduction-cure 
the  patient  may  suffer  from  breaking-down  of  the  body  proteids,  which 
causes  the  weakness.  In  all  cases  the  total  amount  of  nitrogen  in  the 
urine,  which  constitutes  90  per  cent,  of  the  nitrogen  excreted,  should  be 
watched;  if  more  is  excreted  than  ingested  the  nitrogenous  food  should 
be  increased  to  obviate  muscular  and  cardiac  weakness.  The  diet  then 
should  consist  of  moderation  in  all  foods,  with  restriction  of  the  carbo- 
hydrates, whose  easy  reduction  into  water  and  carbonic  acid  spares  the 
tissue  waste.  Alcohol  should  be  forbidden.  Beer  contains  not  only  3  to 
5  per  cent,  of  alcohol,  but  double  this  percentage  of  soluble  starch  and 
dextrin.  The  fluid  ingested  should  be  reduced  to  2  or  3  pints  daily.  A 
milk  or  vegetable  diet  is  sometimes  successful. 

(c)  Active  and  graduated  exercise  is  indispensable,  except  in  marked 
cardiac  disease  (v.  Fatty  Heart,  Myocarditis  and  Dilatation). 

(d)  The  patient  should  sleep  not  more  than  seven  hours  and  should 
bathe  daily  to  avoid  skin  complications  and  to  promote  perspiration. 
Thyroid  extract  is  not  to  be  taken,  unless  thyroid  insufficiency  is  sus- 
pected, for  it  breaks  down  the  albumins  rather  than  the  fats. 

ADIPOSIS   DOLOROSA   OR   DERCUM'S   DISEASE. 

This  dystrophy  was  described  by  Dercum  (1888),  as  a  "disorder 
characterized  by  unequal  symmetrical  deposits  of  fatty  masses  in  various 
parts  of  the  body,  preceded  or  attended  by  pain."  There  were  only  50 
reported  cases  up  to  1909,  most  of  which  were  females.  It  develops  in 
middle  life,  chiefly  after  the  fortieth  year. 

Pathology. — In  the  8  autopsies  the  thyroid  gland  was  affected  in  7  and 
the  hypophysis  in  5.  In  the  cases  of  Dercum  and  Burr  an  interstitial 
neuritis  was  found,  which  is  likewise  noted  in  the  fatty  tumors  removed 
during  life;  symmetrical  lipomatosis  has  been  observed  in  multiple 
neuritis. 

Symptoms. —  Two  cardinal  clinical  features  are  observed,  as  the  term 
adiposis  dolorosa  indicates:  (1)  The  obesity  is  either  diffuse  or  is  local- 
ized fatty  tumors  or  both  in  combination;  lipomata,  from  the  size  of  a 
pea  to  large  dimensions,  occur  on  the  trunk  and  proximal  parts  of  the 
extremities,  but  never  on  the  face,  forearms,  hands,  legs  or  feet.  Indeed 
the  thinness  of  the  wrists  and  legs  contrasts  sharply  with  the  massive 
body,  thighs  and  upper  arms.  The  pendulous  abdominal  fat  may  hang 
down  like  an  apron.    In  one  of  the  author's  cases  the  localized  abdominal 


748  CONSTITUTIONAL  DISEASES 

fat  resembled  a  circular  life-buoy,  sagging  down  over  the  thighs.  In 
another  it  almost  resembled  myxedema,  save  for  its  circumscribed  dis- 
tribution and  facial  exemption.  (2)  The  pains  may  be  neuralgic  or 
paresthetic. 

Subcutaneous  hemorrhages,  hematemesis,  epistaxis  and  metrorrhagia 
are  not  uncommon.  The  patients  are  often  nervous,  perhaps  hysterical 
and  lack  initiative.  In  the  later  stages  epilepsy  has  developed  and 
death  from  asthenia,  psychoses,  nephritis  or  intercurrent  affections  is 
recorded.    A  number  of  cases  improved  under  thyroid  extract. 


SECTION  IX. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 


DISEASES  OF  THE  BEAIN. 

CEREBRAL  LOCALIZATION. 

Autopsy  findings  in  carefully  studied  cases,  animal  experimentation 
and  constantly  increasing  surgical  intervention  have  developed  the 
nature  of  lesions  and  important  results  regarding  their  localization.  The 
doctrine  of  Flourens  that  all  parts  of  the  brain  were  equally  important 
met  its  first  contradiction  in  Broca's  discovery  (1861)  that  motor  aphasia 
was  due  to  disease  of  the  third  left  frontal  convolution.  In  1870  Fritsch 
and  Hitzig  discovered  that  stimulation  of  certain  areas,  now  known  as 
the  motor  cortex,  resulted  in  contraction  of  definite  muscles  of  the  oppo- 
site side  of  the  body.  Since  then  Bevor,  Horsley,  Meynert,  Jackson, 
Flechsig,  Ferrier,  Munk,  Glotz,  Nothnagel,  Charcot,  Wernicke  and 
others  contributed  to  the  development  of  brain  localization. 

I.  The  Motor  Cortex.— This  embraces  chiefly  the  central  convolutions 
on  either  side  of  the  fissure  of  Rolando  (the  ascending  frontal  and  ascend- 
ing parietal  lobes  and  anterior  two-thirds  of  the  superior  parietal  lobe), 
the  foot  of  the  three  frontal  convolutions  and  on  the  inner  surface 
of  the  hemisphere,  the  paracentral  lobule.  In  this  area  lie  the  large 
pyramidal  cells  which  Betz  discovered  were  the  origin  of  the  motor  or 
pyramidal  tracts.  The  centres  run  somewhat  into  adjacent  areas,  espe- 
cially those  with  physiological  associations.  The  leg  centre  occupies  the 
upper  quarter  of  the  ascending  frontal  and  ascending  parietal  convolu- 
tions and  part  of  the  superior  parietal  lobe  (all  adjacent  to  the  longitudinal 
fissure)  and  passes  over  to  the  inner  aspect  of  the  hemisphere  to  the 
paracentral  lobule,  which  is  the  centre  for  the  thigh,  pelvis  and  gluteal 
muscles  (Fig.  50).  A  lesion  in  the  falx  cerebri  or  dura  near  the  longi- 
tudinal fissure  may,  in  rare  cases,  involve  both  leg  centres  and  produce 
cerebral  paraplegia,  although  most  paraplegias  are  spinal  in  origin.  The 
arm  centre  is  the  largest,  covers  the  middle  two  quarters  of  the  central 
convolutions,  lies  below  and  somewhat  overlaps  the  leg  centre.  In  Fig. 
51  it  is  seen  that  there  are  certain  general  as  well  as  separate  centres 
for  the  thumb  and  fingers.  The  head  centre  is  below  the  arm,  covering 
the  lowest  quarter  of  the  central  convolutions  (the  entire  operculum), 
the  upper  part  of  the  Sjdvian  fissure,  the  posterior  part  of  the  lowest 
frontal  convolution  and  possibly  the  first  and  second  frontal  gyri.    The 


750 


DISEASES  OF   THE  BRAIN 


face  centre  lies  directly  beneath  the  arm  centre,  and  is  mostly  located 
on  the  anterior  ascending  convolution,  the  upper  facial  component  lying 
higher  than  the  lower  facial  centres.  The  eye  centre  of  the  facial  is 
bilateral,  probably  consisting  of  several  foci.  The  mouth  has  several 
centres.  The  motor  speech  area  is  principalh'  in  the  lower  left  frontal 
gyrus  and  is  probably  the  chief  centre  for  chewing.  The  trunk  centre 
lies  in  the  posterior  part  of  the  first  frontal  convolution  and  also  on  its 
median  aspect,  just  anterior  to  the  paracentral  lobule;  there  is  a  trunk 
representation  between  the  leg  and  arm  centres  and  a  neck  centre  between 
the  arm  and  face.  The  more  complicated  the  function,  the  larger  is  the 
centre  (as  for  the  tongue,  fingers,  mouth)  and  the  more  unilateral  the 
localization  in  the  brain.     ^Muscles  used  rhythmically  or  in  pairs  are 


Fig.  49. — General  distribution  of  centres  in  cerebral  localization;  outer  surface  of  brain. 


supplied  from  both  hemispheres,  as  the  muscles  of  the  forehead  and 
respiration  or  swallowing  and  to  some  degree  the  legs  and  trunk.  Pro- 
trusion of  the  tongue  to  one  side  has  a  monolateral  centre,  though  its 
protrusion  in  the  median  line  and  its  withdrawal  depend  on  both 
hemispheres. 

Total  lasting  hemiplegia  of  the  opposite  side  of  the  body,  with  sensory 
disturbance,  aphasia  and  intellectual  disturbance,  results  from  complete 
destruction  of  the  entire  motor  cortex  of  one  side.  Cortical  hemiplegia 
is  less  common  than  monoplegia  (paralysis  of  one  member)  which  always 
suggests  a  cortical  lesion.  Crural  monoplegia  is  rare  and  is  due  largely 
to  vascular  lesions  in  the  paracentral  lobule  (anterior  cerebral  artery). 
Brachial  monoplegia  may  result  from  vascular  lesions,  tumors  or  trauma; 


CEREBRAL  LOCALIZATION 


751 


the  finest  selection,  as  of  the  thumb  alone,  fingers  or  wrist,  is  noted. 
Sensory  distm-bance  is  common  {v.  i.).  Pure  facial  monoplegia  is 
unknown,  although  a  faciolingual  form  with  motor  aphasia  is  observed. 
Associated  monoplegia  is  more  usual,  most  commonly  paralysis  or  paresis 
(partial  paralysis)  of  the  arm  and  face  (brachiofacial  monoplegia,  although 
strictly  not  a  monoplegia).  Next  in  frequency  is  the  arm-and-leg  type 
(brachiocrural)  in  which  two  contiguous  centres  are  involved.  A  leg- 
and-face  tjq^e  never  occurs,  because  their  centres  lie  too  far  apart.  A 
lesion  involving  one  part  after  another  speaks  for  cortical  localization. 
Cortical  paralyses  are  not  attended  by  the  reaction  of  degeneration.  In 
cortical  lesions  with  paralysis,  twitchings  or  convulsive  movements  are 
common,  "cortical,  partial  or  Jacksonian  epilepsy;"  the  lesion  partly 
destroys  the  motor  cortex  (paralysis)  and  at  the  same  time  causes  irri- 
tation (convulsions)  precisely  as  contractions  are  produced  in  animals 


Fig.  50. — Cerebral  localization;   inner  surface  of  hemisphere. 

by  electrical  stimulation  of  the  cortex;  they  are  mainly  (a)  mechanical, 
as  irritation  or  increased  intracranial  tension  (50  per  cent,  of  cases  are 
rapidly  growing  tumors),  or  (5)  vascular  (hemorrhage,  embolism  or 
inflammation);  stationary  lesions  rarely  produce  Jacksonian  epilepsy 
unless  they  are  located  in  the  cortex.  The  spasms  may  involve  but  one 
part  (monospasm),  as  the  arm,  exclusively  a  sign  of  cortical  irritation, 
or  they  may  pass  from  one  centre  to  others.  They  always  commence 
in  one  centre  and  proceed  in  a  fixed  order;  if  the  arm  region  is  the  seat 
of  a  tumor  the  Jacksonian  epilepsy  flexes  the  fingers,  moves  the  thumb, 
then  the  forearm,  arm  and  shoulder  and  then  passes  down  the  cortex 
region,  so  that  it  involves  the  face,  mouth  and  finally  the  leg  (see  Fig.  49) . 
If  the  lesion  is  in  the  face  area,  the  various  facial  muscles  contract  and 
the  eye  deviates,  then  the  next  area  above  participates,  and  finally  the 
higher  leg  centre  is  implicated.  That  is,  the  spasm  never  skips  over  a 
centre. 


752 


DISEASES  OF   THE  BRAIN 


The  spasms  are  often  preceded  by  a  tingling  in  the  part  and  are  mostly 
clonic,  or  clonic  broken  by  tonic  spasms.  Consciousness  is  maintained, 
unless  the  fits  reach  the  other  side,  are  very  frequent  or  the  lesion  is 
deep,  below  the  cortex.  The  opposite  side  is  involved  through  the 
commisural  fibers  of  the  corpus  callosum.  Jacksonian  differs  from 
regular  epilepsy  in  that  no  cry  is  observed,  the  commencement  is  local 
and  more  gradual  and  consciousness,  if  lost,  disappears  gradually,  not 
precipitately.  The  seizure  lasts  several  seconds  to  a  minute  or  two  and 
is  followed  by  some  vertigo,  nausea,  stupor  or  disturbance  of  speech;  if 
spasms  occur  without  paralysis,  paresis  in  the  involved  parts  follows. 


HEAD  TO  OPPOSITE  SIDE 


TO  MID  LINE 
CHEWING 


ASSOCIATED 

MOVEMENTS 

OF  EYES 


FINGERS.ALONE 
THUMB,  ALONE 


FISSURE  OF  ROLANDO 
p^  FISSURE  OF  SYLVIUS 

Fig.  51. — Cerebral  localization  in  detail:  Fi,  F2,  Fs,  first,  second  and  third  frontal  con- 
volutions; A.F.,  ascending  frontal  convolution  and  A. P.,  ascending  parietal  convolution; 
S.P.,  supramarginal  and  A.R.,  angular  convolution;  Oi,  O2,  O3,  first,  second  and  third  occipital 
convolutions;  Ti,  Ti,  Tz,  first,  second  and  third  temporal  convolutions.  The  explanation 
of  line  A',  A  is  given  under  Internal  Capsule. 


due  to  transient  exhaustion  of  the  cortex.  Jacksonian  epilepsy  in  its 
lightest  forms  may  be  sensory. 

Regarding  sensory  localization  in  the  cortex,  Munk  held  that  the 
sensory  and  motor  areas  are  the  same  {v.  i.).  Vasomotor  disturbance 
is  common  in  cortical  lesions. 

After  total  lesions  of  the  central  convolutions,  the  hands  improve 
very  little  in  adults;  other  members  improve,  to  some  extent,  through 
assumption  of  function  by  the  sound  side  of  the  brain;  in  young  indivi- 
duals the  sound  pyramidal  tracts  in  the  cord  may  hypertrophy  to  double 
their  size.  The  motor  fibers  running  from  the  pyramidal  cells  of  the  cortex 
to  the  anterior  horns  of  the  spinal  cord,  constituting  the  uyjier  motor 


CEREBRAL   LOCALIZATION  753 

neurone,  undergo  descending  degeneration,  that  is,  degeneration  in  tlie 
direction  of  the  motor  impulse. 

n.  The  Cortex  of  the  Parietal  Lobes. — Our  knowledge  of  function 
is  le-s  definite.  \a^  Lesions  of  the  fird  lobe  (Pi,  Fig.  51,  the  precimeus 
in  Fig.  50 j,  supplied  by  the  anterior  cerebral  artery,  cause  disturbance 
in  motility  of  the  leg,  with  altered  muscle  sense,  "mind-blindness," 
inability  to  read  (alexia)  and  perhaps  hemianopsia,  (b)  Disease  of  the 
supramarginal  convolution  (S.P.,  Fig.  51  j,  also  involving  the  motor  cortex, 
produces  greater  disturbance  of  sensation  than  when  the  lesion  is  con- 
fined to  the  motor  centres;  muscular  sense  is  disturbed,  usually  with  some 
motor  paralysis  or  paresis.  INIuscle  sense  is  disturbed  in  23  per  cent,  of  all 
cases  of  cerebral  hemiplegia;  in  more  than  50  per  cent.,  no  special  sensory 
disturbance  is  noted.  There  may  be  loss  of  the  stereognostic  sense, 
whereby  the  patient  fails,  when  his  eyes  are  closed,  to  recognize  the 
geometric  form  of  soHd  objects,  as  a  key  or  ball.  Cortical  ataxia  some- 
times results,  on  account  of  disturbance  in  the  association  fibers.  It 
differs  from  the  tabetic  and  cerebellar  ataxias  in  that  the  muscular 
strength  is  usually  diminished  and  the  finer  movements  impossible. 
Cortical  hemianesthesia  is  not  frequent,  (c)  Ptosis  and  paralysis  of 
the  orbicularis  palpebrarum  are  said  to  result  from  lesions  of  the  gyrus 
angularis  (A.R.,  Fig.  51)  and  also  inability  to  read  (alexia),  optic  aphasia 
and  "mind-blindness."  Wernicke  diagnosticated  softening  in  this  lobe 
by  conjugate  de\'iation  of  the  eyes  and  head.  Disease  of  the  posterior 
inferior  part  probably  causes  crossed  amblyopia. 

m.  The  Cortex  of  the  Occipital  Lobes. — The  visual  centre  lies  in 
the  cuneus  (Fig.  51j  and  the  first  occipital  lobe.  A  lesion  produces 
(a)  bilateral  homonymous  hemianopsia  (see  Affectioxs  of  the  Optic 
Xer^"e).  (6)  Hemichromatopsia,  an  homonymous  color-blindness,  in 
which  the  lesion  is  superficial  and  anterior;  (c)  total  cortical  blindness, 
if  the  lesion  is  bilateral  or  both  optic  radiations  are  destroyed,  (d) 
"Mind-blindness''  results  from  a  lesion  in  the  anterior  outer  siui'ace  of 
the  left  occipital  region,  especially  the  second  occipital  lobe  or  of  the 
g\TUS  angularis.  The  visual  memory  is  lost;  things  actually  seen  are 
misinterpreted  and  the  patient  confuses  persons  and  things,  {e)  Alexia, 
inability  to  read,  also  called  "word-blindness,"'  wherein  the  patient  can 
read  but  fails  to  understand  the  letters  or  words  he  reads.  His  memory 
for  words  is  lost.  It  is  due  to  destruction  of  the  subcortical  association 
fibers  in  the  second  occipital  lobe  and  the  gyrus  angularis;  it  most 
commonly  follows  vascular  disease.  (/)  Optic  aphasia  results  from  foci 
in  the  left  occipital  lobes  fand  also  in  the  angular  and  supramarginal 
convolutions)  and  consists  of  misinterpretation  of  visual  impressions, 
so  that  the  patient  miswTites  and  misnames  objects  seen,  though  able 
to  name  them  when  he  feels  them. 

rV.  The  Cortex  of  the  Temporal  Lobes  iji,  T^,  Tz,  Fig.  51).— The 
outer  surface  of  the  po.-^terior  half  of  the  first  .(and  second)  temporal 
convolution  is  the  auditory  centre;  disease  in  this  cortex  produces  (a) 
deafness  in  the  opposite  ear;  atrophy  of  this  lobe  is  encountered  in  con- 
genital deafness.  Deafness  is  usually  transitory,  fibers  passing  to  both 
ears  from  each  centre.  If  this  lobe  is  destroyed  on  both  sides,  total 
48 


754  DISEASES  OF  THE  BRAIN 

deafness  results,  (b)  Conjugate  deviation  of  the  eyes  is  said  to  be  a  reflex 
from  auditory  impressions,  (c)  Disease  of  the  first  temporal  lobe  pro- 
duces "word-deafness"  or  "mind-deafness,"  a  loss  of  the  comprehension 
of  speech.  In  the  uncinate  gyrus  (Fig.  50)  the  special  sense  of  smell 
probably  has  its  centre.  The  gyrus  fornicatus  (Fig.  50)  is  said  to  be  the 
centre  for  taste  and  jjain. 

V.  The  Frontal  Cortex  and  Aphasia. — Regarding  the  frontal  lobes 
anterior  to'^their  participation  in  the  motor  cortex,  profound  disease  may 
exist  without  clinical  symptoms.  They  have  long  been  thought  to  be 
the  residence  of  (a)  the  jjsycliical  functions,  especially  for  ethical  and 
abstract  thought  (Meynert  and  Flechsig).  "Defect  in  character"  fol- 
lowed the  passage  of  a  large  crowbar,  1^  inches  thick  and  3|  feet  long, 
through  both  frontal  hemispheres,  in  Harlow's  famous  case,  {h)  Flechsig 
considers  the  frontal  lobe  the  anterior  association  centre,  the  middle  one 
being  the  cortex  of  the  island  of  Reil  and  the  posterior  one  the  large  area 
posterior  to  the  motor  cortex,  (c)  The  motor  speech  area  lies  in  the  lower 
frontal  convolution.  The  history  of  aphasia  marks  the  beginning  of 
cerebral  localization;  Bouillaud,  in  1825,  referred  aphasia  to  the  frontal 
lobes;  Dax,  in  1836,  narrowed  the  localization  to  the  left  frontal  region 
and  the  motor  centre  was  finally  confined  to  the  posterior  part  of  the 
lower  left  frontal  convolution  in  1861  by  Broca,  whose  name  is  given  to 
this  convolution.  The  sensory  element,  necessary  to  all  voluntary  move- 
ments, was  unknown  until  later,  when  Meynert  and  Wernicke  (1874) 
discovered  the  auditory  centre  in  the  first  temporal  convolution;  Wer- 
nicke localized  "  tvord-deafness"  in  the  same  convolution  of  the  left  side 
and  Naunyn  referred  disturbance  of  writing,  visual  aphasia,  etc.,  to  the 
gyrus  angularis  and  adjacent  parts  of  the  occipital  lobes. 

Motor  Aphasia. — The  motor  speech  centre  in  Broca's  lobe  controls  the 
motor  centres  next  described  and  retains  the  impressions  or  memories 
necessary  to  their  exercise.  The  corresponding  lobe  on  the  right  side  is 
the  actual  centre  in  left-handed  persons  and  often  assumes  the  functions 
of  the  left  speech  centres  after  disease  of  the  latter,  especially  in  children. 
Articulate  speech  depends  upon  the  integrity  of  the  lower  part  of  the 
ascending  frontal  convolution,  in  which  lie  the  centres  for  the  mouth, 
lips,  tongue,  jaw  and  larynx,  (a)  These  constitute  the  cerebral  mechanism 
of  speech,  whose  disturbance  is  designated  motor  aphasia.  Motor  fibers 
run  from  the  cortex  through  the  centrum  ovale,  internal  capsule  and 
crus  to  their  nuclei  in  the  pons  and  medulla,  whence  the  peripheral  bulbar 
nerves  to  the  tongue  and  larynx  take  their  origin.  (6)  These  lower 
tracts  constitute  the  bulbar  mechanism  of  speech,  disease  in  which  causes 
abolition  of  articulation  (anarthria)  or  more  often,  imperfect  articula- 
tion (dysarthria).  To  speak,  the  individual  must  have  ideas,  conceptions. 
To  illustrate,  a  cortical  lesion  in  Broca's  convolution,  as  small  as  a  hazel- 
nut, may  produce  motor  aphasia,  either  absolute  or  partial;  the  patient 
may  pronounce  correctly  some  few  words,  possibly  only  under  emotion 
or  in  certain  relations,  or  he  may  pronounce  words  wrongly,  although 
he  recognizes  his  mistake.  He  comprehends  what  is  said  to  him,  for 
the  lesion  involves  no  special  sense  element.  He  can  read  writing  and 
print,  especially  if  educated,  because  "  sight  may  stimulate  images  with- 


CEREBRAL  LOCALIZATION  755 

out  intervention  of  the  motor  centre,"  but  he  cannot  speak  voluntarily 
nor  repeat  what  is  said  to  him;  he  cannot  read  aloud;  as  a  rule  he  cannot 
write  (agraphia),  because  impulses  cannot  pass  to  the  hand  centre.  He 
may  be  able  to  copy.  The  cortical  is  the  usual  form  of  motor 
aphasia. 

A  subcortical  lesion  in  the  centrum  ovale  may  sever  the  fibers  between 
Broca's  convolution  and  the  motor  cortex  for  the  tongue,  lips,  etc.  The 
patient  cannot  speak,  but  the  speech  centre  is  normal,  and  he  can  write. 
This  pure  motor  aphasia  is  a  rare  lesion.  It  involves  the  commissural 
fibers  of  the  corpus  callosum  to  the  right  side  and  produces  permanent 
aphasia,  because  compensation  by  the  right  hemisphere  is  precluded; 
if  the  lesion  is  in  the  internal  capsule,  aphasia  is  transient  (compensation 
through  the  corpus  callosum). 

Sensory  Aphasia. — In  speech  sensory  relations  and  memories  are  neces- 
sary— hearing,  sight,  taste  and,  in  the  blind,  touch. 

Auditory  Aphasia. — Hearing  is  most  important  and  develops  in  the 
child  long  before  speech.  When  a  child  begins  to  talk,  or  when  one  who 
has  lost  speech  relearns  it,  the  brain  cortex,  through  an  association  of 
centres,  learns  to  connect  certain  sounds  or  words  with  definite  objects; 
through  the  auditory  nerves  which  run  from  each  side  to  both  auditory 
centres  in  the  first  temporal  convohdion  of  either  side,  he  hears  mechan- 
ically, as  we  may  hear  without  understanding  a  foreign  language,  and 
learns  to  associate  the  sounds  with  objects,  conditions  or  ideas,  for  which 
an  auditory  speech  centre  in  the  left  first  temporal  convolution  (in  right- 
handed  persons)  is  developed.  Remembering  a  sound  he  has  heard 
but  perhaps  has  never  spoken,  the  child  calls  into  play  Broca's  con- 
volution, the  cortical  centres  for  the  lips,  tongue,  etc.,  and  speaks.  Hear- 
ing is  necessary  to  articulate  speech,  unless,  as  in  deaf-mutes,  education 
replaces,  by  sight  and  touch,  the  associations  usually  acquired  by  hearing. 
Destruction  of  the  auditory  speech  centre  profoundly  disturbs  speech. 
The  patient  then  hears  by  the  auditory  nerves  and  centres  or  reads  by 
the  visual  apparatus,  but  does  not  understand  what  he  hears  or  reads, 
sensory  {auditory)  aphasia  or  word-deafness;  recovery  is  more  common 
than  in  motor  aphasia.  The  subject  in  speaking  transposes  words  (para- 
phasia) but  does  not  realize  his  mistakes,  an  important  distinction  from 
motor  aphasia.  Often  he  later  becomes  speechless.  He  cannot  repeat 
words,  write  from  dictation,  or  revive  words.  Writing  is  impossible, 
but  copying  of  words  is  sometimes  maintained. 

Subcortical  auditory  aphasia  or  pure  word-deafness  (the  rarer •  subcor- 
tical form),  results  from  disease  between  the  auditory  speech  centres  and 
the  two  centres  for  hearing.  Auditory  impressions  cannot  reach  the 
auditory  speech  centres  of  the  patient,  who  cannot  understand  what 
is  said,  cannot  repeat  or  write  from  dictation,  but  can  read,  speak  and 
write,  as  the  auditory  speech  centre  is  normal. 

"Amnestic"  aphasia  may  be  a  simple  difficulty  in  recalling  certain 
words  in  speaking  or  writing,  or  it  may  be  ver}^  pronounced  (word-deaf- 
ness). It  is  also  poorlv  called  conduction  aphasia  (Wernicke)  and  is 
due  to  interruption,  probably  in  the  island  of  Reil,  of  the  fibers  between 
the  motor  and  sensory  speech  centres. 


756  DISEASES  OF   THE  BRAIX 

^  ISUAL  Aphasia. — SigJit  is  very  important  in  sensory  speech.  The 
child  who  has  learned  and  is  able  to  speak  words,  reads  by  associating 
the  sounds  heard  and  spoken,  with  words,  letters  or  s^inbols  seen  by  him. 
^^^lile  in  most  indiA'iduals  mental  processes  are  carried  on  by  the  memory 
of  words,  in  rare  instances  ^•isual  memory  may  be  more  important. 
Destruction  of  the  angular  and  supramarginal  convolutions  by  causing 
a  loss  of  the  visual  memories  produces  alexia,  word-blindness,  an  inability 
to  read.  In  some  eases  the  patient  can  read,  but  without  understanding. 
He  usually  cannot  wTite  Tagraphia)  and  cannot  copy,  but  can  speak  fairly 
well  and  understand  what  is  spoken.  If  the  optic  centre  in  the  occipital 
lobes  is  intact  he  cannot  name  objects  after  seeing  them,  since  the  Aisuai 
memory  centre  is  destroyed,  but  may  recognize  a  watch  by  hearing  it 
tick  or  by  feeling  it.  Lesions  just  below  the  visual  memory  centre, 
involving  the  afferent  fibers,  produce  pure  subcortical  icord-hlindness,  or 
alexia,  with  hemianopsia  and  preservation  of  voluntary  speech  and 
wTiting.  Word-deafness  and  word-blindness  often  coexist;  41  instances 
of  congenital  word-blindness  were  collected  by  ]McCready. 

Pure  are  less  common  than  complicated  forms.  The  anatomical  lesions 
are  largely  the  result  of  softening,  the  entire  sphere  of  speech  being  sup- 
plied by  the  artery  of  the  fossa  of  Sylvius.  Motor  aphasia  is  likelv  to 
occur  with  disease  of  the  motor  cortex  or  cerebral  pyramidal  tracts,  and 
the  sensory  form  with  disease  of  the  optic  fibers.  ApoplexA".  traiuna  and 
in  children  tuberculosis  of  the  brain  or  meninges  are  also  causative. 
Lasting  aphasia  in  children  is  usually  due  to  mental  causes,  since  the 
right  frontal  area  usually  takes  up  the  function  of  Broca's  convolution. 
Congenital  aphasia  may  follow  bilateral  meningeal  hemorrhage.  Aphasia 
also  occius  in  idiocy,  melancholia,  migraine,  convulsions  and  from 
functional  causes  in  children,  as  from  fcA'er,  fright,  worms,  etc.  In 
adults  the  outlook  is  less  favorable;  reeducation  may  yield  fair  restilts. 

VI.  Centrum  Ovale. — Focal  symptoms  may  be  entirely  absent,  if  a 
lesion  occur  between  the  associative,  commissural,  motor  or  sensory 
fibers  (corona  radiataj.  A  lesion  must  be  (a)  very  near  the  cortex  to 
produce  Jacksonian  or  general  con\Tilsions.  A  monoplegia,  hemianopsia 
and  subcortical  aphasia  may  occur  in  this  location.  A  lesion  in  the 
island  of  Reil  may  produce  conduction  aphasia.  Psychic  symptoms  may 
result  from  interruption  of  the  association  fibers  which  run  from  one 
part  to  another  of  the  same  hemisphere  or  commissural  fibers  running 
from  one  hemisphere  to  the  other,  as  through  the  corpus  callosum. 
(6)  Internal  capsule  sAiiiptoms  result  from  lesions  low  in  the  centrum 
ovale. 

VII.  The  Internal  Capsule. — It  i.>  compacted  and  consists  of  nearly  all 
the  motor,  sensory  and  special  sense  fibers  between  the  brain  and  the 
lower  parts.  The  capsule  is  divided  into  an  anterior  limb,  the  knee  and 
a  posterior  limb. 

Anterior  Limb. — It  contains  fibers  from  the  frontal  cortex  to  the  optic 
thalamus  and  fibers  which,  in  lower  horizontal  sections,  run  into  the  knee 
and  are  found  in  the  basal  median  bundle  of  the  crus,  whence  they  run 
to  the  pons  nuclei  for  the  eye,  head,  neck  and  probably  larynx,  tongue 
and  mouth.    Lesions  here  are  verv  rare. 


CEREBRAL  LOCALIZATION  757 

Knee. — The  knee  (see  Fig.  5^)  contains  from  before  backward  fibers 
For  opening  of  the  eyes,  associated  movements  of  the  eyes  and  head, 
the  tongue  and  mouth  and  phonation  fibers  for  speech,  probably  including 
those  of  the  larynx. 

Posterior  Limb. — ^The  posterior  limb  contains  motor  fibers  in  its  anterior 
and  middle  thirds  (v.  Fig.  52);  in  its  posterior  third  (Charcot's  "sensory 
crossway"),  those  for  sensation  and  the  special  senses.  The  number 
of  fibers  to  a  muscle  depends  less  on  its  size  than  on  its  fineness  of  move- 
ment; e.  g.,  the  fingers  receive  a  large  number.  If  a  ruler  be  placed 
anterior  to  the  line  (A',  A)  in  Fig.  51  and  slowly  moved  to  the  right,  pre- 
serving its  parallelism,  the  cortical  motor  areas  touched  will  approxi- 
mately correspond  with  their  order  in  the  internal  capsule.  The  most 
common  sequence  of  lesions  of  the  internal  capsule  is  cerebral  hemiplegia 
of  the  opposite  side  of  the  body.  Though  hemiplegia  may  result  from 
lesions  elsewhere,  in  the  vast  majority  of  cases,  hemiplegia  is  the  result 
of  disease  of  the  internal  capsule.    If  the  latter  is  destroyed,  total  hemi- 


FiG.  52. — Localization  in  internal  capsule. 

ylegia  results,  paralysis  of  the  arm,  leg  and  lower  part  of  the  face  (the 
upper  part  of  which  and  the  head  escape  because  they  have  a  bilateral 
supply  from  both  hemispheres).  The  hypoglossus  is  but  moderately 
involved  and  aphasia  is  usually  temporary.  There  is  also  associated 
hemianesthesia,  hemianopsia  and  unilateral  disturbance  of  smell,  taste 
and  hearing,  by  lesion  of  the  fibers  ascending  from  the  tegmentum;  with 
hemiplegia  are  observed  contractures,  descending  degeneration,  decrease 
or  absence  of  the  skin  refiexes,  especially  the  cremasteric,  and  increase 
of  the  tendon  reflexes.  Monoplegia  is  rare,  because  the  tracts  are  so 
compact;  a  linear  lesion  may  involve  the  outer  part  of  the  capsule's 
knee,  affecting  the  face  and  leaving  the  arm  free.    Hemianesthesia  (skin 


758  DISEASES  OF   THE  BRAIN 

sensation  and  muscle  sense)  rarely  exists  without  some  paresis  of  the 
leg.  Some  tingling  or,  in  incomolete  lesions,  some  pain  may  result,  for 
some  sensory  fibers  course  wdth  the  motor  fibers.  Hemitremor,  -athetosis 
and  -chorea  result  from  lesions  of  the  sensory  area,  usually  associated 
with  disease  in  or  just  below  the  optic  thalamus.  Disease  back  of  the 
general  sensory  tracts  may  injure  the  optic  radiation  (running  between 
the  occipital  sight  centre  and  the  lateral  geniculate  body)  or  interrupt 
the  auditory  and  other  special  sense  fibers.  Psychical  disturbance, 
aphasia,  alexia,  agraphia  and  involvement  of  any  cranial  nerve  are  not 
s\'mptomatic  of  disease  of  the  internal  capsule. 

Vin.  The  Corpus  Striatum. — ^This  is  composed  of  the  caudate  and 
lenticular  nuclei.  The  lenticular  nucleus  is  extensively  connected  with 
the  superior  peduncle  of  the  cerebellum  and  the  tegmentum  of  the  crus. 
The  caudate  nucleus  is  connected  with  the  internal  capsule  and  the  crus; 
these  fibers  seem  to  end  in  the  pons  and  cerebellum.  Xothnagel  held 
that  hemiplegia  is  permanent  only  when  the  internal  capsule  is  injured, 
but  Landouzy  reports  a  case  of  contralateral  hemiathetosis  from  isolated 
disease  of  the  lenticular  nucleus. 

IX.  The  Optic  Thalamus. — This  is  surrounded  by  gray  matter,  con- 
tinuous with  that  surrounding  the  third  ventricle  and  central  canal  of 
the  cord  and  is  connected  by  fibers  with  all  parts  of  the  cerebral  cortex, 
the  tegmentum  and  superior  cerebellar  peduncle.  Xothnagel  (1879) 
first  described  its  topical  symptomatologv.  The  following  findings  are 
observed,  alone  or  in  combination:  (a)  Contralateral  hemianopsia  may 
develop  from  a  lesion  in  the  posterior  part  of  the  thalamus,  the  pulvinar 
or  a  lesion  which  also  invades  the  lateral  geniculate  bodies.  These 
areas  are  connected  by  the  optic  radiation  with  the  optic  centre.  This 
hemianopsia  is  distinguished  from  that  caused  by  a  cortical  lesion  by  the 
hemianopsic  pupillary  reaction  and  the  absence  of  the  marginal  field  of 
vision.  (&)  Disturbance  of  the  mimetic  movements  of  expression  may 
develop  (Xothnagel,  Bechterew).  The  optic  thalamus  is  the  reflex 
centre  of  the  involuntary  moA'ements  of  expression,  as  weeping  or  laugh- 
ing. A  patient  with  hemiplegia  from  destruction  of  the  left  internal 
capsule  cannot  voluntarily  move  the  lower  right  part  of  the  face,  but 
the  paralyzed  portion  of  the  face  moves  when  the  patient  laughs,  for  the 
centre  is  in  the  posterior  part  of  the  thalamus.  On  the  other  hand,  in 
isolated  thalamic  disease,  the  opposite  side — indeed  both  sides  of  the 
face — can  be  voluntarily  moved,  since  the  facial  nerve  runs  in  the  internal 
capsule,  but  the  patient  cannot  laugh  or  weep,  (c)  Sensory  disturbances 
may  occur,  such  as  hemianesthesia,  hemichorea,  hemitremor,  hemi- 
hyperalgesia  or  hemiataxia  (involvement  of  the  internal  capsule?).  There 
may  be  vasomotor  changes,  atrophy  and  disturbance  in  the  evacuation 
of  the  bladder  and  rectum  {v.  Thalamic  Syndrome,  page  794j. 

X.  The  Corpora  Quadrigemina. — ^There  is  variance  of  opinion  regard- 
ing the  function  of  these  masses  of  gray  matter  whose  fibers  lie  over  the 
aqueduct  of  Sylvius  and  the  tegmentum. 

Disease  of  the  anterior  corpora  quadrigemina  produces  (a)  moderate 
involvement  of  sight,  of  greater  localizing  significance  if  there  is  no  optic 
neuritis.    These  bodies  are  connected  with  the  external  geniculate  bodies 


CEREBRAL  LOCALIZATION 


759 


and,  by  way  of  the  internal  capsule,  with  the  optic  radiation.  (6)  In 
acute  lesions,  narrowing  of  the  puyil  is  suggestive.  In  old  lesions,  one 
or  both  pupils  are  wide  and  without  reaction  to  light  or  accommoda- 
tion, (c)  The  eye  muscles  may  be  partiallv  paralyzed  (ptosis  and  upward 
movements)  but  are  not  pathognomonic,  because  the  lesion  is  so  near 
the  nucleus  of  the  third  nerve.  Disease  of  the  'posterior  corpora  quadri- 
gemina  may  result  in  (a)  ataxia;  some  refer  it  to  cerebellar  disease,  to 
connections  with  the  cerebellum  through  the  nucleus  ruber  or  to  disease 
in  the  fillet  of  the  tegmentum;  (6)  trochlearis  paralysis,  in  which  the 
eyes  cannot  be  turned  inward  or  outward;  and  sometimes  abducens 
paralysis;  (c)  difficult  mastication  from  involvement  of  the  descending 
branch  of  the  quintus;  {d)  contralateral  disturbance  of  hearing,   since 


Fig.  53. — Lesion  in  crus  (shown  by  dotted  lines),  producing  a  superior  alternating  or 
crossed  hemiplegia;  the  lesion  involves  the  pyramidal  tract  (P.R.),  the  cranial  nerves  (tongue 
and  face,  C.R.)  and  the  oculomotor  nerve  (IIIf)  which  is  paralyzed  on  the  same  side  as  the 
lesion,  while  P.R.  and  C.R.  are  paralyzed  on  the  opposite  side.  A.S.,  aqueduct  of  Sylvius; 
III,  nucleus  of  third  nerve;  C.G.I.,  corp.  geniculatum  int.;  Fi,  upper  part  and  F2,  lower 
part  of  fillet;   N.R.,  nucleus  ruber;    S.N.,  substantia  nigra. 


the  post.  Corp.  quadrigemina  are  connected  with  the  fillet  of  the  tegmen- 
tum and,  by  means  of  the  "sensory  crossway"  of  the  internal  capsule, 
with  the  hearing  centre. 

XI.  The  Cms  (Cerebral  Peduncle). — The  motor  fibers  to  the  cranial 
nerves  decussate  higher  than  the  pyramidal  tracts  which  decussate  in 
the  medulla;  the  fibers  to  the  third  nerve  largely  cross  in  the  upper 
crus.  Crossed  paralysis  (hemiplegia  alternans  oculomotoria  superior) 
is  common  in  crus  lesions;  it  consists  of  a  hemiplegia  of  the  side  of  the 
body  opposite  to  the  lesion  and  a  paralysis  of  the  third  nerve  on  the  same 
side  as  the  lesion,  known  as  Weber's  paralysis,  though  first  described  by 
Gendrin  (Fig.  53);  the  oculomotor  paralysis  is  peripheral,  with  strabis- 
mus, ptosis,  inability  to  look  up  or  down  and  a  wide,  reactionless  pupil. 
This  crossed  or  alternating  hemiplegia  is  called  superior  because  inferior 


760  DISEASES  OF  THE  BRAIN 

alternating  hemiplegia  may  occur  in  lesions  of  the  pons.  We  distinguish 
whether  the  hemiplegia  and  paralysis  of  the  third  nerve  occurred  together 
(indicating  a  crus  lesion)  or  whether  the  third  nerve  paralysis  followed 
the  hemiplegia  (indicating  a  lesion  near  the  internal  capsule  pressing 
secondarily  on  the  oculomotorius) . 

A  lesion  in  the  tegmentum  may  cause  (a)  sensory  disturbance,  as  hemi- 
anesthesia (skin  sensation  and  muscle  sense);  such  a  lesion  is  in  the 
fillet;  hypesthesia  (reduced  sensation)  is  more  common.  (6)  The 
special  senses  are  sometimes  involved,  hemianopsia,  or  poor  hearing  in 
the  opposite  ear.  (c)  Ataxia,  alone  or  with  other  symptoms,  differs 
from  the  cerebellar  type  in  that  it  is  manifest  only  on  motion.  Involve- 
ment of  the  red  nucleus  produces  cerebellar  ataxia,  {d)  Ocidomotor 
paresis  on  the  side  of  lesion  is  characteristic  when  combined  with  crossed 
hemiataxia,  hemiplegia  or  hemianesthesia.  Fig.  53  shows  how  a  teg- 
mental focus  can  rarely  miss  the  diffuse  nuclei  of  the  third  nerve.  If  the 
lesion  is  in  the  lower  part  of  the  crus,  the  oculomotor  paralysis  is  usually 
complete,  but  if  in  the  tegmentum  it  is  always  partial,  electing  the  pupil, 
the  lid  or  the  superior  or  internal  rectus. 

XII.  The  Pons. — A  small  lesion,  as  a  thin  tumor,  may  give  no  local- 
izing symptoms.  Lesions  (commonly  tumors,  hemorrhage,  softening  or 
abscess)  usually  produce  a  typical  picture:  From  a  lesion  of  the  upper 
pons,  i.  e.,  above  the  facial  nucleus,  a  hemiplegia  results  like  that  pro- 
duced by  lesions  of  the  internal  capsule.  (See  Fig.  54,  focus  A.)  The 
facial  paralysis  is  supranuclear,  partial  and  with  no  reaction  of  degenera- 
tion. In  a  focus  in  the  lower  pons  (focus  B,  Fig.  54),  where  the  facial 
fibers  have  already  crossed,  the  tongue,  arm  and  leg  are  hemiplegic 
on  the  side  opposite  to  the  focus  and  the  facial  paralysis  is  on  the  side 
of  the  lesion,  hemiplegia  alternans  facialis,  first  described  by  Millard 
and  Gubler.  The  facial  paralysis  is  peripheral  and  nuclear,  involves  all 
branches  and  gives  the  reaction  of  degeneration.  Other  alternating 
paralyses  are  also  observed,  as  hemiplegia  tvith  crossed  paralysis  of  the 
third,  fourth,  fifth  and  sixth  nerves,  both  nuclear  and  peripheral.  Hemi- 
plegia may  occur  with  conjugate  paralysis  of  the  lateral  eye  muscles,  as 
the  external  rectus  (abducens  nerve)  of  one  side,  and  the  internal  rectus 
(third  nerve)  of  the  other,  due  to  a  lesion  just  in  front  of  the  abducens 
centre,  involving  its  fibers,  or  sometimes  also  including  its  nucleus.  In 
the  conjugate  paralysis,  the  antagonist  muscles  pull  the  eyes  to  the  other 
side  and  the  eyes  look  aivay  from  the  side  of  the  lesion  toward  the  paralj'^zed 
side.  In  this  form  even  the  paralyzed  internal  rectus  will  functionate 
and  converge  when  one  eye  is  tested  at  a  time.  Involvement  of  the 
motor  branch  of  the  fifth  nerve  produces  difficult  mastication.  While 
alternating  paralysis  is  the  usual  pons  lesion,  sometimes  double  hemiplegia 
occurs,  or  again,  involvement  of  the  third  to  seventh  cranial  nerves  with- 
out hemiplegia.  The  auditory  nerve  is  rarely  involved,  save  in  acute  or 
very  extensive  lesions  afi^ecting  the  lateral  lemniscus.  Dysarthria  and 
dysphagia,  due  to  disease  of  the  cortical  motor  paths  of  the  hypoglossus 
and  vagus,  are  less  common  in  lesions  of  the  pons  than  are  affections  of 
their  nuclei  in  diseases  of  the  medulla  oblongata.  Ataxia  may  result 
from  involvement  of  the  fillet.     An  alternating  sensory  paralysis  may 


CEREBRAL  LOCALIZATION 


761 


occur,  as  (a)  hemianesthesia  involving  the  muscle  sense  and  cutaneous 
sensation  of  the  extremities  opposite  the  lesion,  caused  by  disease  of  the 
tegmentum,  and  (6)  an  anesthesia  of  the  fifth  nerve  on  the  side  of  the 
lesion.  Irritative  symptoms  sometimes  develop,  as  pain,  paresthesia, 
painful  convulsions  of  both  arms  or  both  legs,  tonic  and  clonic  spasms 
in  the  opposite  arm  and  leg,  contractures,  paroxysms  of  coughing  and 
trismus.  The  patient  may  "look  toward  the  lesion"  when  the  eye  mus- 
cles are  irritated  (conjugate  deviation).  A  tendency  to  fall  toward  the 
side  on  which  the  lesion  is  located  is  indicative  of  disease  of  the  middle 
peduncle  of  the  cerebellum.  Aphonia,  dysarthria  and  dysphagia  are 
symptomatic  of  localization  in  the  medulla  (q.  v.),  especially  when  the 


DECUSSATION  OF  PYRAMIDS 


B 

Fig.  54. — A  illustrates  a  lesion  in  the  upper  pons,  producing  the  usual  hemiplegia  (face, 
arm  and  leg  paralyzed  on  the  opposite  side).  B  illustrates  a  lesion  in  the  lower  pons,  produc- 
ing alternating  paralysis;  all  branches  of  the  face  (peripheral  paralysis)  and  tongue  on  the 
side  of  lesion  are  paralyzed  with  paralysis  of  the  contralateral  arm  and  leg. 


hypoglossus  is  paralyzed,  shows  the  reaction  of  degeneration  and  produces 
atrophy  of  the  tongue.  Glycosuria,  albuminuria,  disturbed  respiration 
or  heart  action  (vagus)  and  vomiting  are  other  bulbar  symptoms.  Disease 
may  cause  paralysis  of  both  arms  and  legs  or  rarely  of  one  arm  and  the 
opposite  leg  (hemiplegia  cruciata). 

XIII.  The  Cerebellum. — Physiology. — Physiologists  admit  the  possi- 
bility of  some  psychical  function.  Its  sensory  relations  are  important, 
because  of  its  reception  of  numerous  fibers  from  the  spinal  cord,  including 
the  direct  cerebellar  tract  and  the  posterior  median  column  of  Goll,  of 
which  it  is  an  "end  organ"  (Luciani).  It  harmonizes  the  movements  of 
the  body,  maintains  equilibrium,  conserves  muscular  strength  and,  inhibits 


762  DISEASES  OF   THE  BRAIN 

the  contralateral  cerebral  motor  cortex,  i.  e.,  it  coordinates  (a)  the  sensory 
impressions  ascending  from  the  spinal  cord  with  (h)  those  gained  by 
hearing  (the  auditory  nerve  having  connections  with  the  middle  cerebellar 
lobe)  and  (c)  probably  with  those  impressions  resulting  from  the  eye 
movements. 

General  Pathology. — Disease  of  a  lateral  lobe  affects  the  same  side  of 
the  })ody,  but  lesions  of  the  middle  fvermiformj  lobe  influence  both  sides. 
Krauss  found,  in  100  cases  of  cerebellar  disease,  tumors  in  80  per  cent., 
abscess  in  10,  cysts  in  7  per  cent,  and  softening,  hemorrhage  and  agenesis, 
sclerosis  and  gliomatosis  in  the  balance.  Acute  disease  of  the  cerebellum 
produces  svmptoms  more  frequently  than  does  chronic  disease,  in  which 
latter  the  cerebellum  or  the  cerebrum  has  opportunity  for  accommodative 
compensation;  rapidly  gro-^-ing  tumors,  abscess  and  acute  vascular  disease 
often  produce  the  folloT^-ing  symptoms: 

Topical  Symptoms. — 1.  Cerebellar  ataxia  is  almost  always  present  and 
occurs  when  the  patient  stands;  the  body  sways  (static  ataxia j,  as  though 
the  subject  were  trying  to  balance  himself.  Ataxia  also  occurs  when  the 
patient  moves  (dynamic  ataxia)  and  concerns  especially  the  trunk  and 
legs.  It  is  due  to  disease  of  the  middle  lobe  or  vermis  and  the  consequent" 
withdrawal  from  the  cerebrum  of  the  cerebellar  coordination.  The  gait 
is  that  of  an  inebriate  (demarche  d'ivresse);  the  individual  stumbles  a 
zig-zag  course  sometimes  toward  the  side  of  the  lesion.  The  arm  and 
hand  movements  are  usually  normal.  In  ataxia  resulting  from  other 
cerebral  localization  Tcortex,  internal  capsule  and  tegmentum)  the 
incoordination  affects  the  finer  movements,  is  associated  with  disturbed 
muscle  and  stereognostic  sense  and  very  often  with  paresis.  Bouillaud 
first  described  cerebellar  ataxia  and  differentiated  it  from  the  tabetic 
type;  cerebellar  ataxia  disappears  when  the  patient  is  lying  down  and 
closing  the  eyes  does  not  increase  it  (indeed  it  may  often  disappear). 
The  affected  limbs  can  be  held  steadily. 

2.  Vertigo  is  very  frequent  and  usually  occurs  rather  when  the  patient 
sits  than  when  he  lies  down;  objects  turn  around  him  or  he  feels  himself 
being  turned.  The  vertigo  is  constant  or  paroxysmal  and  is  due  to  lesion 
of  the  vestibular  nerve  which  connects  the  semilunar  canals  with  the 
cerebellum  by  the  corpus  restiforme. 

Secondary  Symptoms. — The  following  are  less  significant  than  ataxia  and 
vertigo:  (a)  Choked  disk  is  rarely  absent  in  cerebellar  tumors  and  amau- 
rosis results  from  hydrocephalus  internus  with  pressure  on  the  chiasm. 
(b)  "Forced"  postures  and  movements  are  due  to  disease  of  the  middle 
peduncle  (cms  cerebelli  ad  i)oiitem).  Constrained  postures  of  the  head 
and  trunk  are  obser^'ed;  one  eye  looks  upward  and  inward,  while  the 
other  is  directed  downward  and  outward.  Forced  movements  consist' 
of  turning  to  one  side,  movement  in  a  circle  and  a  tendency  to  fall  toward 
the  side  of  lesion  and  sometimes  backw^ard.  (c)  Muscular  weakness  is 
frequent  in  animals  and  occasional  in  man,  as  hemiparesis  on  the  side 
of  lesion.  The  patient  may  not  be  able  to  rotate  the  trunk,  straighten 
the  body  after  bending  or  get  up  after  falling,  id)  The  ixitellar  reflexes 
are  usually  normal  or  increased,  (e)  Vomiting  and  pain  in  the  head  or 
neck  are  of  some  localizing  value,    (j)  Occasionally  the  ffjllowing  develop: 


CIRCULATORY  DISEASES  OF  THE  BRAIN  763 

nystagmus,  rhythmical  contractions  of  the  head,  convulsions,  paralysis 
of  the  cerebral  nerves  from  pressure  on  the  midbrain,  disturbed  hearing, 
intention  tremor,  muscular  rigidity,  irritability  and  weak  memory. 

CIRCULATORY   DISEASES    OF    THE    BRAIN. 

I.  Anemia  of  the  Brain. — This  term  has  been  much  abused. 
Etiology. — (a)  General  systemic  anemia  may  result  from  cachexia  and 

hemorrhages  of  medical,  surgical  or  obstetrical  nature,  (b)  Decreased 
blood  supply,  due  to  cardiac  insufficiency,  valvular  stenosis,  vessel  stenosis, 
evacuation  of  an  enormously  distended  bladder  and  tapping  of  pleurisy 
or  ascites  leading  to  paresis  of  the  thoracic  or  abdominal  vessels  may  be 
causal,  (c)  Capillary  compression  by  hydrocephalus  or  tumors  may 
produce  anemia,  {d)  Local  causes  in  the  vessels  will  be  considered  under 
softening.  Convulsions  by  pressure  on  one  carotid  are  indicative  of 
cerebral  atheroma. 

Pathology. — The  brain  is  pale,  firm  and  dry  and  puncta  vascnlosa  fewer. 
The  fluid  in  the  ventricles  is  often  increased. 

Symptoms. — Local  anemia  of  the  brain  leads  to  imperfect  function, 
then  loss  of  function  and  finally  to  necrosis,  as  in  embolism  or  thrombosis 
(g.  v.).  In  sudden  general  anemia  after  hemorrhage  or  fainting,  the  sub- 
ject becomes  drowsy,  syncope  occurs  and  subsequent  amaurosis,  or  ring- 
ing in  the  ears  is  frequent.  The  pupils  at  first  contract  from  irritation 
of  the  third  nerve  and  later  dilate  from  its  paralysis,  a  sign  of  danger. 
The  skin  is  pale  and  clammy,  the  muscles  lax  and  nausea  frequent. 
Epileptiform  convulsions  often  occur  when  much  blood  is  lost.  Anemia 
of  the  medulla  causes  the  slow,  sighing  respiration  and  yawning.  Death 
after  syncope  was  called  nervous  apoplexy  by  the  old  writers.  In  grad- 
ually developing  anemia  symptoms  develop,  as  described  under  Pernicious 
Anemia.  Palpitation  and  thoracic  oppression  are  common  symptoms. 
The  pulse  varies  in  rate  and  rhythm. 

Marshall  Hall  described  hydrencephaloid,  a  variety  of  cerebral  anemia, 
seen  in  children  suffering  with  acute  diarrhea,  and  characterized  by 
contracted  and  later  dilated  pupils,  depressed  fontanelles,  sunken  face, 
pallor,  early  irritation  followed  by  stupor  or  even  coma.  It  may  resemble 
meningitis  from  the  strabismus. 

Treatment. — Treatment,  diagnosis  and  prognosis  are  chiefly  those  of  the 
cause.  The  anemia  \^  treated  by  putting  the  patient  in  the  recumbent 
posture  and  employing  opiates,  stimulation,  coffee  by  rectum  and 
enemata  or  subcutaneous  infusions  of  salt  solution.  Firm  bandaging  of 
the  extremities,  sometimes  called  autotransfusion,  is  valuable.  Nitro- 
glycerin is  valuable  in  cases  due  to  vasomotor  spasm. 

II.  Hyperemia  of  the  Brain. — Andral  (1836)  described  eight  varieties, 
and  when  Trousseau,  in  1861,  referred  some  varieties  to  epilepsy  and 
Meniere's  disease,  he  drew  down  upon  him  the  wrath  of  the  entire 
Academy.  The  hyperemia  in  nephritis  is  usually  uremic  and  the  arterial 
fluxion  once  attributed  to  erysipelas  is  toxemic.  When  the  vessels  dilate 
from  paralysis  of  the  sympathetic  system  the  rapidity  of  the  capillary 
flow  decreases,  whence  there  is  no  hyperemia,  but  a  lessened  capillary 


764  DISEASES  OF   THE  BRAIN 

flow,  adidmorrhysis.  When  the  vessels  contract  from  sympathetic  irri- 
tation, the  brain  is  not  anemic,  but  the  capillary  flow  is  accelerated, 
hi/perdidmorrhysis. 

Etiology. — Active  congestion  results  from  cardiac  overaction;  overfilling 
of  the  brain  vessels,  as  in  stenosis  of  the  isthmus  of  the  aorta;  contraction 
of  the  arterioles  in  other  parts;  dilatation  of  the  brain  vessels  by  alcohol, 
nitroglycerin,  coffee,  thyroidism,  excessive  brain  work,  neurotic  states 
and  insolation.  In  plethoric  men  with  florid  faces,  thick  necks  and  short 
thoraces,  active  congestion  may  cause  fugitive  brain  symptoms. 

Passive  congestion  results  from  general  venous  stasis,  as  in  vahular 
heart  lesions,  or  local  venous  stasis,  as  sinus  thrombosis. 

Pathology. — The  brain  may  appear  anemic  after  death  by  strangula- 
tion and  may  become  congested  after  death  because  of  its  posture  alone. 
The  sinuses  and  A'eins  are  turgid  and  the  color  of  the  brain  is  darker. 
^Microscopic  examination  shows  distention  of  the  capillaries  or  rupture 
into  the  perivascular  lymphatic  sheaths  or  brain. 

Symptoms. — In  active  congestion,  chronic  cause  fewer  s.ymptoms  than 
acute  factors.  ^Miether  toxemic  symptoms  of  the  acute  infections  are 
due  to  hyperemia  is  an  open  question.  Paroxysmal  throbbing  of  the 
vessels,  flushing,  headache,  delirium,  sometimes  nausea  and  fever  are 
relieved  by  nosebleed  and  venesection.  Irritability,  spots  before  the 
eyes  and  ringing  in  the  ears  are  said  to  occur.  In  progressive  paralysis 
the  transient  pyrexia,  heat  in  the  head  or  coma  is  referred  to  congestion 
of  the  brain. 

Passive  congestion,  if  gradual  in  onset,  may  be  well  tolerated  or  may 
produce  stupor,  dulness  or  delirium.  If  intermittent,  as  from  coughing, 
there  are  a  fulness  in  the  head,  headache  and  sometimes  conMalsions. 

Diagnosis. — Focal  symptoms,  as  hemiplegia,  indicate  organic  disease. 
Flushing,  heat  and  pressure  in  the  head,  are  most  often  neurasthenic 
or  hypochondriacal.  ^Marie  and  Leube  never  made  the  diagnosis  of 
brain  hyperemia. 

Treatment. — Active  congestion  is  treated  by  elevation  of  the  head, 
venesection  in  plethoric  adults  or  in  children  by  leeches  over  the  mastoid 
bone,  the  veins  of  which  connect  with  those  of  the  brain;  hy  free  jmrga- 
tion,  by  2  drops  of  croton  oil,  followed  by  concentrated  salines,  to  draw 
the  blood  to  the  large  abdominal  vessels;  by  hot  baths,  to  draw  the  blood 
to  the  periphery;  bromides  and  vasoconstrictors,  especially  digitalis. 
Alcohol  and  opiates  should  be  avoided;  ice  may  be  applied  to  the  head 
and  carotids;  a  fluid  diet  should  be  given. 

III.  Edema  of  the  Brain. — Etiology. — Edema  of  the  brain  results 
from  the  same  causes  as  general  edema:  circidatory  disturbances,  as 
venous  congestion  in  cardiac  disease  and  the  marantic  group,  including 
cachexia  and  nephritis.  Collateral  and  inflammatory  edema  may  develop 
around  brain  tumor,  abscess  or  hemorrhage.  Brain  edema  may  de^•elop 
in  the  death  agony  or  when  the  brain  shrinks,  hydrops  ex  vacuo. 

Pathology. — The  brain  is  pale,  moist  and  glistening  on  section,  the 
so-called  "wet-brain."  The  affection  may  be  general  or  local;  the  ven- 
tricular and  subarachnoid  fluid  is  increased.  The  volume  of  the  brain 
may  be  increased  in  the  generalized  form. 


CEREBRAL  HEMORRHAGE  765 

Symptoms. — A  diagnosis  cannot  be  made  between  edema  and  decreased 
capillary  velocity'.  When  the  edema  is  localized,  transient  focal  symp- 
toms may  develop,  as  unilateral  convulsions  or  hemiplegia,  or  even  crossed 
paralysis,  observed  personally  in  nephritis.  Traiibe  held  that  brain 
edema  causes  uremia,  a  view  opposed  by  Cohnheim.  ^^ariability  in  the 
symptomatology  of  organic  brain  disease  may  be  due  to  associated  edema. 

rV.  Cerebral  Hemorrhage. — This  most  common  and  important  of  all 
brain  lesions  involves  an  enormous  part  of  brain  pathology.  Apoplexy 
strictly  refers  to  a  "stroke,"  which  is  symptomatic  of  various  other 
lesions,  yet  it  is  used  to  designate  spontaneous  hemorrhage  into  the 
brain  (Rochoux). 

Etiology. — (a)  Miliary  aneurysms  are  the  direct  cause  of  cerebral 
hemorrhage.  Their  pathogenesis  relates  to  (6)  arteriosclerosis  (alcoholism, 
plumbism,  hard  work,  contracted  kidney,  overeating),  but  some  main- 
tain that  atheroma  does  not  per  se  predispose  to  hemorrhage.  Eighty 
per  cent,  of  hemorrhages  occur  after  the  fortieth  year  of  life,  and  in  men. 
It  may  occur  in  early  life  from  glioma,  whooping-cough  or  trauma.  Her- 
edity relates  rather  to  renal  and  arterial  lesions  than  to  an  actual  heredity. 
Hemorrhage  is  most  common  among  civilized  races  and  in  temperate 
zones,  because  of  the  strenuous  habit;-'  of  life.  The  importance  of  the 
apoplectic  habitus  (plethora,  ruddy  face,  short,  thick  neck,  wide  shoulders 
and  chest,  round,  small  body  and  large  muscles)  has  been  much  empha- 
sized; Gowers  finds  most  cases  in  thin  individuals.  Contracted  Sidney, 
found  in  .33  per  cent,  of  cerebral  hemorrhage,  is  a  prominent  cause 
of  atheroma  and  miliary  aneurysm,  (c)  Increased  arterial  tension  is 
less  important  than  its  relation  to  arteriosclerosis  and  miliary  aneurysms, 
which  occur  where  the  blood-pressure  is  greatest,  as  where  the  vessels 
branch.  Rupture  is  seen  in  cardiac  hypertrophy  from  stenosis  at  the 
isthmus  of  the  aorta.  Syphilis  more  frequently  produces  softening  than 
hemorrhage;  it  is  a  causal  factor  of  aneurysms  of  the  large  cerebral  vessels. 
Molent  exertion,  alcoholic  excesses,  excitement,  coitus,  overeating, 
vomiting,  coughing  or  convulsions  may  rupture  an  already-diseased 
vessel  or  a  miliary  aneurysm;  a  healthy  vessel  almost  never  bursts. 
Embolism  from  heart  disease  may  produce  the  "embolic  aneurysm." 
Sometimes  trauma  is  a  factor,  usually,  however,  with  the  causes  above 
mentioned,  (c/)  Permeability  of  the  bloodvessels  causes  a  few  cases,  by 
hemorrhage  by  diapedesis,  as  in  nephritis,  purpura,  anemias  and 
infections. 

Pathology. — Hemorrhage  most  often  occurs  in  the  branches  of  the 
arteria  fossse  Sylvii;  the  lenticidostriate  artery  of  Duret,  Charcot's  artery 
of  hemorrhage,  is  the  seat  of  hemorrhage  in  75  per  cent,  of  cases.  This 
small  vessel  is  likely  to  rupture  because  it  is  so  near  to  the  large  internal 
carotid  and  its  course  is  very  direct;  it  has  no  special  external  support; 
and  there  is  no  collateral  circulation,  hence  no  relief  to  pressure,  render- 
ing the  vessel  tortuous.  Rupture  occurs  very  often  in  the  long  direction 
of  the  fibers  of  the  internal  capsule,  where  also  the  veins  stagnate  very 
easil>'.  Miliary  aneurysms  were  described  by  Brunner  (1700)  and 
Morgagni  (1761),  but  Charcot  and  Bouchard  (1866)  emphasized  their 
relation  to  brain  hemorrhage.    They  are  fusiform,  more  rarely  sacciform, 


766 


DISEASES  OF   THE  BRAIN 


INTERNAL 
CAPSULE — ^PTIC_ 
THALAMUS 


enlargements  of  the  arterioles,  usually  multiple,  like  a  bunch  of  grapes, 
and  measuring  y^g^  to  ^  of  an  inch;  they  are  false  aneurysms;  they  may 
be  seen  with  the  naked  eye,  by  careful  washing  or  macerating  in  water, 
or  on  a  slide  under  a  low  power.  They  are  found  where  hemorrhages  are 
most  common,  i.  e.,  the  central  ganglia  and  where  the  blood-pressure  is 
highest.  Charcot  and  Bouchard  described  periarteritis  but  Eichler  and 
Zeigler  held  that  intimal  changes  were  primary;  Roth  finds  atrophy  of 
the  muscular  coat  the  accepted  theory.  Large  aneurysms  will  be 
considered  separately. 

Localization. — ^Hemorrhage  is  most  common  in  the  caudate  and  len- 
ticular nuclei,  internal  capsule  and  adjacent  centrum  ovale,  extending 
to,  but  rarely  beginning  in,  the  optic  thalamus.  Hemorrhage  in  the  white 
matter  has  usually  an  elongated  form.    It  is  much  less  common  in  the 

cortex,  pons,  crus,  cerebellum  or  medulla. 
It  occurs  mostly  in  the  substance  of  the 
brain,  but  may  rupture  on  the  surface  or 
into  the  ventricles,  causing  sudden  death, 
the  usual  autopsy  finding.  Hemorrhage 
is  usually  single.  The  multiple  form  is 
observed  in  anemia.  When  the  skull  is 
removed,  the  dura  is  tense,  the  convolu- 
tions flattened  and  pale,  the  falx  pushed 
toward  the  other  side  and  the  fissures 
indistinct.  Fluctuation  may  be  felt  in 
rare  cases;  on  section  the  focus  is  seen, 
usually  the  size  of  a  hazel-nut  or  walnut; 
it  sometimes  involves  the  entire  hemi- 
sphere or  may  be  no  larger  than  a  pea. 
The  brain  around  the  focus  is  softened 
from  pressure,  edematous  and  in  the 
focus,  torn  and  pulpy.  The  dark  clot  be- 
comes chocolate-colored,  then  yellowish- 
red  and  finally  yellowish-white.  The  wall 
of  the  focus  is  irregular  in  the  gray  nuclei 
and  regular  in  the  white  matter  and 
threads  of  bloodvessels  run  through  it. 
Leukocytes  laden  with  fat  drops,  hematoidin  and  disorganized  tissue  are 
found.  As  the  blood  absorbs,  the  cavity  becomes  encapsulated  by  inflam- 
mation and  contains  a  serous,  milky  fluid  (the  ayaylectic  cyst  of  Virchow). 
An  apoplectic  scar  is  much  less  common.  Traumatic  hemorrhage  may  occur 
infrequently  near  the  point  of  injury  or  contre  coup  on  the  opposite  side; 
the  late  traumatic  hemorrhage  of  Bollinger  takes  place  after  a  week  or 
more,  near  the  fourth  ventricle  and  aqueduct  of  Sylvius,  and  probably 
in  areas  of  traumatic  softening.  Brain  hemorrhage  may  sever  the  internal 
capsule. 

Secondary  degeneration  occurs  in  the  pyramidal  tracts,  chiefly  from 
a  lesion  of  the  internal  capsule;  sound  and  diseased  flbers  intermingle; 
it  descends  through  the  crus,  pons,  medulla  and  cord  (the  direct  anterior 
pyramidal  tract  and  part  of  the  crossed  lateral  tract).     These  areas 


Fig.  55. — Showing  course  of  individ- 
ual fibers  of  motor  tracts. 


CEREBRAL  HEMORRHAGE 


767 


become  progressively  smaller  and  cease  just  above  the  conus  medullaris. 
In  children  a  cerebral  lesion  may  cause  degeneration  in  the  anterior  horns 
of  the  cord  and  their  fibers.  An  ascending  degeneration  occurs  only 
when  the  large  pyramidal  tracts  of  the  cortex  are  diseased,  except  in  the 
young,  in  whom  degeneration  of  all  neurones  is  prone  to  follow  the 
destruction  of  one  neurone.     (See  figures  under  Localization  in  the 


Fig.  56. — Horizontal  section  through  the  right  hemisphere:  1,  cortex;  2,  white  substance; 
3,  internal  capsule;  4,  optic  thalamus;  5,  lenticular  nucleus;  6a,  anterior  horn;  and  66, 
posterior  horn  of  the  lateral  ventricle.     (After  Dejerine.) 


Spinal  Cord.)  Other  degenerations :  (a)  The  o^^ic  ra(iiaii07i  degenerates 
when  a  lesion  occurs  in  the  cortex  of  the  cuneus  and  also  degenerative 
changes  in  the  external  geniculate  body  and  pulvinar.  After  years  it 
may  reach  the  optic  nerve,  (b)  Hemorrhage  in  the  second  and  third 
frontal  lobes  leads  to  degeneration  in  the  anterior  limb  of  the  capsule, 
median  basal  fibers  of  the  crus  and  the  fibers  connecting  the  optic  thala- 


768  DISEASES  OF   THE  BRAIX 

mils  with  the  cortex,  (c)  Lesions  in  the  temporal  lobes  cause  degenera- 
tion in  the  lateral  part  of  the  cms.  id)  Degeneration  in  the  median 
lemniscus  follows  diseases  of  the  cortex,  the  subthalamic  region  and  the 
upper  part  of  the  pons;  it  crosses  to  the  opposite  nuclei  of  the  medulla 
and  after  years  destroys  the  ganglion  cells  in  the  posterior  columns  of 
the  cord. 

Symptoms. — ^Miliary  aneurysms  produce  no  symptoms  until  they 
rupture  and  premonitory  symptoms  are  due  to  atheroma  and  are  not 
pathognomonic.  They  may  be  general  (v.  i.,  softening);  cardiorenal, 
as  hypertrophied  heart  or  hypertension;  or  rarely  focal,  as  alexia,  facial 
paresis,  preparalytic  chorea,  etc.  Prodromal  symptoms  are  seldom  due 
to  an  initial  small  hemorrhage  or  to  hemorrhage  developing  very  slowly. 

1.  The  IxsrLT  axd  its  Primary  Sy:mptoms. — ^The  "stroke"  is  usually 
sudden;  its  most  common  general  symptom  is  coma,  which  may  be  absent 
in  small  lesions  and  its  most  common  focal  symptom  is  hemiplegia.  It 
may  develop  during  effort  or  excitement,  or  more  often  without  cause, 
as  during  sleep.  In  ingravescent  apoplex;^"  the  onset  is  gradual,  with 
delirium,  convulsions  and  finally  coma;  it  is  due  to  hemorrhage  external 
to  the  lenticular  nucleus,  which  later  involves  the  internal  capsule. 
Death  may,  in  very  rare  instances,  occur  in  five  minutes  from  rupture 
into  the  ventricles  or  direct  pressure  on  the  medulla  (fulminating 
apoplexy) . 

The  insult  is  due  chiefly  to  anemia  of  the  cortex  and  to  some  extent 
to  direct  brain  trauma,  pressure  on  other  vessels,  serous  infiltration 
and  alterations  in  the  cerebrospinal  fluid  in  which  lumbar  puncture 
sometimes  shows  blood.  Its  cardinal  typical  symptoms  are  coma,  which 
is  greater  the  nearer  the  lesion  is  to  the  optic  thalamus  and  third  ven- 
tricle; flushed  face,  sometimes  pallor  or  cyanosis;  a  tense,  regular  and 
slov)  pidse;  long,  deep,  stertorous  breathing  (due  in  part  to  palate  par- 
alysis) ;  the  cheeks  puff  out,  but  are  drawn  in  on  inspiration,  as  a  result  of 
paralysis  of  the  buccinator  muscle;  inspiration  is  sometimes  irregular; 
yawning  is  frequent;  the  tempjerature  usually  suffers  an  initial  fall,  but 
rises  when  reaction  sets  in,  though  lesions  in  the  pons,  medulla  or  central 
ganglia  may  cause  an  initial  rise.  The  pupils  are  usually  wide,  from 
paralysis  of  the  third  nuclei  or  sympathetic  stimulation;  they  are  some- 
times unequal  and  in  deep  coma  reactionless.  They  may  be  narrow  from 
irritation  of  the  oculomotor  nucleus  in  lesions  of  the  pons,  or  when  the 
ventricles  are  involved.  The  head  and  eyes  look  toward  the  side  of  the 
brain  lesion  ("conjugate  deviation"),  a  flaccid  hemiplegia  occurs,  in  which 
the  limbs  fall  limp  when  they  are  lifted;  the  reflexes  are  gone  and  there 
are  involuntary  evacuations  of  urine  and  feces.  An  increase  of  the  lu-ine 
with  a  low"  specific  gravity  (1.004)  and  transitory  albuminuria  and  glyco- 
suria are  due  to  a  large  lesion  exerting  indirect  pressure  on  the  medulla 
or  to  a  lesion  in  the  medulla  itself. 

2.  The  permaxext  damage  can  be  estimated  only  when  the  reaction 
is  passed.  The  direct  focal  symptoms  are  those  of  the  hemorrhage  itself 
and  the  subsequent  cyst  or  scar;  they  are  permanent  if  essential  struct- 
ures are  involved,  as  the  internal  capsule.  Indirect  focal  symptoms  are 
those  of  other  structures  disturbed  by  pressure,  edema  or  inflammator}- 


CEREBRAL  HEMORRHAGE  769 

reaction  (the  pulse  and  respiratory  symptoms,  conjugate  deviation, 
albuminuria  and  temperature).  Time  is  required  to  separate  these  two 
classes  of  symptoms. 

3.  Details  of  Important  Symptoms. — (i)  Convulsions  are  not  common 
(pons,  ventricles,  cortex  or  corpus  striatum  lesions). 

(ii)  Conjugate  deviation  is  a  phenomenon  in  which  the  lateral  muscles 
of  the  head  and  eyes  are  paralyzed;  their  fellows  on  the  sound  side  con- 
tract, so  that  "the  patient  looks  at  his  lesion^'  (Prevost) ;  in  left  hemiplegia 
the  eyes  and  head  look  toward  the  right  side  of  the  brain.  The  centres 
paralyzed  are  the  g^Tus  angularis  and  gyrus  supramarginalis.  It  disap- 
pears in  a  few  days  because  the  sound  side  of  the  brain  compensates 
or  because  it  is  a  distant  pressure  symptom.  Conjugate  deviation  may 
also  be  due  to  irritation  or  Jacksonian  epilepsy  when  the  patient  "looks 
away  from  his  lesion"  (Landouzy),  i.  e.,  toward  the  side  affected  with 
convulsions.    These  differ  from  the  deviation  in  localization  in  the  pons 

(?.  ^;)-     •       •      , 

(iii)  The  hemiplegia  is  due  (75  per  cent.)  to  a  lesion  of  the  internal  cap- 
sule (v.  p.  757).  During  deep  coma  it  is  often  difficult  to  determine  which 
side  is  paralyzed.  The  affected  side  is  usually  flaccid  and  the  mouth 
shows  greater  puffing  on  the  hemiplegic  half.  If  the  coma  is  not  pro- 
found the  sound  arm  and  leg  may  move.  Sometimes,  especially  with 
hemorrhage  into  the  lateral  ventricle,  the  paralyzed  side  exhibits  early 
rigidity.  The  temperature  is  at  first  lower  on  the  hemiplegic  side  from 
paralysis  of  a  cortical  centre.  Later,  during  reaction,  it  is  higher  on  the 
side  of  paralysis.  After  consciousness  returns  the  contralateral  hemi- 
plegia is  more  clearly  seen.  The  low^er  two-thirds  of  the  face  (nose, 
mouth,  cheek)  are  paralyzed;  the  nasolabial  fold  is  obliterated,  the  lips 
cannot  be  puckered  as  though  to  whistle,  the  mouth  is  oblique  or  a  little 
triangular  when  the  teeth  are  shown.  The  upper  third  (eye  and  fore- 
head) is  unaffected  because  it  is  innervated  from  both  hemispheres  or 
has  two  distinct  centres  and  paths;  in  peripheral  facial  paralysis  all 
branches  are  involved,  with  atrophy  and  the  reaction  of  degeneration. 
If  the  optic  thalamus  (g.  v.)  is  intact,  the  paralysis  is  not  apparent  on 
laughing.  The  tongue,  w^hen  protruded,  deviates  slightly  toward  the 
diseased  side  because  the  sound  genioglossus  muscle  pulls  the  tongue 
forward  and  over  toward  the  hemiplegic  side;  the  base  of  the  tongue  is 
higher  on  the  paralyzed  side  which  may  lead  to  some  difficulty  in  the 
external  speech  mechanism  (dysarthria),  while  internal  speech  is  not 
often  disturbed  unless  there  is  psychical  alteration  (aphasia).  The 
palate  may  hang  lower  on  the  paralyzed  side,  but  this  is  of  little  impor- 
tance because  it  varies  physiologically.  Deglutition,  mastication  and 
phonation  are  but  little  or  only  transitorily  involved;  marked  difficulty 
in  mastication  is  usually  associated  with  total  hemianesthesia.  In  the 
trunk  paralysis  of  the  trapezius  and  levator  anguli  scapulae  causes 
sagging  of  the  shoulder;  certain  cerebral  fibers  of  the  spinal  accessory 
may  be  involved.  Hughlings-Jackson  finds  respiratory  movement 
greater  on  the  paral^'zed  side  in  automatic  breathing  and  greater  on  the 
sound  side  in  forced  breathing.  Early,  the  paralysis  of  the  arm  and  leg 
is  often  absolute,  sometimes  partial  (hemiparesis) .  In  the  typical 
49 


770  DISEASES  OF   THE  BRAIN 

case  the  arm  is  most  involved,  though  all  parts  on  one  side  usually  are 
somewhat  paralyzed.  The  arm  abductors,  hand  flexors  and  finger  exten- 
sors, the  extensors  of  the  leg,  dorsal  foot  flexors  and  knee  flexors  are  most 
implicated.  The  paralysis  is  flaccid.  In  rare  linear  lesions  the  arm,  leg 
or  face  remains  free  (see  page  757) ;  monoplegia  is  much  less  common  than 
in  cortical  and  subcortical  disease.  The  hemiplegia  is  almost  invariably 
contralateral,  i.  e.,  opposite  to  the  side  of  the  lesion;  Lederhose  collected 
45  cases  of  collateral  hemiplegia  due  to  more  than  one  lesion,  to  a  focus 
pressing  on  the  other  side  of  the  brain,  or  to  mistaking  the  early  rigidity 
of  the  paralyzed  side  for  the  normal  side. 

(iv)  Sensory  dishirhance  (r.  page  757)  is  less  important,  less  frequent, 
less  complete  and  less  stable  than  hemiplegia.  Some  hemianesthesia 
is  frequently  found  in  early  cases  after  careful  examination,  as  disturbed 
tactile  sensation,  stereognostic  sense  and  sometimes  muscle  sense,  pains 
and  hyperesthesia  or  paresthesia.  A  large  lesion  only  can  cause  a  com- 
plete hemianesthesia.  It  affects  the  skin  and  mucosa  of  the  nose,  mouth, 
palate  and  eyes,  but  not  the  cornea.  Cortical  hemianesthesia  is  usually 
partial  and  most  often  associated  with  monoplegia;  lesions  just  above 
the  capsule,  may  produce  hemianesthesia,  involving  the  fibers  from  the 
thalamus  to  the  cortex.  It  also  occurs  in  lesions  of  the  crus,  pons, 
medulla  and  cord  (g.  v.). 

(v)  Syecial  senses.  Hemianopsia,  due  to  pressure  on  the  optic  thal- 
amus, usually  occurs  with  conjugate  deviation,  is  temporary  and  is  often 
overlooked. 

(vi)  The  reflexes  of  the  skin,  cornea,  pupils,  mucosse  and  tendons  are 
suspended  during  complete  coma,  in  which  the  central  nervous  system 
is  almost  wholly  paretic.  After  the  stroke  they  return  slowly,  first  on 
the  sound  side.  On  the  hemiplegic  side  they  return  more  slowly;  the 
periosteal,  tendon  and  patellar  reflexes  often  become  exaggerated  from 
interrupted  inhibition;  the  skin  reflexes  return  slowly,  especially  the  epi- 
gastric, cremasteric,  scrotal  and  mammillary,  a  point  of  early  diagnostic 
value. 

Bahinski's  toe  sign  usually  indicates  organic  pyramidal  disease  and 
may  be  found  very  early;  when  a  sharp  object  is  slowly  drawn  over  the 
outer  part  of  the  sound  sole  there  is  plantar  flexion  of  the  large  and  some- 
times of  the  other  toes;  when  dra'WTi  over  the  diseased  sole  there  is  great 
dorsal  flexion  (extension)  of  the  great  toe. 

4.  Chronic  or  Secoxdary  Sy:mptoms. — The  indirect  symptoms, 
inflammatory  reaction  and  collateral  edema  disappear. 

(i)  If  the  hemiplegia  is  indirect,  from  a  lesion  without  the  capsule, 
marked  improvement  or  rarely,  recovery  ensues.  Complete  lasting 
hemiplegia  follows  total  division  of  the  pyramidal  tracts,  due  to  hemor- 
rhage from  the  anterior  choroid  artery  (Kolisko).  The  face  often  recovers 
rapidly;  Broadhent  held  that  the  intercostals,  masseters  and  trunk  muscles 
used  in  pairs,  innervated  from  both  hemispheres  and  having  little  differ- 
entiation in  function,  escape  permanent  paralysis.  The  functions  of  the 
arm  and  hand  are  especially  complicated,  are  more  often  used  alone,  are 
innervated  mostly  from  one  hemisphere  and  therefore  suffer  the  greatest 
permanent  damage.     The  legs  are  much  used  together  and  often  show 


CEREBRAL  HEMORRHAGE  771 

improvement.  The  bilateral,  spinal  and  bulbar  nuclei  enable  "paired 
muscles"  to  be  innervated  from  the  sound  hemisphere,  or  possibly  uncrossed 
fibers  in  the  anterior  (and  lateral)  columns  explain  thephenomenon. 
Compensation  is  offset  by  the  fact  that  the  sound  side  is  reduced  in 
strength  in  50  per  cent,  of  cases.  In  the  arm.  the  residual  paralysis  affects 
functionally  associated  muscle  groups  rather  than  individual  muscles, 
as  the  muscles  supinating  the  forearm,  those  abducting  and  lifting  the 
arm  and  shoulder,  those  moving  the  elbow,  opening  the  hand  and  appos- 
ing the  thumb.  The  shoulder  improves  a  little,  the  elbows  considerably, 
the  hands  very  little.  In  the  leg  the  flexors,  dorsal  flexors  of  the  foot 
which  shorten  the  leg  in  walking,  abductors  and  internal  rotators  of  the 
hip  are  most  involved.  The  hemiplegic  gait  is  awkward,  the  foot  is 
swung  out  in  a  half -circle  and  scrapes  the  ground.  The  power  of  the 
paralyzed  leg  is  greater  when  it  is  used  with  the  sound  leg,  as  in  walking, 
than  when  it  is  used  by  itself. 

(ii)  The  contracture,  the  important  posthemiplegic  manifestation,  fixes 
a  joint  in  an  abnormal  posture.  Early  contractures  are  often  regarded 
as  myotatic  irritability.  The  typical  late  contracture  develops  in  two 
to  four  weeks;  the  shoulder  is  lifted,  the  arm  adducted  to  the  chest,  the 
elbow  rigid,  the  forearm  pronated,  the  wrist  flexed  and  the  fingers  flexed 
even  violently  into  the  palm.  When  the  wrist  is  passively  flexed  the 
fingers  can  sometimes  be  extended.  Contractures  involve  both  extensors 
and  flexors,  but  more  often  the  latter,  and  occur  in  the  least  paralyzed 
muscles.  In  the  lower  extremity,  the  contracture  is  not  marked,  in  the 
thigh  there  is  often  only  a  trace,  the  knee  is  extended,  plantar  flexion 
of  the  foot  occurs  (ijes  equinovarus) ,  and  the  great  toe  is  dorsally  flexed. 
Locomotion  is  difficult,  perhaps  painful,  for  there  is  bending  of  the  trunk 
to  the  sound  side,  lifting  of  the  pelvis  because  of  the  abduction  paralysis 
and  swinging  of  the  paralyzed  foot  over  the  sound  foot.  The  sound  leg  also 
suffers  slight  contracture.  Contracture  may  occur  in  the  face,  platysma 
and  sternomastoid,  but  rarely  in  the  trunk.  In  rare  cases,  largely  in 
children,  the  paralyzed  side  remains  lax  (JiemifUgie  flasque  of  Bouchard). 

(iii)  Associated  movements  are  explained  as  movements  reflected  to  the 
associates  of  the  paralyzed  muscles  or  as  due  to  bilateral  representation 
in  the  hemispheres;  an  effort  to  grasp  with  the  sound  hand  produces  a 
similar  movement  in  the  one  paralyzed;  movement  of  the  diseased 
side  occurs  after  passive  movement  of  the  sound  one,  etc. 

(iv)  Hemitremor  is  uncommon.  The  muscles  are  stimulated,  but  not 
enough  vibrations  occur  for  actual  involuntary  movement. 

(v)  Atrophy  may  occur  in  spastic,  though  more  in  the  flaccid,  cerebral 
forms.  Charcot  referred  it  to  degeneration  of  the  anterior  horns,  while 
Quincke  and  Senator  assume  an  injury  to  some  trophic  paths.  It  has 
no  relation  to  the  degree  of  paralysis,  is  often  associated  with  disturbed 
sensation  and  muscle  sense,  affects  principally  the  arm  and  occurs  in 
large  lesions  which  are  cortical  in  the  region  of  the  third  branch  of  the 
artery  of  Sylvius  or  central  in  the  lenticulothalamic  distribution.  The 
skin  may  atrophy. 

(vi)  Posthemiplegic  chorea  results  in  80  per  cent,  of  cases  from  lesions 
in  the  internal  capsule  or  near  it,  in  the  optic  thalamus,  lenticular  or 


772  DISEASES  OF   THE  BRAIN 

caudate  nucleus,  from  which  irritation  is  reflected  to  the  brain  cortex. 
It  develops  months  or  years  after  small  lesions,  when  the  hemiplegia  and 
rigidity  are  largely  gone.  It  occurs  especially  in  the  arm,  causes  move- 
ments similar  to  but  coarser  than  those  of  chorea  and  is  often  associated 
with  pain  and  sensory  disturbance  (see  page  757) .  It  sometimes  is  pre- 
paralytic. In  posthemiplegic  athetosis  the  fingers  and  toes  are  incessantly 
moved;  athetosis  means  "without  fixed  position,"  a  "mobile  spasm" 
consisting  of  spasmodic,  slow,  coordinated  movements  in  paralyzed 
members;  it  is  frequent  in  partial  paralysis  acquired  early  in  life,  appears 
long  after  the  paralysis  has  regressed  and  has  the  same  localization  as 
hemichorea. 

(vii)  In  trophic  and  vasomotor  disturbance  (v.  s.)  the  paralyzed  members 
are  usually  cool,  moist  and  sometimes  edematous.  The  skin  is  glossy, 
even  livid  and  fissured.  In  some  cases  paralysis  of  the  cervical  sym- 
pathetic causes  redness,  narrowing  of  the  eye  fissure,  drooping  of  the 
upper  lid,  retraction  of  the  eye-ball,  lachrymation  and  narrow  pupils. 
Sometimes  there  is  overgrowth  of  the  hair.  Bed-sores  were  considered 
trophic  by  Charcot,  but  can  usually  be  avoided  by  care  regarding  press- 
ure or  heat  and  by  cleanliness.  Swelling  of  the  joints  and  hypertrophic 
neuritis  on  the  hemiplegic  side  are  rare. 

(viii)  Psychic  disturbance,  referable  not  to  brain  hemorrhage  but  to 
arteriosclerosis,  is  evidenced  by  self-concentration,  weak  memory  and 
irritability  and  more  when  the  left  half  of  the  brain  is  diseased.  Laugh- 
ing and  weeping  are  referable  to  disease  of  the  thalamus  (g.  v.)  or  median 
fibers  of  the  pons. 

Diagnosis  of  Brain  Hemorrhage. — Two  cardinal  features,  coma  and 
hemiplegia,  together  with  the  typical  insult,  facilitate  diagnosis. 

1.  Coma. — In  syncope  the  pulse  is  fast,  weak  and  often  irregular; 
in  "cardiac  apoplexy"  (an  insult  from  heart  rupture,  myocarditis,  etc.) 
differentiation  from  rapidly  fatal  hemorrhage  may  be  impossible.  It 
is  dangerous  to  make  a  diagnosis  of  alcoholic  coma;  an  intoxicated  indi- 
vidual may  suffer  basal  fracture  or  actual  apoplexy;  an  opinion  should 
be  withheld  until  such  complications  can  be  excluded,  though  the  alco- 
holic coma  is  usually  incomplete,  the  vomitus  and  breath  smell  of  alcohol 
and  violent  struggling  is  frequent.  Opium  coma  is  characterized  by  slow 
onset,  slow  respiration,  slow,  hard  pulse,  flushed  skin,  contracted  pupils, 
opium  in  the  stomach  washings  and  later  Cheyne-Stokes's  respiration, 
rapid  pulse,  clammy,  cyanotic  skin,  and  dilated  pupils;  in  all  intoxica- 
tions the  focal  symptoms  and  reflexes  of  apoplexy  are  lacking.  Hemor- 
rhage in  the  pons  produces  narrow  and  often  unequal  pupils.  While 
diagnosis  of  apoplexy  during  the  coma  is  precarious,  uremic  coma  rarely 
occurs  without  premonitory  symptoms,  as  headache,  drowsiness,  delirium, 
restlessness,  vomiting,  myosis,  retinitis  or  convulsions;  the  coma  is  often 
less  profound.  The  cardiorenal  findings  of  nephritis  may  also  occur  in 
apoplexy,  of  which  nephritis  is  a  frequent  cause  (33  per  cent.)  and  the 
author  repeatedly  observed  hemiplegia  and  crossed  paralyses  in  uremia, 
sometimes  with  Babinski's  sign.  In  deep  coma  rigidity  may  be  observed 
in  both  uremia  and  apoplexy,  but  in  uremia  it  is  often  variable.  In 
diabetic  coma  the  fruity,  acetone  breath,  acetonuria,  unrest,  Kussmaul's 


CEREBRAL  HEMORRHAGE  773 

breathing,  granular  casts,  history  of  glycosuria,  and  absence  of  focal 
symptoms  are  characteristic.  Symptomatic  apojjle.ry,  transient  coma  and 
hemiplegia  sometimes  occur  in  brain  edema,  congestion,  progressive 
paralysis,  multiple  sclerosis,  epilepsy  and  tabes. 

2.  Hemiplegia. — ^This  is  a  prominent  finding  in  embolism  and  throm- 
bosis {q.  D.);  Kolisko  states  that  most  cases  diagnosticated  embolism 
prove  to  be  hemorrhage  and  vice  versa.  When  hemiplegia  occurs  in 
meningitis  with  coma,  there  are  headache,  general  convulsions,  rigidity, 
hyperesthesia,  optic  neuritis,  fever,  etc.  In  extradural  hematoma  and 
pachymeningitis  the  Jacksonian  epilepsy  followed  later  by  cortical 
paralysis  is  distinctive.  Hemiplegia  may  also  occur  in  hysteria  {q.  v.), 
syphilis,  brain  tumor  or  abscess,  trauma,  chorea,  paralysis  agitans, 
alcoholism,  plumbism,  uremia,  etc. 

3.  Other  Locations  of  Hemorrhage.^ — (a)  Hemorrhage  may  occur 
in  diseases  of  the  meninges  (g.  v.).  (b)  It  occurs  rarely  in  the  cortex; 
Jacksonian  epilepsy  and  rigidity  may  be  severe  in  subcortical  lesions, 
(c)  Ventricular  hemorrhage  is  secondary  to  hemorrhage  in  the  corpus 
striatum  or  thalamus  and  usually  reaches  all  the  ventricles;  in  rare 
cases  it  is  primary  from  aneurysms  or  ruptured  veins  in  the  choroid 
plexus.  One-third  of  all  cases  are  in  persons  under  forty  years  of  age. 
It  occurs  usually  with  violent  symptoms,  convulsions  (33  per  cent.), 
early  and  sometimes  bilateral  rigidity.  The  conjugate  deviation  changes 
to  the  other  side,  the  pulse  is  slowed,  the  temperature  falls,  the  reflexes 
are  suspended.  Cheyne-Stokes's  breathing,  glycosuria  and  polyuria 
develop  and  death  usualh^  results  within  a  day.  {d)  Hemorrhage  in  the 
cms  (v.  page  759)  is  usually  descending,  from  bleeding  near  the  internal 
capsule.  Crossed  paralysis  may  be  observed,  (e)  Apoplexy  in  the 
pons  (q.  V.)  occurs  in  10  per  cent,  of  cases.  Paralysis  and  convulsions 
may  occur  in  the  arms  or  legs  only;  the  trunk  musculature  is  involved 
more  frequently  than  in  higher  hemorrhages.  The  eyes  look  away  from 
the  side  of  the  lesion.  The  pupils  may  be  large  from  paralysis  or  small 
from  stimulation  of  the  third  nerve,  as  in  opium  poisoning.  Respiration 
is  affected  early,  vomiting  is  frequent,  there  is  often  early  high  fever 
and  death  is  usual  within  twenty-four  hours  (it  has  occurred  in  seven 
minutes).  (/)  Hemorrhage  in  the  medulla  will  be  considered  later. 
It  is  rarely  diagnosticated.  Early  or  instantaneous  death  is  frequent. 
{(j)  Cerebellar  apoplexy  occurs  in  7  per  cent,  of  cases.  Vomiting  is  very 
frequent.  The  insult  is  sometimes  less  marked  and  the  occasional  hemi- 
plegia is  due  to  indirect  pressure  or  secondary  ventricular  hemorrhage. 
Cerebellar  symptoms  may  result. 

Prognosis. — The  prognosis  concerns  the  immediate  danger  and  ulti- 
mate outcome,  (a)  The  immediate  prognosis  is  always  serious;  66  per 
cent,  survive  the  first  stroke,  33  per  cent,  the  second  and  very  few  the 
third.  When  death  occurs  it  is  usual,  in  one-half  to  two  days,  but  the 
outcome  is  uncertain  for  a  week,  because  light  cases,  even  rare  forms  with- 
out coma,  may  rupture  into  the  ventricle  with  rapidly  fatal  result.  Coma 
lasting  over  thirty  hours,  early  low  fall  of  temperature  or  its  early  rapid 
rise  is  unfavorable,  indicating  a  large  focus.  Conjugate  deviation, 
relaxed  sphincters,  impaired  breathing,  bilateral  or  ventricular  symptoms. 


774  DISEASES  OF   THE  BRAIX 

glycosuria,  albuminuria,  decubitus  and  convulsions  are  unfavorable. 
The  mode  of  death  is  as  follows :  the  breathing  becomes  more  rapid,  irreg- 
ular and  rattling  from  accumulated  secretion  and  of  the  ominous  Cheyne- 
Stokes's  type ;  the  slow  regular  pulse  becomes  rapid,  small,  irregular,  often 
with  a  rise  of  temperature  and  finally  ceases;  death  occurs  in  coma. 

(6)  Ultimate  Ovtcome. — The  symptoms  of  shock  disappear  and  the 
patient  becomes  partly  conscious  or  delirious.  Reaction  begins  usually 
within  forty-eight  hours  after  the  onset;  the  pulse  becomes  faster, 
the  temperature  rises,  pain  develops  in  the  head  and  limbs.  Life  hangs 
in  the  balance  and  the  patient  may  die  from  hypostatic  pneumonia, 
pulmonary  edema,  decubitus  or  a  second  hemorrhage.  Reaction  is  over 
in  one  to  six  weeks.  If  the  patient  survives  there  is  improveinent,  depend- 
ing on  the  extent  and  localization  of  the  injury;  if  movement  appears 
in  three  weeks  the  outlook  is  good ;  if  it  does  not  return  in  three  or  four 
months  it  is  not  likely  to  develop  later.  Disappearance  of  indirect 
pressure  leads  to  bettering  (i)  of  damage  to  the  sensory  nerves  and 
those  of  special  sense,  (ii)  of  motility,  first  of  the  trunk  and  face,  then  of 
the  leg,  and  less  of  the  arm.  Absolute  recovery  is  improbable.  Hemi- 
chorea  and  hemiathetosis  are  incurable.  Broken  neurones  never  unite 
and  secondary  degeneration  results;  exaggerated  reflexes,  developing  a 
few  weeks  after  the  insult  are  forerunners  of  contractures  and  preclude 
full  regression.  The  outlook  is  fairly  good  in  children  when  the  hemor- 
rhage is  not  due  to  blood  affections,  because  some  compensation  is  likely 
to  occur.  Piprurrence  is  possible  in  decrepid  and  aged  subjects,  although 
less  common  than  usually  believed;  the  average  expectancy  is  five 
years. 

Treatment. — 1.  Prophylaxis  concerns  the  causative  factors. 

2.  The  Ixsult. — (a)  Absolute  quiet  is  indicated;,  movement,  trans- 
portation or  extended  examination  is  avoided,  (h)  The  head  is  slightly 
elevated,  but  flexion  of  the  neck,  tight  clothes  or  any  hindrance  to  the 
return  venous  flow  avoided.  Bowles  thinks  that  stertorous  breathing 
is  due  to  the  position  of  the  paralvzed  palate;  turning  the  patient  on  his 
side  relieves  it  more  efi'ectivelv  than  does  venesection,  (c)  Venesection 
is  indicated  only  in  robust  individuals  with  strong  hearts  and  tense 
vessels;  about  12  ounces  of  blood  are  withdrawn;  the  chief  objection 
to  venesection  is  the  difficulty  of  differentiation;  in  thrombosis  and 
embolism,  venesection  increases  the  anemia  of  the  brain,  and  Gushing 
has  shown  that  the  high  tension  is  a  vicarious  eft'ort  to  keep  the  medulla 
supplied  with  blood.  This  objection  holds  to  compression  of  the 
common  carotid,  id)  Leeches,  sinayisms  and  the  ice-cap  cannot  in- 
fluence the  circulation  in  the  brain,  (e)  Evacuation  of  the  bladder  and 
hoicels  is  indicated.  Croton  oil  was  Hughlings  Jackson's  only  remed>-; 
two  drops  act  in  an  hour  or  two  and  may  be  repeated,  (f)  The  diet 
should  be  fluid  and  administered  by  the  nasal  catheter  or  by  rectum. 
(g)  Decubitus  is  prevented  by  change  of  posture  and  cleanliness;  heat 
and  sinapisms  must  be  avoided  because  the  hemiplegic  side  is  prone 
to  necrosis,  (h)  Symjjtoviatic  treatment  of  cardiac  failure  is  met  by 
ammonia,  etc;  restlessness  or  convulsions  are  managed  by  chloral  per 
rectum  or  morphine. 


CEREBRAL  EMBOLISM  775 

3.  The  Reaction. — During  the  inflammatory  reaction  the  treatment 
is  expectant  and  if  possible  should  be  conducted  without  drugs. 

4.  The  Chronic  Stage. — (a)  Gentle  massage  of  the  muscles,  move- 
ment of'  the  joints  and  alcohol  rubs  are  instituted  as  soon  as  the  coma 
subsides,  {h)  Potassium  iodide  is  indicated  when  the  reaction  subsides, 
(c)  In  four  weeks,  the  patient  should  be  encouraged  to  sit  up  and  walk. 
{d)  The  faradic  current  is  valuable  after  four  weeks  and,  supplemented 
with  massage  of  the  paralyzed  groups  and  their  antagonists,  minimizes 
the  contractures,  (e)  Hy dr other apy:  cool  baths  or  rubs  are  efficacious 
except  in  poorly  nourished  individuals.  Strychnine  is  contra-indicated 
in  all  cases. 

V.  Cerebral  Embolism. — Embolism  and  thrombosis  of  a  cerebral 
artery  result  in  brain  softening  (encephalomalacia),  which,  next  after 
hemorrhage  in  importance  and  frequency,  is  one  of  the  best-developed 
subjects  in  brain  pathology.  Brain  softening  from  arterial  occlusion  is 
not  the  "softening  of  the  brain"  known  to  the  laity  who  give  that  name 
to  progressive  paralysis  of  the  insane.  Encephalomalacia  must  not  be 
confused  with  encephalitis.  Softening  was  first  recognized  by  Abercrombie 
(1818)  and  Rostan  (1820). 

Etiology. — Embolisms  involve  the  kidneys  in  77  per  cent.,  spleen  in 
54  and  brain  in  22  per  cent,  (a)  About  90  per  cent,  are  due  to  heart 
disease,  most  commonly  acute  endocarditis.  Calcareous  fragments  or 
parts  of  torn  valves  may  be  thrown  into  the  brain.  Of  valvular  diseases, 
mitral  stenosis  produces  embolism  most  frequently  because  of  stasis 
in  the  left  auricle.  Less  frequent  are  cardiac  clots  formed  in  the  weak 
hearts  of  decrepid,  cachectic  subjects,  in  myocarditis  or  acute  diseases, 
as  typhoid.  (6)  Atheroma  of  the  arch  and  aneurysm  are  far  less  frequent 
causes,  as  are  (c)  lung  lesions,  as  tuberculous  cavities,  abscess,  gangrene 
or  empyema  (after  irrigation),  tumors,  echinococcus,  gumma  or  abscess 
of  the  heart,  {d)  In  the  rarest  instances  lung  tissue,  fat  embolism  from 
fractures,  pigment  embolism  in  malaria  or  liver  cells  in  acute  yellow 
atrophy  may  produce  cerebral  embolism,  (e)  With  a  patent  foramen 
ovale,  thrombi  may  reach  the  brain  from  the  venous  system,  as  in  manual 
expression  of  the  placenta.  (/)  Most  cases  occur  in  youth  when  acute 
infections,  are  most  frequent,  as  chorea,  scarlatina  or  endocarditis. 

Pathology. — (a)  The  embolus  first  is  grayish-red  but  later  paler  and  fri- 
able; "riding  emboli"  straddle  the  point  of  arterial  branching;  they  may 
by  slipping  produce  another  embolism  farther  on.  Secondary  thrombosis 
may  occur  at  the  infarction.  (6)  The  artery  beyond,  save  where  the 
embolus  retracts  or  softens,  becomes  a  thin,  hard,  impervious  cord. 
Behind  the  plug  an  aneurysm  may  form.  If  the  embolus  is  septic,  in- 
flammation intervenes  in  and  around  the  vessel,  (c)  As  to  the  fate  of  the 
hrain  tissue:  (i)  If  the  stoppage  is  partial,  only  stasis,  edema  and  swelling 
occur;  if  total,  necrosis  results,  (ii)  The  brain  arteries  are  "  end  arteries," 
as  Cohnheim  pointed  out,  whence  complete  collateral  circulation  is 
unlikely,  although  the  necrosis  is  rarely  as  extensive  as  the  distribution 
of  the  artery  occluded.  There  is  more  collateral  compensation  at  the 
cortex  than  at  the  base  and  the  least  in  the  deep  parts  of  the  centrum 
ovale  or  basal  ganglia.     The  brain  tissue  is  ischemic,  but  a  degree  of 


776  DISEASES  OF   THE  BRAIN 

collateral  fluxion  saves  some  tissue^  especially  if  the  heart  is  strong. 
With  a  weak  heart  or  diseased  collateral  arteries,  ischemic  necrosis  must 
follow.  A  marked  hemorrhagic  infarct  is  not  common,  being  prevented 
by  swelling  of  the  nervous  tissue.  Microscopic  changes  are  seen  after 
one  or  two  days;  the  brain  becomes  edematous,  gelatinous,  marbled, 
fusing  with  the  slightl}'  edematous  brain  tissue  surrounding  the  focus; 
the  brain  rapidly  becomes  fluid  and  pulpy,  although  its  remarkable 
cohesion  is  a  matter  of  frequent  comment;  certain  convolutions  may 
waste  or  wholly  disappear,  as  the  hippocampus,  lingual  and  fusiform 
lobules,  especially  after  plugging  of  the  posterior  cerebral  artery.  The 
white  matter  often  disappears  and  is  replaced  by  lax  cellular  tissue, 
in  whose  meshes  are  cystic  formations  with  turbid  fluid  and  flocculi  of 
brain  tissue.  Durand-Fardel  described  three  forms  of  softening:  (a) 
The  red  softening  found  most  often  in  embolism  is  usually  fresh  and 
there  is  capillary  extravasation;  it  is  irregularly  oval  or  wedge-shaped 
in  basilar  lesions;  it  usually  measures  but  a  centimeter  or  two;  it  is 
prominent  on  section  from  blood  and  serum;  it  is  soft,  but  not  fluid 
in  the  centre;  it  is  mostly  located  in  the  cortex  or  central  ganglia  and 
lasts  one  or  two  weeks.  (6)  Yellow  softening  follows  the  red;  the  yellow 
color  is  due  to  old  blood  pigment  or  fatty  change;  it  is  sunken  on  section, 
from  atrophy  of  the  brain  substance;  is  fairly  demarked  and  may  contain 
fluid,  hydrops  ex  vacuo;  it  may  last  years  and  is  found  especially  in  the 
cortex,  (c)  W^hite  softening  may  represent  (i)  afresh  lesion  about  tumors 
or  abscesses  or  in  various  cachexias,  is  sunken  below  the  cut  surface 
and  occurs  where  few  vessels  are  involved  and  little  regurgitation  from 
adjacent  vessels  occurs;  (ii)  old  snow-white  lesions,  occurring  when  the 
blood  and  fat  are  absorbed ;  if  diffuse  it  gives  rise  to  the  spongy  etat  crihle. 

Demarcation  may  occur  after  weeks,  producing  a  "cyst."  IMore 
rarely  neurogliar  increase  may  lead  to  shrinking  and  scarring.  Myelin 
and  fat  drops,  leukocytes  laden  with  granules  and  fat,  collapsed  vessels 
and  necrotic  nervous  relics  are  observed.  Secondary  degeneration  occurs 
when  the  pyramidal  tracts  are  involved  (see  page  776). 

Symptoms. — As  in  apoplex^^,  we  consider  the  insult,  the  'permanent 
symptoms,  and  those  of  the  causal  disease  (mitral  stenosis,  etc.). 

1,  The  insidt  is  (a)  sudden  and  without  prodromes  (save  when  the 
embolism  does  not  wholly  occlude  the  vessel  and  symptoms  appear  only 
when  secondary  thrombosis  develops).  Embolism  in  a  small  vessel 
may  occur  without  symptoms.  The  patient  may  be  stricken  without 
coma  and  sit  "astonished"  at  the  stroke.  The  insult  is  caused  by  hrain 
anemia,  negative  pressure  and  shock.  In  some  cases  (6)  coma  occurs, 
generally  less  profound  and  less  protracted  than  in  hemorrhage;  irritative 
symptoms,  as  (c)  convulsions,  tonic  spasms  and  conjugate  deviation  are 
more  common;  convulsions  are  often  unilateral,  corresponding  vnth  the 
hemiplegia.  (d)  Intermediate  types  are  observed;  cases  with  vertigo; 
tendency  to  fall  to  one  side;  hemianopsia,  alexia,  hemianesthesia,  aphasia 
or  only  confusion  and  delirium,  (e)  The  pulse  is  full  but  not  slow. 
(/)  The  temperature  rarely  suffers  initial  depression  and  later  may  rise. 

2.  The  permanent  symptoms  and  secondary  degeneration  are  the  same 
as  in  hemorrhage. 


CEREBRAL  EMBOLISM 


777 


Localization  of  Embolism. — 1,  The  Artery  of  the  Fossa  of  Sylvius. — 
This  most  frequently  involved  (80  per  cent.),  largest  and  most  direct 
branch  of  the  middle  cerebral  is  practically  a  continuation  of  the  internal 
carotid.  Convulsions  occur  in  33  per  cent.,  with  or  without  loss  of  con- 
sciousness, and  are  most  frequent  when  the  smaller  branches  are  em- 
bolized.  High  temperature  is  common.  The  clinical  picture  varies 
with  the  site  of  infarction;  embolism  at  A  (Fig.  57)  where  the  perforat- 
ing branches  (P.P.)  are  given  off  to  the  internal  capsule,  corpus  striatum 
and  anterior  part  of  the  thalamus,  must  involve  (a)  these  structures, 


Fig.  57. — Embolism  of  artery  of  the  fossa  of  Sylvius:  I.C.,  internal  carotid;  P.C.,  post, 
communicating;  A.C.,  anterior  cerebral  artery;  A.S.,  art.  fossae  Sylvii  and  1,  2,  3,  4  and  5, 
its  main  branches.  CR,  corona  radiata  from  cortex  to  internal  capsule.  (See  text  for 
explanation  of  lesions  at  A,  B,  C,  D,  E,  F  or  G.) 


and  (6)  the  motor  and  sensory  cortex,  with  hemiplegia,  hemianesthesia, 
motor  aphasia  (alexia),  deafness  and  word-deafness  (if  it  occurs  on  the 
left  side).  Convulsions  are  absent,  because  the  injured  internal  capsule 
cannot  convey  the  cortical  irritation  to  the  extremities;  the  large  areas 
rendered  anemic  may  cause  marked  reaction,  sometimes  death.  In  rare 
cases,  only  the  central  perforating  branches  are  involved  and  the  cortex 
obtains  the  blood  by  anastomoses  with  the  posterior  and  anterior  cere- 
brals. The  left  Sylvian  artery  is  more  frequently  involved  (63  per  cent.) 
because  the  left  carotid  comes  directly  from  the  arch.    If  the  lesion  is  at 


778  DISEASES   OF   THE  BBAIX 

(B)  (Fig.  57),  the  motor  speech  area,  F^,  the  anterior  and  po.^terior  motor 
convolutions  A.C.C.,  P.C.C.  (hemiplegia;,  the  gyrus  angularis  and 
gA-rus  supramarginalis  P2  (alexia)  and  the  temporal  convolutions  Ti 
and  T2  (deafness  or  word-deafne.>-j  are  in\-oh"ed.  Somnolence  and 
delirium  are  common;  convulsions  occur,  because  the  internal  capsule 
escapes.  Convulsions  and  pain  are  most  frequent  in  embolism  of  the 
smaller  vessels.  Little  hemianesthesia  is  observed.  A  lesion  at  C 
is  the  most  frequent  site.  It  affects  the  island  of  Reil  (IR)  in  part; 
cortical  convulsions,  hemiplegia,  monoplegia,  sensory  aphasia  (Ti,  T2), 
alexia  (P2)  and  sometimes  sensory  disturbance  occur.  It  is  seen  hoTv  an 
isolated  lesion  at  D  could  produce  motor  aphasia;  at  E,  monoplegia; 
at  F,  alexia;  or  at  G,  word-rleafness. 

2.  Po>TEEiOR  Cerebral  Artery. — Embolism  'in  2  per  cent.j  comes 
from  the  vertebral  artery  and  often  occurs  with  embolism  of  the  Sylvian 
artery;  it  -upplies  (a)  all  the  ventricles,  the  thalamus,  ant.  corp.  quad- 
rigemina,  the  geniculate  body  and  the  peduncle  by  its  central  branches, 
and  (h)  the  mesial  aspect  of  the  occipital,  part  of  the  parietal  and  most  of 
the  temporosphenoidal  lobes.  The  most  common  general  symptoms  are 
convulsions,  coma,  vertigo,  conjugate  deviation  and  nystagmus;  while 
the  most  important  focal  .symptoms  are  sensory  hemianesthesia,  sensory 
aphasia  and  hemiano'psia.    The  lesions  are  sometimes  symmetrical. 

3.  AxTERiOR  Cerebral  Artery. — Few  clear  cases  are  recorded,  since 
the  artery  originates  at  a  right  angle  to  the  carotid. 

J:.  IxTERXAL  Carotid  Artery. — In  this  embolism  (A  per  cent.;  the 
plug  must  be  large  to  produce  damage,  for  if  the  vessels  of  the  circle  of 
\Yillis  are  normal,  only  transient  hemiplegia  results.  Disease  of  these 
vessels,  abnormalities  in  size  or  secondary  thrombosis  may  produce 
permanent  or  fatal  residts.    Sepsis  is  a  frequent  factor. 

5.  Basilar  Artery. — Embolism  occurs  in  6  per  cent.;  the  clot  never 
fills  the  vessel,  because  it  first  passes  the  smaller  vertebral  artery; 
symptoms  occur  more  frequently  when  secondary  thrombosis  occurs — 
convulsions,  trismus,  paralysis  of  the  third,  fifth  and  seventh  nerves, 
crossed  hemiplegia,  diplegia,  narrow  pupils  and  conjugate  de\dation. 
The  temperature  often  falls  low  and  then  rapidly  rises.  Death  may 
follow  in  two  to  five  days  from  respiratory  failure. 

G.  Vertebral  Artery. — Involvement  of  the  tongue,  larynx,  lips, 
pharynx  and  spinal  branch  of  the  fifth  nerve  results  in  anesthesia,  dys- 
phagia or  other  signs  of  acute  bulbar  palsy.  Hemianesthesia,  hemiplegia 
and  hemiataxia  may  develop.    It  is  often  fatal. 

7.  Cerebellar  Arteries. — This  is  the  rarest  of  all  embolisms. 

Diagnosis. — The  main  points  are  (a)  recognition  of  the  cardiac  cause; 
(h)  absence  of  prodromes;  (c)  sudden  insult,  frequent  convulsions  and 
infrequent  coma  (see  page  781). 

Prognosis. — The  outlook  depends  (a)  on  the  primary  disease,  being 
most  favorable  after  acute  infections  and  in  youth;  (h)  on  the  intensity 
of  the  onset  itself,  during  which  deatli  may  occur;  'c)  on  the  localization. 
The  initial  symptoms  may  improve;  tlie  outlook  is  more  favorable  than 
in  hemorrhage.  Psychical  symptoms  are  cortical  in  origin.  Avhile  the 
vegetative  or  trophic  are  due  to  a  le.-ion  in  tlie  basal  ganglia;  basilar 


CEREBRAL  THROMBOSIS  ,  779 

and  vertebral  embolisms  are  most  unfavorable,  (cl)  Recurrence  is  pos- 
sible, although  it  is  less  likely  than  usually  stated,  (e)  The  condition  of 
other  orcjans,  as  the  vessels  of  the  circle  of  Willis,  the  strength  of  the 
heart  muscle,  etc.,  determine  the  prognosis. 

Treatment. — {a)  The  insult  is  treated  as  in  hemorrhage  in  regard 
to  diet  and  quiet.  (6)  All  derivative  measures,  as  drastics  and  vene- 
section, are  absolutely  to  he  avoided,  (c)  The  heart  must  be  stimulated, 
if  hemorrhage  is  excluded,  to  relieve  the  brain  ischemia  by  a  strong 
collateral  circulation  and  to  strengthen  the  heart  to  avoid  recurrence. 
Digitalis  acts  too  slowly,  and  camphor,  strychnine  and  ammonia  are 
preferable,  {d)  Conmdsions  should  be  treated  by  chloral  given  by  rectum, 
avoiding  alcohol;  more  than  a  dram  of  chloral  in  three  hours  is  very 
dangerous,  {e)  The  after-treatment  is  as  in  the  corresponding  stage  of 
apoplexy. 

VI.  Cerebral  Thrombosis. — It  is  more  common  than  embolism. 
Etiology  and  Pathology. — 1.  Changes  in  the  Vessel  Wall. — (a) 
Arteriosclerosis  {q.  v.)  is  the  most  important  cause.  Blood  plaques  are 
deposited  on  the  rough  intima  of  the  tortuous,  inelastic,  calcareous 
vessels,  with  their  unequal  caliber;  layer  after  layer  of  fibrin  is  deposited, 
aided  by  local  slowing  of  the  blood  stream  and  weakening  of  the  heart. 
Tumors,  abscesses  and  traumatic  meningitis  may  initiate  thrombosis. 
Brain  atheroma  usually  occurs  with  general  atheroma.  The  vessels 
most  involved  are,  in  order  of  frequency,  the  carotid,  middle  cerebral 
and  its  Sylvian  branch,  basilar,  vertebral  and  posterior  cerebral,  {b) 
In  syphilitic  endarteritis  the  initial  proliferation  may  of  itself,  without 
thrombosis,  obliterate  the  vessel  lumen  (see  Brain  Syphilis).  The 
pathological  sequence  is  the  same  as  in  embolism;  ischemia,  necrosis 
(softening)  and  loss  of  function  occur,  save  that  in  gradual  thrombosis 
the  focus  is  less  homogeneous  than  in  the  sudden  lesion  of  embolism. 
The  foci  are  often  multiple. 

2.  Changes  in  the  Heart. — Sudden  cardiac  insufficiency  in  arterio- 
sclerosis may  precipitate  thrombosis,  as  brought  out  especially  by 
Kolisko.  An  acute  infection  in  the  aged,  low  arterial  tension  from 
exhaustion,  grief  and  similar  causes  may  induce  encephalomalacia. 

3.  Changes  of  the  Blood. — This  constitutes  the  smallest  class  of 
cases.  Burns,  poisoning  by  carbon  monoxide  and  illuminating  gas, 
gout,  chlorosis,  leukemia,  metallic  poisons,  jaundice  and  marasmus  in 
very  young  children  or  in  extreme  old  age  may  cause  thrombosis.  Acute 
infections  and  heart  weakness  are  frequent  factors  in  this  class.  Throm- 
bosis affects  the  smaller  vessels  and  is  usually  multiple. 

Symptoms. — In  some  cases  thrombosis  is  found  at  necropsy  without 
previous  symptoms  ("latency"). 

1.  Prodromes. — These  are  frequent  and  may  appear  hours,  days, 
even  months  before  focal  symptoms  develop.  The  most  common  are 
headache,  which  is  severe  in  the  syphilitic  variety,  vertigo,  numbness 
and  weakness  in  a  limb  or  in  one-half  of  the  body,  disturbance  in 
sight,  mind,  articulation  or  character. 

2.  Onset. — The  onset  varies;  (a)  an  acute  insvlt  is  not  frequent. 
If  consciousness  is  lost,  the  coma  is  less  deep  and  protracted  than  in 


780  DISEASES  OF   THE  BRAIX 

hemorrhage;  a  "stroke"  indicates  thrombosis  in  one  large  or  in  several 
vessels.  Conjugate  deviation,  flaccidity  and  paralysis  are  frequent 
during  the  coma.  Consciousness  is  usually  preserved  in  the  syphilitic 
type.  (6)  The  onset  is  usually  gradual.  Layer  after  layer  is  added 
to  the  clot  but  strengthened  heart  action  may  for  a  time  maintain 
collateral  circulation.  When  the  heart  weakens,  the  clot  increases 
and  the  collateral  blood  supply  decreases,  so  that,  after  alternating 
advance  and  regression,  the  final  thrombosis  results,  vnlh  irreparable 
softening.  The  cardiac  strength  and  the  number  and  size  of  the  A'essels 
involved  determine  the  acuity  or  chronicity  of  the  course.  Reaction 
may  be  marked,  especially  in  the  aged,  fc)  In  the  chronic  or  long  latent 
variety,  prodromes  are  absent,  psychic  alteration  is  apparent  and  focal 
symptoms  develop. 

3.  Cheoxic  Stage. — Focal  symptoms  are  common.  Apoplectiform 
seizures  mark  the  advance  of  the  process  in  new  vascular  areas.  The 
motor  or  sensory  paralysis  presents  much  the  same  picture  as  hemorrhage 
and  embolism  in  their  chronic  stage. 

Localization. — ^Localization  is  impossible  when  multiple  foci  exist,  as  in 
the  Sylvian  artery  of  one  side  and  the  posterior  cerebral  artery  of  the 
other;  to  the  few  reported  cases  Senator  adds  one  in  which  left-sided 
hemiplegia  was  associated  with  aphasia. 

1.  Sylvian  Aeteey. — The  most  common  cause  is  syphilis  or  atheroma. 
When  the  main  trunk  is  involved,  the  same  symptoms  appear  as  in  em- 
bolism, viz.,  hemiplegia,  etc.,  with  this  modification — the /oca/  symptoms 
are  more  severe  in  thrombosis,  because  other  vessels  are  somewhat  dis- 
eased; the  general  symptoms  are  less  severe.  Prodromes  appear  first,  as 
tingling,  then  hemiplegia,  possibly  with  delirium  or  loss  of  consciousness; 
the  sjTuptoms  may  improve,  then  there  may  be  recurrence  with  aphasia 
and  coma.  The  course  is  a  "step-like"  progression  and  regression. 
Monoplegia  is  more  common  than  in  embolism,  because  thrombosis  seeks 
the  cortical  vessels,  whence  the  face  and  arm  may  be  affected;  aphasia 
may  exist  alone,  or  alexia,  mind-blindness  or  deafness. 

2.  AxTEEiOE  Ceeebeal  Aeteey. — This  artery  is  rarely  totally 
occluded.  A  clot  beyond  the  anterior  communicating  vessel  produces 
crural  monoplegia  with  arm  paresis.  Very  gradual  ischemia  produces 
ivasting  without  softening;  sudden  ischemia  produces  softening.  The 
frontal  lobes  present  the  "worm-eaten"  atrophy,  with  abundant  hydrops 
ex  vacuo;  its  close  arterial  connection  is  obvious. 

3.  PosTEEiOE  Ceeebeal  Aeteey". — Thrombosis  may  result  in  hemi- 
plegia alternans  oculomotoria,  hemihypesthesia  and  optic  changes  varying 
as  the  optic  radiation,  cuneus  or  other  parts  are  affected. 

4.  Basilae  Aeteey. — If  the  thrombosis  is  acute  the  symptoms  are 
like  those  of  embolism.  If  slow,  ophthalmoplegia  which  is  rarely  lasting, 
or  other  motor  paralyses,  hemiplegia  with  alternating  palsy  of  the  fifth, 
sixth  and  seventh  nerves,  may  develop. 

5.  Veetebeal  Aeteey. — Acute  bulbar  palsy,  Avith  stormy  sA-mptoms, 
cannot  be  distinguished  from  embolism.  Subacute  bulbar  palsy,  with 
dyspihagia,  dysarthria,  hemianesthesia,  homolateral  ataxia,  contralateral 
h  em  i  analgesia  orhemiplegm  with  crossed  paralysis  of  the  tongue  may  result. 


CEREBRAL   THROMBOSIS 


rsi 


Hemorrhage. 


Thrombosis. 


Embolism. 


(1)  Predisposing  etiology.  Before 
third  year  (glioma) ;  80  per  cent, 
after  fortieth  year. 

MiUary  aneurj'sms;  atheroma  and 
cardiac  hypertrophy. 


Heredity.     Nephritis;   cause  in  33 
per  cent.,  "granular  kidney." 

(2)  Attack  precipitated  by  hea^-y 
meal,  acute  alcoholism,  high  art. 
tension  (excitement,  effort,  shock). 

(3)  Prodromes  unusual,  unless  from 
causal  arteriosclerosis. 


(4)  Insult:  Usually  sudden;  with- 
out prodromata;  long  duration 
(fatal  if  more  than  two  daj-s). 
Cause;  positive  pressure  produc- 
ing brain  anemia. 

(5)  Infra-cranial  pressure:  "Press- 
ure symptoms"  present,  poljTiria, 
albuminuria,  glocosuria,  red  face, 
beating  arteries,  Cheyne-Stokes's 
breathing;  slow,  hard  pulse  is  the 
fundamental  difference  (Brissaud); 
bruit  de  gallop  speaks  strongly  for 
hemorrhage.  Irregularity,  if  com- 
bined with  strength  not  against 
hemorrhage.  Pulse  may  be  fast 
(Brissaud). 

(6)  Temperature:  Rectal  tempera- 
ture usually  depressed  at  first, 
may  fall  tUl  death.  I\Iay  rise  later 
(inflammatory  reaction).  Early 
rise  (pons,  medtilla,  gangha). 
Sudden  rise  of  bad  omen;  rises 
before  death. 

(7)  Coma:  More  frequent,  greater 
in  degree,  longer  in  duration,  usu- 
ally complete.  If  lesion  seems 
small,  coma  speaks  for  hemorrhage. 
Deep  and  prolonged  speaks  for 
hemorrhage  and  usually  fatal  if 
over  twenty-four  hotirs. 

(8)  Paralysis,  sudden,  complete, 
hemiplegic,  non-progressive  after 
first  seizure.  Foot  gains  more 
rapidly  than  hand.  Persistent 
aphasia  exceptional.  Spasmodic 
laughing  and  weeping  common. 


(9)  Convulsions:  Usually  general- 
ized; very  rare  from  cortical  irri- 
tation or  in  corpus  striatima;  post- 
hemiplegic  are  rare. 

(10)  Sensation:  Anesthesia  usually 
transient. 

Postplegic  chorea,  trembling,  athe- 
tosis, common. 

(11)  Atheroma  retinal  arteries,  hence 
retinal  hemorrhage  (not  signifi- 
cant unless  large).  Aneurysms 
verj'  rare  but  speak  strongly  for 
hemorrhage.  Retinitis  albumin- 
vu-ica. 

(12)  Secondary  reaction;  not  much. 
Psychical  symptoms;  far  less. 


After  eightieth  more  year  frequent 
than  hemorrhage.  Twentieth  to 
fortieth  year  sjishilis  (S-i  per  cent, 
occur  between  these  years). 

Weak,  irregular  heart;  fevers,  cach- 
exia. Atheroma,  especially  sjTphilis, 
alcoholism,  plumbism. 


Youth;  hemorrhage  practi- 
cally never  in  youth. 


Endocarditis  (rheumatism, 
sepsis),  especially  mitral. 
Weak,  fatty,  dilated  heart. 
In  heart  disease  Eichhorst 
found  in  60  per  cent,  hem- 
orrhage and  in  40  per  cent, 
embolism. 

Rare. 

Rare. 

By  exertion,  dislodging  clot. 


Rare. 
Rare. 

Low  arterial  tension;  by  sleep,  grief, 
exhaustion,  fatigue.  : 

Very    common,    mental   LrritabUity,    Absolutely  none. 

weak  memory,  headache,  vertigo, 

numbness,    tingling,    weakness    in 

extremities. 
Rarely  acute  onset  (unless  in  a  large 

vessel) ;  usually  gradual,  especially 

in  senile  softening.     If  an  insult, 

focal  and  general  sjinptoms  usually 

appear  during  the   coma. 
None. 
Pulse  soft,  weak. 

(Wassermann  test)  . 


Sudden,  shorter  and  less 
severe  thanin  hemorrhage. 
Cavise;  negative  pressure. 
Slow  insult  only  with  sec- 
ondary thrombosis. 

None  (pallor  rather  than 
congestion) . 


Initial  depression,  usually  lasting. 
Seldom  temperature  unless  lesion 
in  pons.  !NIore  probably  early 
reaction.     Especially  in  the  aged. 


Less  frequent  and  shorter.  Recovery 
possible  after  several  days  of  coma. 
None  in  syphilitic  thrombosis.  If 
lesion  seems  large,  consciousness 
speaks  for  softening.  If  coma,  usu- 
ally focal  symptoms  are  then  seen. 
Coma  in  large  bilateral  lesions. 

Gradual,  incomplete,  monoplegia, 
hemianopsia;  repeated,  often  sjTn- 
metrical  paralysis. 

Converse. 

Aphasia  common.  Absence  of  focal 
symptoms  rather  more  common 
(central  gangha).  Laughing  and 
weeping  exceptional. 

Less  than  in  embolism.  IMore  local- 
ized, Jacksonian  epilepsy  speaks 
for  softening.  IMay  recur.  Post- 
plegic frequent. 

Paresthesia  persists  and  more 
marked.  Cerebral  pains  (hyper- 
esthesia dolorosa). 

Less  common. 

Arteriosclerosis. 


Greater    secondary    reaction. 
Often  greater;  intelligence,  memory 
aphasia,  word-deafness,  etc. 


Temperature  may  rise  high 
at  once  -n-ithout  bad  omen. 
Temperature  no  absolute 
guide;  occurs  especially 
when  large  trunk  embol- 
ized. 

No  coma  usually. 


^lore     like     hemorrhage. 
Monoplegia   rare.      In   63 
per  cent,  it  is  in  the  left 
side  of  the  brain. 

Fairlv  common. 


More  common  (33  per  cent.) 
than    in    hemorrhage    or 
j     thrombosis    (lesion    corti- 
cal.) 
Paresthesia  persists  and  more 
marked.     Cerebral     pains 
(hyperesthesia  dolorosa). 
Less  common. 

Optic  retinitis  sometimes 
from  endocarditis  (Broad- 
bent    and    IMackenzie). 

Occasionally  embolism  in 
retinje. 


Very   seldom;    after   attack 
may  be  some  delirium. 


Diagnosis  and  DifEerentiation. — The  prodromes,  gradual  onset  and 
cortical  location  are  most  distinctive,  although  the  differentiation  may 
be   wholly  theoretical  or  impossible  (page   781).     In  brain  twnor  the 


782  Di;SEASES  OF   THE  BRAIN 

course  is  slower,  and  stabile  focal  symptoms  less  frequent — that  is, 
headache,  vomiting,  choked  disk  and  Jacksonian  epilepsy  are  far  more 
frequent  than  permanent  paralysis.  We  may  consider  hemi'plegia  in 
the  aged,  Marie's  les  lacunes  de  desintegration  cerebrale;  multiple  degenera- 
tion clefts  occur,  chiefly  in  the  large  basal  ganglia,  sometimes  in  the  in- 
ternal capsule,  pons,  or  centrum  ovale.  Marie  holds  that  the  lesion  is  a 
rarefaction  (cavity  formation)  of  brain  tissue  due  to  chronic  sclerosing 
encephalitis,  without  vessel  occlusion.  It  is  said  to  cause  90  per  cent,  of 
"insults"  in  the  aged,  usually  with  partial  ^paralysis;  sometimes  with 
aphasia,  dysarthria  or  dysphagia;  rarely  with  loss  of  consciousness; 
and  never  with  sensory  disturbance  or  contractures.  The  gait  is  the 
demarche  a  petits  yas.    The  patient  may  live  ten  years. 

Prognosis. — The  prognosis  depends  on  (a)  the  cause;  it  is  unfavorable 
in  arteriosclerosis,  because  collateral  vessels  are  probably  diseased.  If 
the  other  vessels  are  sound,  enormous  disease  may  be  compensated, 
as  in  Kussmaul's  case  of  occlusion  of  both  the  subclavian  and  carotid 
arteries.  In  recent  syphilis  the  prognosis  is  more  favorable,  though 
old  specific  thrombosis  is  incurable.  The  younger  the  patient  the  better 
is  the  outlook.  (6)  The  onset;  most  cases  with  a  brusque  beginning 
die.  Coma  indicates  thrombosis  in  large  vessels  or  in  both  hemispheres. 
If  there  is  no  insult  the  focal  symptoms  are  irreparable,  i.  e.,  there  are 
no  indirect  symptoms.  The  first  seizure  does  not  usually  threaten  life. 
(c)  The  location  and  extent  of  the  lesion.  The  number  of  vessels  involved 
is  obviously  important.  In  Sylvian  thrombosis  involving  the  branches 
to  the  central  ganglia,  the  patient  dies  in  four  to  six  weeks  with  involun- 
tary evacuations,  cachexia  and  bed-sores.  Cortical  lesions  are  prone  to 
produce  psychical  alteration.  Basilar  or  vertebral  thrombosis  is  directly 
dangerous,  {d)  The  focal  symptoms  are  likely  to  persist  and  recur.  Oph- 
thalmoplegia may  regress,  ie)  The  condition  of  other  organs,  above  all 
the  heart,  is  of  prognostic  import. 

Treatment. — (o)  The  general  treatment  is  the  same  as  in  hemorrhage. 
(6)  The  causal  treatment  relates  to  the  iodides,  valuable  in  atheroma 
and  syphilis,  (c)  The  heart  must  be  stimulated  with  digitalis ;  absolute 
quiet  in  the  prone  position  and  free  administration  of  food  and  fluid  by 
rectum  or  by  nasal  catheter  are  indicated.  Drastics  and  depleting 
measures  must  be  avoided.  On  the  heart  devolves  the  entire  possibility 
of  collateral  compensation,  (d)  In  the  period  of  reaction  alcohol  only 
accentuates  the  inflammation.  For  delirium  and  headache,  bromides 
are  most  useful;  no  cardiac  depressants,  e.  g.,  chloral  or  coal-tar  products 
may  be  used,  (e)  The  chronic  stage  is  treated  as  in  hemorrhage.  At  all 
times  catheterization  must  be  conducted  antiseptically  and  great  care 
exercised  against  bed-sores. 

VII.  Intracranial  Aneurysms. — Etiology. — Aside  from  miliary  aneur- 
ysms, aneurysms  may  occur  in  the  large  brain  vessels,  more  frequently 
in  males  (60  per  cent.),  and  more  (53  per  cent.)  before  than  after  the 
fortieth  year.  The  causes  are  (a)  atheroma  in  whose  causation  alcohol 
is  particularly  important;  (6)  trauma,  initiating  arteritis,  especially  in 
the  internal  carotid,  as  after  .basal  fracture;  (c)  syphilis,  especially  pro- 
ductive of  basilar  aneurysm,  often  within  a  year  after  infection;  (d) 


SINUS  THROMBOSIS  783 

embolism,  the  most  frequent  cause  in  early  life;  endocarditis  is  the  usual 
cause  when  trauma  and  syphilis  are  excluded.  The  embolus  produces 
arteritis  from  which  the  vessel  dilates.    The  clot  may  later  disappear. 

Pathology. — Location. — Statistics  show  the  following  frequency; 
middle  cerebral,  29  per  cent.;  basilar,  26;  internal  carotid,  14;  anterior 
cerebral,  8;  anterior  communicating,  6  per  cent.  They  are  rather  more 
frequent  on  the  left  side,  in  20  per  cent,  are  multiple,  are  usually  saccu- 
lated, of  the  size  of  a  pea  or  walnut  (rarely  as  large  as  an  egg)  and  are 
genuine  aneurysms  involving  all  coats.  Beadles  collected  555  cerebral 
aneurysms  with  autopsy  (1907). 

Symptoms. — In  only  37  per  cent,  are  symptoms  present.  They  are 
(fl.)  general,  as  headache,  which  is  the  most  common  sign,  or  convulsions, 
wdiich  result  from  aneurysm  of  the  Sylvian  branch;  a  systolic  murmur 
was  found  in  but  21  per  cent.;  in  a  personal  observation,  cured  by 
operation,  a  continuous  murmur  over  half  the  head  was  associated  with 
exophthalmos,  ih)  Local  symptoms;  according  to  their  location,  hemi- 
anopsia, ocular  paralysis,  hemiplegia,  optic  neuritis  (extension  of  inflam- 
mation from  the  sac),  aphasia  and  symptoms  referable  to  the  pons  or 
medulla  may  be  noted.  Rupture  occurs  in  67  per  cent.,  into  the  men- 
inges, brain  substance  or  ventricles,  from  which  death  rapidly  results; 
healing  has  been  observed. 

Diagnosis. — Rupture  is  generally  the  first  symptom  and  differentiation 
from  apoplexy  is  therefore  necessary;  cerebral  hemorrhage  in  a  young 
individual  with  a  history  of  trauma,  heart  disease  or  syphilis  suggests 
aneurysm,  especially  when  the  location  is  basilar;  iodides  and  mercury 
usually  are  not  beneficial  in  aneurysm.  The  suggestive  murmur  is 
rare  and  may  be  found  in  tumors  which  compress  vessels  or  in  very 
vascular  brain  tumors.  Aneurysm  is  most  often  embolic  in  the  Sylvian 
and  specific  in  the  basilar  artery.  Loss  of  sight  in  an  eye,  sometimes  wdth 
impairment  of  smell,  rather  indicates  aneurysm  of  the  anterior  cerebral 
or,  if  the  eye  muscles  are  paralyzed,  of  the  internal  carotid  artery.  Oculo- 
motor paralysis  without  loss  of  vision  suggests  aneurysm  of  the  posterior 
communicating  artery.    Some  cases  closely  resemble  arterial  thrombosis. 

Treatment. — The  indications  are  rest  and  iodides.  Ligation  of  the 
carotid  is  occasionally  opportune. 

VIII.  Sinus  Thrombosis. — Lebert  (1854)  diagnosticated  the  first  case 
and  with  Tonnele  built  up  its  clinical  recognition. 

Etiology  and  Pathology. — There  are  two  varieties,  the  marantic  and 
the  inflammatory  types. 

1.  Marantic  thrombosis  of  the  sinuses  and  veins  is  the  prim.ary  non- 
inflammatory type,  due  to  altered  blood  states  and  weakened  circulation. 
It  occurs  (a)  in  children  mostly,  especially  in  the  first  six  months  of  life 
and  after  acute  infections,  particularly  infective  diarrheas;  (b)  less  fre- 
quently in  the  aged  from  w^eak  heart  and  venous  stasis;  (c)  in  cachexia; 
{d)  in  chhn-osis;  (e)  compression,  as  by  tumors,  is  rare.  Its  most  frequent 
site  is  the  superior  longitudinal  sinus,  especially  in  children,  because  the 
sinus  is  fixed,  its  lumen  is  triangular  and  irregular,  crossed  by  trabeculse 
and  compressed  by  the  Pacchyonian  granulations;  the  tributary  veins 
ascend  against  the  current  of  the  sinus  and  their  stream  is  verv  weak. 


784 


DISEASES  OF   THE  BRAIN 


Simple  slowing  of  the  current  is  not  sufficient  for  coagulation  and  the 
vessel  wall  must  be  altered.  In  the  aged,  marantic  thrombosis  elects 
the  cavernous  or  transverse  sinus.  The  marantic  clot  may  enter  the 
tributary  veins  which  are  seen  as  firm  cords  over  the  hemispheres. 

2.  The  inflammatory  thrombosis,  thromhophlehitis,  is  secondary  to 
disease  near  the  sinus;  as  (a)  ear  disease,  chiefly  chronic,  suppurative 
otitis  or  caries  of  the  bone;  infection  reaches  the  sinus  by  (i)  infecting 
the  mastoid  cells,  which  infect  the  transverse  sinus;   (ii)  by  infecting 


COMMUNICANS  WITH  THE  NECK 


Fi(j.  58. — Diagram  showing  the  connections  (*)  of  the  transverse  and  cavernous  sinuses 

(Leube) . 


small  communicating  veins  or  (iii)  its  passage  along  the  petromastoid 
canal,  (b)  Acute  infections,  with  otitis  media;  sepsis;  trauma,  tuberculous 
meningitis,  disease  of  the  orbit,  nose  and  face.  The  most  common 
sites  are  the  transverse,  petrosal  and  cavernous  sinuses,  whence  it  may 
extend  to  their  branches.  The  clot  is  puriform,  fetid,  soft,  discolored 
and  contains  pyogenic  organisms;  the  process  is  frequently  associated 
with  meningitis  and  brain  abscess. 

Most  frequently  the  thrombosis  is  bilateral;  suggillations  in  the  pia, 
bloody  imbibition  of  the  brain  or  reddening  of  the  cerebrospinal  or  ven- 


SINUS  THROMBOSIS 


'85 


tricular  fluid  may  occur.  Simple  or  septic  pulmonary  infarcts  occur  in 
50  per  cent. 

Symptoms  and  Diagnosis. — Clinical  signs  may  be  absent. 

1.  Extracranial  Stasis. — (a)  In  thrombosis  of  the  superior  longitu- 
dinal sinus,  stasis  in  the  nasal  veins  is  often  shown  by  epistaxis,  an 
effort  of  nature  to  deplete  the  cerebral  congestion.  Gerhardt  observed 
cyanosis  in  the  anterior  frontal  veins  and  edema  in  the  temples  between 
the  great  fontanelle  and  ear  (by  way  of  the  emissaria  Santorini  through 
the  foramen  parietale).  Edema  is  often  absent  in  chlorotic  thrombosis. 
(&)  In  thrombosis  of  the  cavernous  sinus  stasis  develops  in  its  tributaries, 
producing  exophthalmos,  edema  of  the  lids  and  conjunctiva  (vena  oph- 
thalmica) ;  retinal  stasis,  more  rarely  choked  disk  or  retinal  thrombosis, 


VEINS  COMMUNICATING  THROUGH 
THE  PARIETAL  FORAMEN  WITH 
THE  EXTERNAL  SKULL  VEINS. 


CONFLUENS 
SIN. 


VENA  JUGULARIS  EXT 


VESA  JUGUL  INT 


Fig.  59. 


-Leube's  diagram  showing  the  connections  (*)  of  the  superior  longitudinal  sinus 
■nith  the  external  veins. 


results  from  congestion  of  the  vena  centralis  retinae.  Sometimes  edema 
of  the  forehead  results,  (c)  In  thrombosis  of  the  lateral  sinus,  edema 
behind  the  ear  and  in  the  neck  (communicating  with  the  posterior  auricular 
vein)  occurs  in  over  50  per  cent.  Occasionally  the  swollen  thrombotic 
internal  jugidar  rein  may  be  felt.  The  external  jugular  collapses,  or  if 
the  internal  jugular  is  thrombosed  it  becomes  overfilled  (Gerhardt). 
In  33  per  cent,  the  disk  is  hyperemic  and  in  another  33  per  cent,  there  is 
choked  disk  from  complicating  abscess  or  meningitis. 

2.  Intracranial  Stasis. — Progressive  clouding  of  the  mind,  delirium 
in  adults,  convulsions  in  children,  conjugate  deviation  of  the  eyes  and 
head,  stiff  neck,  vomiting,  headache,  irregular  pupils,  nystagmus  or 
strabismus  are  noted.  Bilateral  symptoms,  as  paraplegia,  are  due 
to  the  involvement  of  the  veins  in  both  hemispheres  or  more  often  to 
50 


786  DISEASES  OF  THE  BRAIN 

meningitis.  Bouchut  thought  that  antemortem  convulsions  in  children 
were  often  thrombotic  in  origin.  The  fontanelles,  sunken  at  first  in 
infantile  diarrhea,  may  later  become  prominent  (increased  cerebrospinal 
fluid).  Sometimes  chlorotic  thrombosis  may  extend  to  the  vena  Galeni 
magna,  producing  hydrocephalus  internus,  stupor,  coma  and  death. 
Irritation  or  paralysis  of  the  third,  fourth  and  sixth  nerves  may  occur 
because  of  their  intimate  relation  to  the  cavernous  sinus;  involvement 
of  the  first  branch  of  the  fifth  nerve  may  result  in  ophthalmia  neuro- 
paralytica. 

The  temperature  is  often  normal  in  the  simple,  or  in  the  thrombo- 
phlebitic  variety  attended  by  fever,  chills  and  sweats. 

Differentiation. — Differentiation  from  meningitis  {q.  v.)  and  brain 
abscess  (g.  v.)  is  often  impossible;  the  cause,  the  extracranial  stasis  and 
evidences  of  sepsis  are  of  diagnostic  importance.  Korner  held  that 
metastases  occur  in  the  lungs  from  sinus  thrombosis  and  in  the  bones 
and  joints  from  mastoid  caries. 

Prognosis.- — Death  occurs  in  the  second  week,  possibly  later.  Few 
recoveries  from  either  type  are  on  record. 

Treatment. — Prophylaxis  relates  chiefly  to  the  otitic  variety;  discharges 
from  the  ear  are  too  lightly  regarded  by  the  laity.  In  marantic  throm- 
bosis stimulation  and  avoidance  of  constriction  of  the  neck  are  the 
chief  indications.  In  septic  types  operation  is  indicated;  recovery  is 
most  likely  when  there  is  early  diagnosis  with  early  operation.  Opening 
and  packing  the  lateral  sinus  was  first  performed  by  Zaufal  in  1884. 
Ligature  of  the  internal  jugular  veins,  as  first  performed  by  Thersley 
and  Lane  in  1888,  gives  recovery  in  50  per  cent,  and  in  72  per  cent,  of 
Macewen's  series. 

rX.  Infantile  Cerebral  Paralysis. — Cerebral  infantile  palsy  is  classed 
under  circulatory  diseases  because  of  the  frequent  etiological  hemorrhage, 
embolism  and  thrombosis.  Pathologically,  it  is  sometimes  encephalitis, 
sclerosis  or  porencephalia.  Clinically,  it  is  variously  classed  according 
to  the  dominant  syndrome,  hemiplegia,  diplegia.  Little's  disease,  para- 
plegia, hemiathetosis  and  athetosis. 

L  The  Hemiplegic  Form. — Etiology, — It  is  equally  frequent  in  either 
sex.  Gowers  finds  88  per  cent,  in  the  first  five  years  of  life.  Infections 
as  scarlatina,  measles,  pertussis  and  diphtheria  are  apparent,  and  hered- 
ity, maternal  syphilis  and  trauma  are  doubtful  causes.  The  causes  may 
operate  before,  during  or  after  birth. 

Symptoms. — (a)  Initial  symptoms,  present  in  66  per  cent.,  are  severe 
in  character,  consist  of  fever,  vomiting  and  delirium,  and  last  from  a  few 
hours  to  several  days;  convulsions,  present  in  50  per  cent.,  are  often 
unilateral  and  are  usually  followed  by  coma.  In  33  per  cent,  of  cases 
the  onset  is  insidious,  (b)  The  paralysis  (hemiplegia)  usually  develops 
when  consciousness  returns.  It  is  more  frequently  right-  than  left-sided. 
The  lower  face  is  involved,  but  usually  soon  improves;  the  leg  improves 
more  than  the  arm  and  hand;  and  the  paralysis,  at  first  flaccid," soon 
becomes  spastic  and  permanent.  Tactile  and  stereognostic  sense  may  be 
reduced,  but  sensation  is  slightly  implicated.  (<?)  The  residual  symptoms 
are  the  same  as  in  adults,  with  some  exceptions;  the  paralysis  is  spastic 


INFANTILE  CEREBRAL  PARALYSIS  787 

(spastic  infantile  hemiplegia,  Heine)  but  also  atactic  and  athetotic;  re- 
tarded development  appears,  intellection  is  retarded  or  actual  idiocy  results 
and  epileptiform  seizures  are  common.  Contractures  are  frequent,  the  re- 
flexes are  increased  and  the  gait  is  somewhat  impaired — the  foot-dragging. 
In  rudimentary  or  benign  cases  the  paralysis  may  almost  disappear,  and, 
after  months  or  years,  may  be  replaced  by  epileptic  seizures,  hemiathe- 
tosis,  hemichorea,  hemitremor  (described  under  Hemorrhage)  or  hemi- 
hypertonia  (rigidity  with  but  little  paralysis).  Aphasia  is  rarely  lasting; 
{a)  reflex  aphasia  is  very  common  in  childhood  from  fever  or  digestive 
difficulties;  (6)  the  brain  readily  compensates  in  childhood;  (c)  per- 
manent aphasia  indicates  great  or  total  loss  of  intelligence.  Trophic 
changes  are  in  part  a  moderate  atrophy  and  in  part  a  lack  of  later  devel- 
opment; they  are  most  common  in  porencephalia  {v.  i.).  Epilepsy 
increases  in  frequency  after  the  paralysis  and  is  rated  at  from  13  per  cent. 
to  even  66  per  cent.;  it  occurs  at  the  onset  with  the  paralysis  or  a  year 
or  two  later;  it  is  more  marked  in  rudimentary  palsy;  it  is  most  often 
like  the  Jacksonian  type,  but  may  end  in  total  loss  of  consciousness; 
there  is  less  violence,  initial  cry,  foaming  and  involuntary  evacuations 
than  in  ordinary  epilepsy.  After  a  decade  or  more  it  often  becomes 
very  marked. 

Diagnosis. — Its  separation  from  poliomyelitis  is  thus  made: 


Cerebral  type. 

Spinal  type. 

Tendon  reflexes. 

Increased. 

Decreased  or  abolished. 

Muscular  atrophy. 

Only  after  a  long  time. 

Rapid. 

Electrical  reaction. 

Normal,    or  little   quantita- 

Partial  or  total  reaction   of 

tive  decrease. 

degeneration. 

Distribution  of  paralysis. 

Hemiplegic — diplegi  c . 

Chiefly  monoplegic. 

Intelligence. 

Often  involved. 

Usually  not. 

Epilepsy  and  hemichorea. 

Common. 

Rare. 

2.  The  Double  Hemiplegic  or  Diplegic  Form. — Etiology. — (a)  Prenatal 
causes,  apparent  in  20  per  cent.,  include  fright,  trauma,  malnutrition 
or  syphilis,  especially  in  cases  which  develop  athetosis.  (6)  Anomalies  of 
labor  include  difficult  or  long  labor,  malpresentation,  resistant  maternal 
tissues,  twin  pregnancy,  version  and  cord  prolapse;  delivery  by  forceps 
is  less  important  than  the  causes  calling  for  their  use.  Asphyxia  is  an 
important  etiological  factor.  In  premature  delivery  the  soft  skull  may  be 
injured  or  venous  stasis  occurs,  (c)  Extra-uterine  causes  include  trauma 
and  acute  infections. 

Pathology. — The  initial  lesion  cannot  always  be  determined,  (a)  In 
the  traumatic  class,  meningeal  hemorrhage  causes  66  per  cent,  of  the  diplegic 
cases;  it  is  promoted  by  asphyxia  and  the  sliding  of  the  skull  bones  of 
one  side  under  or  over  those  of  the  other  side.  The  blood  is  absorbed 
slowly,  if  the  brain  is  lacerated,  resulting  in  atrophy  of  both  motor  areas. 
(6)  Vessel  disease  (18  per  cent.)  may  be  arterial  (thrombosis,  embolism 
or  hemorrhage)  or  venous  (in  the  cortical  veins),  (c)  Striimpell  ad- 
vanced the  views  that  acute  poliencephalitis  in  the  motor  cortex  causes 
the  acute  onset,  an  argument  largely  based  on  analogy  (poliomyelitis  in 
children). 


■88 


DISEASES  OF   THE  BRAIN 


Chronic  Lesions. — The  most  important  are  diffuse  lobar  sclerosis 
and  porencephalia,  which  are  peculiar  to  infantile  brain  palsies:  (a) 
Diffuse  lobar  sclerosis  and  atrophy  of  the  brain  occur  in  55  per  cent. 
About  the  atrophic  areas  and  in  the  ventricles  the  cerebrospinal  fluid 
is  increased.  The  lobe  affected  is  shrunken,  hardened.  The  convolutions 
are  wasted  and  smooth  or  "worm-eaten."  The  nervous  tissue  is  wasted, 
the  neuroglia  increased  and  the  bloodvessels  tortuous  and  thickened. 
The  nature  of  the  initial  lesion  is  disputed;  it  may  be  encephalitis, 
poliencephalitis  or  embolism.  (6)  Porencephalia  (Heschl,  1859)  consists 
of  loss  of  brain  substance  and  cavity  formation.    It  occurs  in  26  per  cent. 

of  cases.  The  initial  lesion  is  ascribed  to 
agenesis,  encephalitis  or  meningo-encepha- 
litis,  trauma  or  anemic  necrosis  (Kundrat), 
the  most  widely  accepted  view.  It  is  most 
frequent  in  the  distribution  of  the  Sylvian 
or  occipital  vessels.  ]Most  often  it  is  con- 
genital and  then  the  convolutions  radiate 
from  the  defect,  while  in  yostnatnin  cases, 
the  convolutions  stop  short  of  the  defect 
"as  though  cut  off."  Sixty  per  cent,  are 
bilateral  and  somewhat  symmetrical,  (c) 
The  hypertrophic,  nodular  sclerosis,  de- 
scribed by  Bourneville,  consists  of  multiple 
discrete,  prominent,  often  umbilicated 
nodes  the  size  of  a  quarter-  or  half-dollar. 
They  are  overgrowths  of  the  neuroglia. 

Sy^iptoms. — Diplegic  cases  are  half  as 
frequent  as  the  hemiplegic.  Freud  de- 
scribes the  following  forms:  (a)  General 
rigidity,  or  Little's  disease,  33  per  cent, 
of  which  are  caused  by  asphyxia.  The 
main  characteristics  are  (i)  predominance 
of  the  rigidity  over  the  paresis,  and  (ii) 
predominance  of  the  leg  paresis  over  that 
of  the  arms,  the  converse  of  adult  cerebral 
paralysis  (hemorrhage  occurs  most  often 
over  the  leg  centres).  Convulsions  often 
usher  in  the  symptoms,  which  appear  after 
birth  or  a  few  months  later.  The  rigidity  is  general  but  most  conspicuous 
in  the  flexors  and  adductors,  leading  to  unusual  postures.  The  face  is 
slightly  involved,  the  maximum  manifestation  being  spasm  of  the  mouth; 
in  rare  cases  the  child  cannot  nurse  or  swallow.  Speech  is  slow  in  develop- 
ment and  stuttering  is  common.  In  33  per  cent,  the  head  cannot  be  lifted 
or  the  trunk  flexed,  due  to  involvement  also  of  the  uncrossed  pyramidal 
tracts.  The  arms  may  be  but  slightly  paretic,  but  the  legs  suffer  extensor 
spasm  on  movement  and  the  toes  turn  down  (talipes  equinus  or  equino- 
varus).  The  child  learns  to  walk  late,  if  at  all,  because  of  the  adductor 
rigidity,  which  may  cause  crossing  of  the  legs.  The  reflexes  are  greatly 
increased.    The  intellect  is  somewhat  affected  in  66  per  cent.    Xutrition 


Fig.   60.- — Spastic  paraplegia,  cross- 
legged  progression.     (Dercum.) 


BRAIN   TUMORS  789 

in  the  paretic  members  is  usually  intact.  Later  epilepsy  is  uncommon. 
The  paresis  may  regress  and  the  mind  improve,  but  the  legs  remain 
spastic.  (6)  Paraplegic  rigidity  resembles  type  («)  except  that  the  arms 
are  but  little  or  not  at  all  affected  and  the  legs  alone  are  rigid.  The 
name  Little's  disease  is  also  given  to  this  form.  Strabismus  is  common. 
Premature  delivery  is  a  factor  in  50  per  cent,  of  cases,  (c)  Paraplegia 
is  rare  and  is  referred  to  extra-uterine  causes  or  infantile  infections.  The 
legs  are  rigid  and  paralyzed.  Li  severe  types  there  may  be  strabismus 
and  imbecility,  (d)  In  bilateral  spastic  hemiplegia  (spastic  diplegia), 
mental  degeneration,  nystagmus,  convergent  strabismus,  bulbar  symptoms 
and  speech  involvement  (60  per. cent.)  are  frequent,  (e)  General  infantile 
chorea  is  also  called  "choreic  diplegia";  asphyxia  is  a  factor  in  25  per 
cent.  Its  clinical  characters  are  paralysis,  rigidity  and  chorea-like  move- 
ments which  are  irregular,  slight  in  degree  and  wide  in  distribution,  (/) 
In  bilateral  athetosis  the  mind  is  less  involved  than  in  the  preceding  types. 
The  paralysis  may  precede  it  or  it  may  be  primary. 

In  all  forms  epilepsy  may  (i)  replace  the  regressing  paralysis;  (ii) 
overshadow  the  paralysis;  (iii)  paralysis  may  appear  only  after  years 
of  epilepsy,  or  (iv)  may  not  appear  at  all,  "cerebral  paralysis  without 
paralysis." 

Diagnosis. — Separation  from  the  family  spastic  paralysis  (g.  v.)  may 
be  difficult  or  impossible. 

Treatment. — In  the  initial  stage  convulsions  may  be  treated  by  chloral. 
Some  regression  in  the  paralysis  is  frequent,  but  the  hemiplegia,  mental 
changes  and  epilepsy  are  incurable.  Marked  improvement  can  be 
expected  in  the  syphilitic  cases  alone.  Orthopedic  devices  are  valuable. 
The  resulting  epilepsy  is  usually  intractable  and  bromides  with  opium 
are  of  little  avail.  Twenty-five  per  cent,  die  from  operations,  but  the 
surviving  cases  seem  to  improve,  especially  in  regard  to  the  convulsions. 

BRAIN  TUMORS. 

Etiology  and  Pathology.^ — Eichhorst  found  brain  tumors  in  |  of  1 
per  cent,  of  his  cases.  Sixty-six  per  cent,  of  tumors  occur  in  the  male 
sex,  especially  glioma  and  tubercle.  Age.  In  the  first  decade,  18.5 
per  cent,  of  cases  are  observed;  in  the  second,  14;  third,  20;  fourth, 
18.5;  and  in  the  fifth,  14  per  cent.  Trauma  may  act  as  the  "agent  pro- 
vocateur" in  glioma,  gumma,  sarcoma,  tubercle  or  aneurysm.  The  author 
has  seen  endothelioma  of  the  dura  develop  years  after  and  directly  at  the 
seat  of  an  unhealed  skUll  fracture. 

Classification. — 1.  The  Infectious  Granulomata.. — (a)  Tubercle  con- 
stitutes 50  per  cent,  of  cerebral  tumors,  75  per  cent,  being  found  in  the 
first  and  second  decades;  33  per  cent,  occur  in  the  cerebellum,  33  per 
cent,  in  the  cerebrum  and  the  remainder  in  the  pons,  central  ganglia, 
crus,  etc.  With  equal  frequency  they  are  single  or  multiple  (even  20  or 
80).  They  are  firm,  rounded  tumors,  with  grayish-red  periphery  and 
yellow,  caseated  centre.  Tubercles  range  from  the  size  of  a  pea  or  walnut 
to  that  of  an  egg  or  the  fist,  from  fusion  of  many  small  growths.  They 
grow  along  the  lymph  vessels,  cause  vascular  thrombosis,  present  the 


790  DISEASES  OF   THE  BRAIN 

degenerations  of  tubercle  of  other  tissues  and  may  be  shelled  out  of  the 
brain  tissue,  which  is  compressed  and  atrophied,  but  neither  infiltrated 
nor  softened.  (6)  Giimmata  (see  Brain  Syphilis)  in  the  adult  are  the 
most  common  type  of  tumor.  They  are  most  frequent  in  the  cerebral 
hemispheres  and  pons  and  are  rare  in  the  cerebellum  and  central 
ganglia;  they  are  most  often  the  size  of  a  pea  or  hazel-nut.  Their  centre 
is  yellowish-gray  and  their  periphery  is  reddish-gray,  gelatinous,  rich  in 
cells  and  ultimately  cicatricial.  Gummata  are  usually  multiple.  The 
adjacent  brain  tissue  is  not  infiltrated,  but  commonly  softened  and 
compressed.  ]\Iicroscopically,  they  closely  resemble  tubercle,  but  are 
more  nodose,  irregular,  more  distinctly  connected  with  the  dura,  even 
when  deeply  located,  more  gelatinous  and  less  caseated. 

2.  Neuro-epithelial  Growths.— (a)  Glioma  constitutes  25  per  cent, 
of  brain  growths;  50  per  cent,  occur  in  the  hemispheres,  especially  the 
cortex;  25  per  cent,  in  the  cerebellum  and  the  balance  in  the  central 
ganglia,  pons,  medulla,  crus,  .etc.  They  occur  more  frequently  in  the 
brain  than  in  the  cord  or  retina,  to  which  three  structures  they  are  peculiar. 
Gliomata  are,  in  90  per  cent.,  single  and  are  seen  most  frequently  in  adults, 
largeh'  in  the  gray  substance,  which  they  so  closely  resemble  in  tint  that 
detection  is  difficult  at  operation  or  indeed  at  autopsy.  Their  size 
varies  from  that  of  a  pea  to  that  of  a  hemisphere.  Glioma  infiltrates 
without  sharp  demarcation  rather  than  compresses  the  brain  tissue.  The 
cells  resemble  the  neurogliar  structure  and  usually  have  round  or  oval 
nuclei;  Klebs  found  ganglionic  cells.  Their  processes  are  fine;  numerous 
and  branched  delicate  band-like  lines  result  from  fiber  degeneration. 
(b)  The  rare  cerebroma  of  Hayem  is  heterotopic  gray  matter,  (c)  Ade- 
noma of  the  pineal  gland  and  hypophysis,  growths  from  the  plexuses 
and  neuromata  may  be  brought  under  this  heading. 

3.  CoNNECTr\^E-TissuE  TuMORS. — (tt)  Sarcoma  consitutes  20  per  cent, 
of  brain  tumors;  it  may  develop  in  the  meninges,  periosteum  or  vessels. 
It  is  most  common  in  adults.  Though  it  infiltrates  more  than  tubercles 
or  gummata,  many  are  well  demarked.  Its  structure  and  degenerations 
are  those  of  sarcoma  elsewhere.  Though  commonly  single,  diffuse  or 
multiple  sarcomatosis  is  sometimes  encountered.  Endothelioma,  cylin- 
droma, angiosarcoma  and  melanosarcoma  are  but  varieties.  The  sand 
tumors  (psammomata)  are  sometimes  described  as  angiolithic  sarcomata. 
The  "pearly  tumors"  (cholesteatomata)  are  formed  of  flat  endothelial 
cells,     (b)  Lipoma,  fibroma  and  osteoma  are  very  infrequent. 

4.  Metastatic  Tltmors. — Cancer  is  not  infrequent  (7  per  cent.), 
especially  from  mammary  or  lung  carcinoma.  It  often  invades  the 
hemispheres  and  basal  ganglia  and  may  attain  huge  dimensions.  Like 
sarcoma,  it  infiltrates.     Cancer  is  very  rarely  primary. 

5.  Cystic  Tumors. — Cysts  may  result  from  hemorrhage  or  soften- 
ing, degeneration  in  neoplasms,  porencephalia,  trauma  or  inflammation 
in  the  choroid  plexus.  Dermoids  and  teratomata  are  most  rare. 
Echinococcus  cysts  may  be  single  or  multiple,  chiefly  on  the  surface 
of  the  brain  or  in  the  meninges.  Cysticerciis  cysts  develop  mostly  on 
the  pia  and  arachnoid  over  the  cortex  along  the  sulci  or  in  the  ventricles. 
Diamond  could  collect  but  8  cases  from  the  American  literature;  they 


BRAIN   TUMORS  791 

vary  from  the  size  of  a  pea  to  that  of  a  hazel-nut,  are  usually  multiple 
(200  in  Snell's  case)  and  contain  clear  fluid  with  black  dots,  the  heads 
of  the  parasites. 

6.  Aneurysms. — Aneurysms  have  been  considered. 

Localization. — The  localization  is:  cerebrum,  42  per  cent.;  cerebellum, 
25;  base,  11;  pons,  8;  central  ganglia,  7;  medulla,  4;  corp.  quadrigemina, 
2;  and  crus,  1  per  cent. 

Symptoms. — In  rare  instances,  tumor  is  found  at  autopsy  without 
clinical  symptoms  (latency),  due  to  location  in  a  "silent"  or  tolerant 
brain  area.  Symptoms  result  from  the  following  mechanisms:  (a) 
Direct  pressure  on  the  brain,  which  may  flatten  the  convolutions,  ob- 
literate the  sulci,  force  open  the  skull  fissures  in  children,  absorb  or 
perforate  the  cranium,  conspicuously  in  growths  of  the  posterior  fossa 
closed  by  the  rigid  tentorium.  (6)  Internal  hydrocephalus,  distention  of 
the  ventricles,  may  follow  closure  of  the  aqueduct  of  Sylvius  or 
compression  of  the  veins  (choroid  plexus  and  vena  Galeni  magna), 
especially  by  tumors  of  the  cerebellum  and  corp.  quadrigemina.  (c) 
The  brain  may  be  softened  by  pressure  on  its  vessels,  or  hemorrhage  may 
develop  (as  in  glioma) .  {d)  Infiltration  or  destruction  of  the  brain  matter. 
(e)  Meningitis,  local  as  in  gumma,  or  general  as  in  tubercle.  (/)  Auto- 
intoxication from  the  growth,  {g)  Distortion  of  the  cerebral  or  spinal 
nerves  may  cause  their  degeneration,  or  changes  in  the  posterior  columns 
of  the  cord  and  its  roots. 

1.  General  Symptoms. — General  symptoms  usually  introduce  the 
disease  and  include  the  following:  (a)  Headache  is  present  in  almost  all 
cases,  is  usually  constant,  with  accessions  (especially  in  the  morning), 
is  general,  severe,  is  increased  by  alcohol,  exertion  and  coughing,  and 
rarely  corresponds  with  the  tumor's  site  except  when  the  pain  is  per- 
sistently local  and  the  tumor  near  the  surface.  Headache  is  best  explained 
by  stretching  of  the  dural  branches  of  the  fifth  nerve.  It  may  be  pulsating 
in  aneurysm.  (6)  Choked  disk,  the  most  important  general  symptom, 
consists  of  a  grayish-red  swelling  of  the  disk  to  even  two  or  three  times 
its  normal  dimensions,  which  lessens  its  sharpness  of  outline  and  physio- 
logical cupping;  the  arteries  become  less  lustrous  and  smaller,  the  veins 
turgid  and  tortuous,  extravasations  of  blood  and  white  patches  of  fatty 
degeneration  or  exudation  appear.  (See  Plate  IV,  Fig.  3).  It  is  due  to 
increased  intracranial  tensio7i,  which  causes  mechanical  hydrops  of  the 
optic  sheath  or  to  inflammation  from  choking  of  the  veins  by  toxic 
products.  It  is  bilateral,  although  more  marked  on  the  side  of  the  lesion, 
is  not  an  early  symptom  and  does  not  depend  on  the  size  of  the  tumor. 
It  is  constant  in  growths  of  the  corp.  quadrigemina,  is  present  in  90  per 
cent,  of  cerebellar  growths  and  in  35  per  cent,  of  those  of  the  pons,  medulla 
and  corp.  callosum.  There  is  often  limitation  of  the  fleld  of  vision  (sco- 
toma for  color).  In  many  cases  it  develops  into  atrophy,  oftener  still 
into  stasis  and  blindness,  perhaps  suddenly,  while  in  some  it  may  regress. 
Transitory  amaurosis  results  from  compression  of  the  optic  tract  or  chiasm 
by  the  distended  third  ventricle,  (c)  Convulsions  occur  in  50  per  cent., 
are  called  the  "signal  symptoms"  by  Seguin  and  may  be  general;  general 
tonic  precede  clonic  convulsions  in  no  special  order;  the  pupils  react 


792  DISEASES  OF  THE  BRAIN 

poorly,  the  skin  reflexes  are  increased  unless  deep  coma  develops,  the 
tendon  reflexes  are  not  suspended  and  respiration  is  labored.  Convulsions 
are  more  frequently  late  than  early.  Slight  seizures,  like  the  petit  mal 
of  epilepsy,  may  occur.  Jacksonian  epilepsy  belongs  to  the  focal  symp- 
toms, {d)  Vomiting  is  usually  an  early  general  symptom,  indicating 
irritation  of  the  vomiting  centre  (in  the  medulla  it  is  a  focal  symptom). 
It  is  of  the  cerebral  type,  occurring  without  effort,  nausea  or  pain,  often 
on  an  empty  stomach,  as  in  the  morning,  or  at  once  after  eating,  regard- 
less of  the  kind  of  food  ingested.  Vomiting  is  due  to  increased  intra- 
cranial pressure  or  meningeal  irritation.  It  is  rarely  absent  in  growths 
of  the  cerebellum  or  medulla,  is  very  frequent  in  disease  of  the  corp. 
quadrigemina  and  occurs  in  25  per  cent,  of  tumors  in  the  hemispheres. 
ie)  Sensorium.  The  most  common  change  is  dulness,  which  often  deepens 
into  stupor  and  coma.  Tumors  affecting  the  association  fibers  and  avoid- 
ing the  motor  centres  may  cause  disturbance  of  intelligence,  judgment 
or  memory  only ;  they  are  frequently  discovered  at  autopsy  in  the  frontal 
or  temporosphenoidal  lobes  in  subjects  committed  to  asylums  for  psy- 
choses or  general  paralysis.  (/)  Vertigo  is  an  early  symptom;  it  may  be 
mere  "giddiness"  or  it  may  affect  the  labyrinth,  pons  or  cerebellum  and 
be  a  sense  of  actual  rotation.  It  is  present  in  31  per  cent,  and  as  a  focal 
symptom  when  the  middle  cerebellar  peduncle  is  implicated,  (g)  Slowed 
pulse  results  more  often  from  indirect  pressure  on  the  vagus  fibers  behind 
and  lateral  to  the  hypoglossal  nucleus.  The  vagus  fibers  become  accus- 
tomed to  pressure  and  the  heart  rate  increases.  It  is  often  associated  with 
yawning,  hiccough,  Cheyne-Stokes's  breathing,  glycosuria  or  polyuria. 

2.  Focal  Symptoms. — Focal  symptoms  may  be  absent  when  the 
disease  is  limited  to  "silent"  or  "tolerant"  areas,  when  the  tumor  does 
not  destroy  nerve  structures  and  when  vicarious  compensation  by  other 
parts  is  possible.  Focal  symptoms  of  irritation  or  paralysis  may  result 
directly  from  actual  lesion  of  a  centre  or  its  fibers,  or  indirectly  from 
"distance  pressure"  upon  them.  They  are  most  significant  when  no 
particular  increase  of  intracranial  tension  exists. 

(a)  Frontal  Lobes. — Early  observers  claimed  that  mental  changes  were 
no  more  frequent  in  frontal  localization  than  in  localization  elsewhere. 
A  dementia  with  characteristic  irritability  and  excitement,  a  tendency 
to  make  jokes,  apathy  and  suffering  are  described.  Homolateral  tremor 
and  contralateral  loss  of  the  abdominal  reflexes  are  described  by  Granger 
Stewart.  Mental  alteration  sometimes  follows  other  localizations. 
Tumors  in  the  frontal  lobes  may  be  thought  to  be  in  the  motor  areas 
from  indirect  pressure  upon  the  latter.  The  head  and  eyes  may  deviate 
and  the  neck  and  back  are  sometimes  rigid;  frontal  tumors  may  induce 
cerebellar  ataxia,  caused  by  unequal  innervation  with  disturbance  of  the 
sensorium  or  involvement  of  the  trunk  centres.  Bradyphasia  is  probably 
psychical  and  differs  from  the  separation  of  syllables  sometimes  seen  in 
tumor  of  the  pons.  In  "laryngeal  aphasia"  the  patient  moves  his  lips 
and  attempts  to  speak,  but  finds  the  voice  lacking. 

(b)  Motor  Cortex. — (i)  Jacksonian  convulsions  (50  per  cent.)  are  often 
dissociated,  and  follow  a  given  sequence  (see  page  751).  The  convulsions 
may  run  into  the  hundreds  (17,000  in  eleven  months).    When  the  con- 


BRAIN  TUMORS  -        793 

ducting  fibers  are  destroyed  they  cannot  occur,  whence  they  may  be 
observed  in  the  part  nearest  the  seat  of  greatest  damage.  As  long  as 
convulsions  are  present  the  motor  centres  cannot  be  wholly  destroyed. 
Tapping  the  skull  may  initiate  spasms,  (ii)  Cortical  paralysis  is  usually 
monoplegic  and  associated  with  cortical  spasm;  at  first  a  weakness  from 
exhaustion  follows  the  spasms;  later  it  becomes  more  marked.  Slowly 
progressive  hemiplegia  without  other  symptoms  may  suggest  tumor 
(Williamson)  and  paresis  may  be  the  first  sign  of  tumor,  perhaps  narrowly 
localized,  as  in  the  thumb  alone,  fingers  or  great  toe;  paralysis  is  accom- 
panied by  increased  reflexes  and  rigidity.  Surgical  extirpation  has  relieved 
both  spasms  and  paralysis.  In  infrequent  instances  the  paralysis  may 
be  bilateral,  as  when  a  cortical  tumor  near  the  median  line  presses  on  the 
opposite  hemisphere  or,  when  there  are  bilateral  symmetrical  growths. 
(iii)  Sensory  changes  are  less  frequent,  because  the  sensory  is  larger  than 
the  motor  area,  extends  posterior  to  it  and  possibly  is  bilateral.  Hyp- 
esthesia,  especially  for  tactile  and  muscular  sensibility  and  paresthesia, 
are  not  rare. 

(c)  Parietal  Lobes. — Sensory  disturbance  is  fairly  common.  Inco- 
ordinate movements,  ataxia,  conjugate  eye  movements  and  sensory 
aphasia,  hemianopsia,  deafness  and  word-deafness  are  observed. 

(d)  Temyoral  Lohes. — Hemianopsia,  disturbed  eye  movements  toward 
the  opposite  side,  ptosis  and  agraphia  are  recorded.  Uncinate  "fits" 
are  characterized  by  subjective — and  usually  disagreeable — sensations  of 
smell  and  taste,  of  which  Mills  collected  12  cases  (1908). 

(e)  Occipital  Lohes. — Hemianopsia  is  the  most  constant  finding.  Optical 
hallucinations  indicate  a  cortical  occipital  localization.  Alexia,  optic 
aphasia  and  psychical  blindness  are  seen. 

(/)  Pons. — Focal  may  precede  the  general  symptoms,  as  enumerated 
under  Cerebral  Localization.  Hemiplegia  with  alteryiating  paralysis  of 
some  of  the  first  eight  cranial  nerves  is  the  most  common  type  (50  per 
cent.) .  Foci  in  the  substance  of  the  pons  involving  the  sixth  nerve  usually 
involve  the  opposite  third  nerve;  foci  near  the  surface  involving  the 
sixth  nerve  do  not  involve  the  third  nerve.  Sometimes  the  nerves  may 
be  involved  without  hemiplegia  (25  per  cent.),  but  rarely  without  crossed 
motor  irritation  or  hemianesthesia;  hemiplegia  alone  occurs  in  25  per 
cent.  Unilateral  tumor  may  compress  the  opposite  motor  tracts  (para- 
plegia or  diplegia)  and  cranial  nerves.  Motor  irritation  is  not  uncommon, 
as  trismus,  facial  spasm,  trigeminal  neuralgia,  convulsions  in  the  contra- 
lateral limbs,  etc.  Sensory  disturbance  is  usual,  as  hemianesthesia  cruciata 
(in  arm  and  leg  of  one  side  and  in  the  face  of  the  opposite  side  when  the 
focus  is  low  in  the  pons),  hemianesthesia  of  face,  arm  and  leg  of  the 
same  side  (tumor  in  the  upper  pons)  and  anesthesia  of  one  or  perhaps  of 
both  sides.  Dysarthria,  dysphagia,  difficult  urination  or  defecation  and 
disturbed  respiration  on  change  of  posture  have  been  observed. 

{g)  Medulla. — It  is  remarkable  that  tumors  may  produce  no  symptoms 
or  only  such  that  localization  in  the  pons  or  cord  is  first  suggested.  In  a 
small  number  of  cases  only  are  the  symptoms  not  ambiguous.  Bilateral 
paralysis  of  the  ninth  to  twelfth  nerves  with  degeneration  and  atrophy 
of  the  lips,  tongue,  palate,  pharynx  or  larynx  is  characteristic  and  presents 


794  DISEASES  OF  THE  BRAIN 

a  picture  like  progressive  bulbar  palsy.  Alternating  hemiplegia  is  rare. 
Sensory,  motor,  atactic  and  nerve  involvements  are  usually' bilateral. 
Stern  (1907)  collected  72  cases  of  cysticerci  of  the  fourth  ventricle  and 
50  of  tumors,  characterized  by  suboccipital  pain,  bowing  of  head  forward, 
paroxysmal  attacks  of  vomiting,  headache  and  cervical  rigidity.  Growths 
outside  the  medulla  may  cause  paralysis  of  the  neck  muscles.  Slowed 
or  rapid  pulse,  singultus,  embarrassed  breathing,  glycosuria  and  polyuria 
are  not  uncommon. 

(A)  Cerebellum.- — Cerebellar  ataxia,  referred  by  Nothnagel  and  Gowers 
to  lesions  of  the  vermis  in  85  per  cent,  of  the  cases,  occurs  but  half  as 
frequently  in  disease  of  the  cerebellar  hemispheres.  Compression  of  the 
pons,  medulla,  corpora  quadrigemina  and  fifth  to  twelfth  cranial  nerves 
is  somewhat  characteristic.  Extra-cerebellar  tumors  may,  in  the  ponto- 
medullocerebellar  angle,  involve  hearing  and  also  the  eighth,  fifth  or 
sixth  nerves  (disturbance  of  hearing,  paralysis  of  winking  and  tardy 
corneal  reflex).  Of  the  general  symptoms,  choked  disk  is  almost  in- 
variable; occipital  headache  and  rigid  neck  are  very  frequent.  Con- 
vulsions are  common  and  opisthotonos  with  tetanic  rigidity  of  the  body 
and  extremities  is  most  suggestive. 

(^)  O'ptic  Thalamus. — Moderate  hemiplegia  (transient  and  without  con- 
tractures), hemichorea,  hemiathetosis,  hemianesthesia  (always  marked 
as  to  deep  sensation),  slight  hemiataxia,  marked  astereognosis  and 
persistent  pains  (hemiplegie  douloureux)  constitute  the  thalamic  syndrome 
of  Roussy  (1907).  Less  common  are  Nothnagel's  mimetic  paralysis, 
unilateral  convulsions,  forced  movements  or  postures,  contralateral 
hemianopsia,  paralysis  of  the  eye  muscles,  widening  of  the  opposite 
pupil  and  monoplegia. 

(j)  Corjms  Callosum. — According  to  Bristowe,  dementia  (in  90  per 
cent.),  absence  of  initiative  in  speech  and  action,  paraplegia,  dysarthria 
and  few  general  symptoms,  as  choked  disk,  are  characteristic.  Oppen- 
heim  holds  that  there  are  no  distinctive  symptoms. 

{k)  Corpora  Quadrigemina. — Paralyses  of  the  third  nerve  are  common, 
sometimes  associated  as  double  ptosis,  and  bilateral  paralysis  of  the 
internal  recti.  The  pupils  are  usually  free.  There  may  also  be  crossed 
hemiataxia,  disturbed  hearing,  amblyopia  and  intention  tremor.  No 
paralysis,  except  of  the  third  nerve,  is  present  unless  the  tumor  extends 
beyond  the  corp.  quadrigemina  (Oppenheim). 

(I)  Pineal  Gland. — The  symptoms  are  the  same  as  when  the  corp. 
quadrigemina  are  affected,  save  that  the  fourth  and  sixth  nerves  are 
involved  more  than  the  third  and  compression  of  the  pons  or  medulla 
is  more  common.    There  may  be  obesity  or  genital  hypertrophy. 

(m)  Tumors  at  the  Base. — ^These  include  osseous  tumors,  aneurysras, 
hypophysis  growths  and  those  from  the  nerves  or  meninges,  (i)  In 
the  anterior  fossa,  hypophysis  tumors  (see  Acromegaly)  disturb  vision 
and  produce  bitemporal  hemianopsia  with  amblyopia  or  sometimes 
irregular  or  transverse  hemianopsia.  Usually  there  is  no  choked  disk, 
but  simple  optic  atrophy.  The  third  nerve  is  paralyzed  in  most  cases, 
sometimes  other  ocular  trunks.  Exophthalmos  is  occasional  and  the 
growth  may  perforate  externally  into  the  eye,  pharynx  or  nose.    Loss  of 


BRAIN  TUMORS  795 

smell  (anosmia)  and  mental  symptoms  are  observed,  (ii)  In  the  middle 
fossa,  mental  symptoms  and  convulsions  are  less  common.  The  Gasserian 
ganglion  may  be  compressed  and  result  in  neuroparalytic  ophthalmia. 
Other  cerebral  nerves,  as  the  third  and  sixth,  sometimes  suffer.  Sj'philis 
and  sarcomatosis  may  be  diffusely  basal,  (iii)  Lesions  in  the  posterior 
fossa  may  simulate  bulbar  palsy.  The  lower  eight  cranial  nerves  usually 
suft'er  more  readily  and  earlier  than  the  pyramidal  tracts;  the  grouping 
of  the  cranial  nerve  implication  is  different;  thus  paralysis  of  the  sixth 
nerve  is  rarely  associated  with  the  conjugate  fourth  nerve,  as  occurs  when 
the  lesion  is  central.  The  seventh  and  eighth  nerves  are  often  conjointly 
paralyzed  in  disease  of  the  posterior  fossa  and  but  rarely  so  in  central 
tumors.  The  symptoms  often  resemble  those  of  lesions  of  the  pons, 
medulla,  etc. 

Diagnosis. — Four  general  groups  of  cases  are  encountered:  (1) 
Absolute  clinical  latency;  (2)  general  and  focal  symptoms,  the  typical 
case;  (3)  general  but  not  focal  symptoms;  (4)  definite  symptoms  of 
some  brain  disease  but  of  equivocal  significance.  According  to  Bruns, 
80  per  cent,  of  cases  can  be  detected. 

Analysis  of  the  General  Syiviptoms. — (a)  Headache  is  suggestive 
when  it  is  severe  and  when  the  skull  is  tender  to  percussion.  Organic, 
irritative  brain  disease,  as  abscess  or  inflammation,  may  cause  headache. 
Headache  may  result  from  migraine,  neurasthenia,  hypochondriasis, 
eye  disease,  intoxications  (uremia,  gastro-intestinal  disorder  and  poison- 
ing by  nicotine,  opium,  alcohol  or  lead),  and  from  arteriosclerosis,  (b) 
CJwked  disk  in  85  per  cent,  of  cases  indicates  brain  tumor  (Oppenlieim) 
and  if  very  marked  it  is  seldom  due  to  other  causes.  It  is  less  frequent 
in  abscess  and  meningitis,  in  which  neuritis  optica  is  more  frequent. 
It  is  most  rare  in  embolism,  softening,  hemorrhage,  hematoma  durse 
matris,  arteriosclerosis,  poliencephalitis,  encephalitis,  the  acute  fevers, 
lead  poisoning,  neuritis  multiplex  or  alcoholism.  Uremia  and  tumor 
have,  in  common,  headache,  epileptiform  or  apoplectiform  attacks, 
hemiplegia,  aphasia  and  slow  pulse,  yet  neuroretinitis  is  more  common 
in  nephritis.  The  rare  choked  disk  of  chlorosis  responds  to  iron,  (c) 
General  epileptiform  convidsions  occur  in  meningitis,  pachymeningitis, 
abscess,  vascular  disease,  syphilis,  alcoholism,  plumbism,  multiple 
sclerosis,  paretic  dementia,  uremia,  etc. 


Epileptic  Convulsions. 


More  coarse;  more  biting  of  tongue;  more 
frequent  cry;  more  sudden,  complete 
loss  of  consciousness,  frequently  an  epi- 
gastric aura;  usually  longer  interval 
between  attacks. 


Convulsions  resulting  from  organic  brain  disease. 


ConATilsions  more  orderly,  slow,  clonic, 
broken  by  tonic  contractions;  often  with 
gradual  local  commencement,  without  loss 
of  consciousness,  and  •^'ith  paresis  in  the 
Jacksonian  type. 


(d)  Vomiting  is  probably  cerebral  and  due  to  tumor,  if  hysteria, 
migraine,  toxemia  and  gastric  disease  can  be  excluded. 

Combination  of  General  Syjiptoms. — Headache  and  choked  disk 
occur  in  chlorosis,  plumbism  (also  with  delirium,  convulsions  and  coma, 


796  DISEASES  OF   THE   BRAIX 

but  distmgiiished  by  the  lead  line  on  the  gumsj  or  m  uremia,  in  which 
special  examination  for  albumin,  casts  and  cardiovascular  changes  are 
definitive.  The  same  combination  may  prevail  in  hypermetropia  in 
anemic  girls,  in  amenorrhea  and  in  injuries  of  the  head,  but  care 
usually  distinguishes  them  from  the  slow  onset  and  focal  signs  of  brain 
tumor. 

Topical  Dl^gxosis. — Focal  symptoms  usually  follow  the  general, 
whereas,  in  apoplexy-,  for  example,  the  focal  hemiplegia  is  early.  In 
tumor  with  hemiplegia,  contracture  or  spasticity  accompanies  rather  than 
follows  the  paralysis,  as  usually  occurs  in  hemorrhage  or  embolism. 
Hemiplegia  from  a  tumor  is  less  pure,  less  circumscribed,  less  systematic 
(Fournier).  A  tumor  at  the  base  may  cause  hemiplegia  from  pressure 
on  the  middle  cerebral  artery  with  encephalomalacia.  Jacksonian  epi- 
lepsy with  paresis  is  due  to  cortical  tumors  in  .50  per  cent,  of  cases.  It 
is  also  produced  by  hemorrhage,  softening  and  inflammation  and  is  then 
earlier,  is  not  confined  to  as  small  an  area  and  is  not  as  progressive  as  in 
neoplasm. 

Nature  of  the  Growth. — 'aj  Location.  Cortical  growths  are  prob- 
ably gumma  or  tubercle  fpossibly  glioma,  cysts,  cysticercus  or  sarcoma); 
suhcortical,  glioma  or  sarcoma;  pons,  tubercle,  gumma,  ghoma;  cere- 
helium,  tubercle  or  glioma;  extracerehral,  sarcoma;  multiple  occurrence, 
tubercles  or  gummata.  (h)  Course.  A  rapidly  growing  tumor  is  probably 
glioma  or  sarcoma.  An  apoplectic  attack  indicates  glioma  or  ruptured 
aneurysm.  Growth  with  remissions  is  characteristic  of  tubercle  or 
glioma.  A  very  slow  course  suggests  fibroma  or  osteoma.  Coincident 
meningitis  indicates  tubercle  or  s\~philis. 

DiFFEREXTiATiox. — Brcdn  abscess:  abscess  and  tumor  may  result 
from  trauma,  but  brain  abscess  is  almost  always  traumatic,  otitic  or 
metastatic;  unilateral  optic  neuritis  is  more  common  than  choked  disk, 
and  abscess  is  more  prone  to  fever,  chills,  rapid  course  and  apoplectic 
seizures  than  is  tumor,  while  involvement  of  the  cranial  nerves  is  less 
frequent.  Differentiation  from  paretic  dementia,  pachymeningitis, 
meningitis^  syphilis,  hysteria  and  hydrocej^halus  will  be  considered  under 
each  disease. 

Multiple  Sclerosis.  The  pressure  symptoms  of  tumor  are  absent  and 
in  the  disk  there  is  an  incomplete  optic  atrophy.  The  tremor  may  be 
confused  with  incoordination  tremor  of  tumor  in  the  optic  thalamus, 
pons  or  cerebellum. 

Course  and  Prognosis. — The  first  symptoms  are  usually  general;  the 
later  are  focal.  The  disease  runs  a  fatal  course  in  one-half  to  tico  years, 
in  rare  cases  four  to  fourteen  years.  Exacerbations  result  from  aneurysmal 
rupture,  hemorrhage  into  a  glioma,  cyst  formation,  ventricular  effusions, 
meningitis  or  local  neuritis.  Remissions  are  not  uncommon;  heahng 
of  parasitic  and  simple  cysts,  aneu^^^sms,  tubercles  (in  the  young)  and 
gummata  is  possible.  Unfavorable  symptoms  are  pronounced  mental 
change,  incoercible  vomiting,  irregular,  rapid  pulse,  repjeated  fits,  apo- 
plectiform seizures  or  festinating  neuritis  optica.  The  mechanism  of 
death  is  exhaustion  from  vomiting,  pain  or  cachexia;  inhalation  pneumonia; 
coma   with   disturbed   respiration,    circulation   or   other    bull  jar    -igns; 


ENCEPHALITIS  797 

sudden  death  in  tumors  of  the  base;  meningitis  or  arterial  disease;  and 
intercurrent  infections. 

Treatment. — ^Medical  treatment  is  not  encouraging  save  in  syphihs, 
but  erevy  patient  should  be  given  a  long  course  of  mercury  and  iodide. 
Tubercle  is  sometimes  arrested  by  increasing  the  physiological  resistance 
by  forced  feeding,  fresh  air,  cod-liver  oil  and  arsenic.  The  headache 
is  often  relieved  by  iodide,  the  ice-bag,  morphine,  atropine,  coal  tars 
and  decompression  operations.  Convulsions  should  be  treated  by  chloral. 
Brain  congestion  from  alcoholism,  excitement,  exertion,  overeating  or 
obstipation  should  be  avoided. 

Surgical  Ixterferexce. — ^Nlacewen,  Horsley,  Bennett,  Ferrier  and 
Godle  are  the  pioneers  in  brain  surgery,  (a)  In  radical  operation  the 
outlook  is  not  encouraging.  Allan  Starr  estimates  that  but  18  per  cent, 
of  tumors  are  accessible,  and  but  7  per  cent,  removable.  The  best  results 
are  obtained  in  meningeal  and  cortical  g^0T^•ths,  especially  of  the  motor 
and  occipital  zones.  Duret  found  that  18  per  cent,  died,  64  per  cent. 
improved  and  vision  was  completely  restored  in  60  and  partially  in  18 
per  cent.  Recurrence  is  common.  Death  occurs  from  hemorrhage, 
sepsis,  dislocation  of  the  brain,  basal  compression,  brain  edema  and 
shock.  Horsley  and  ^Nlacewen  suggested  two  steps;  first  exposing  the 
tmnor  and  later  removing  it  after  the  brain  had  accommodated  itself  to 
the  change  of  relations,  (b)  Palliative  decompression  may  be  beneficial, 
often  greatly  relieving  headache  and  blindness  and  permitting  the  tumor 
to  grow  outward  when  it  cannot  be  removed.  From  lumbar  puncture 
38  cases  of  sudden  death  are  reported,  the  withdrawal  of  the  supporting 
colmnn  of  cerebrospinal  fluid  accentuating  a  hernia  of  the  medulla  into 
the  foramen  magnum. 


INFLAMMATION  OF  THE  BRAIN. 

I.  Encephalitis. — "Inflammation  of  the  brain"  as  understood  by  the 
laity,  is  meningitis.  Coswell  and  Hasse  (1850)  definitely  distinguished 
between  encephalomalacia  and  encephalitis. 

Etiology. — The  three  main  factors  are:  (a)  Intoxications,  from  alcohol, 
illuminating  gas,  sulphuric  acid,  ptomaines  in  decayed  meat,  nicotine 
and  sunstroke,  (b)  Infections,  as  influenza,  scarlatina,  hydrophobia,  etc. 
Some  relation  to  chlorosis,  chorea  insaniens  or  maniacal  forms  of  exoph- 
thalmic goitre  is  possible,    (c)  Trauma. 

Pathology. — The  process  begins  as  multiple  disseminated  foci,  prin- 
cipally in  the  gray  matter;  these  usually  are  the  small  "flea-bite"  areas 
of  capillary  hemorrhage,  which  glisten  and  stain  the  adjacent  tissues, 
show  above  the  cut  section  and  later  become  foci  of  softening.  Micro- 
scopically, hyperemia,  perivascular  exudation  of  red  and  white  cells, 
serous  eff'usion,  aggregations  of  mononuclear  cells  somewhat  resembling 
a  tubercle,  and  degenerated,  fatty  and  swollen  ganglion  cells  are  observed; 
the  medullary  sheaths  and  later  the  axis-cylinders  degenerate.  Its  issues 
are:  (a)  regression  (recovery);  (6)  necrobiosis  with  softening;  (c)  cyst 
formation;  (d)  cicatrix  formation  or  (e)  possibly  dift'use  brain  sclerosis 


798  DISEASES  OF   THE  BRAIN 

or  multiple  sclerosis.  Associated  nervous  changes  are  optic  neuritis, 
multiple  neuritis  and  poliomyelitis,  and  general  changes  are  enlarged 
spleen,  general  hemorrhages  and  parenchymatous  degeneration,  etc. 

Special  Pathology  and  Symptomatology. — 1.  Poliexcephalitis  Actta 
Superior  Hemorrhagica  or  Ophtha.lmoplegica. — Wernicke  (1881) 
described  this  affection  in  alcoholic  adults;  it  attacks  the  gray  matter 
about  the  third  and  fourth  ventricles  and  aqueduct  of  Sylvius,  whence 
it  may  spread  upward  or  do-^nward;  it  is  analogous  to  acute  polio- 
myelitis. The  general  symytoms  are  delirium  tremens,  or  somnolence  in 
non-alcoholics,  headache,  vomiting  and  rigid  neck.  The  local  symptoms 
consist  of  an  early  extensive  ophthalmoplegia,  which  involves  associated 
eye  muscles,  as  the  two  internal  recti,  or  the  internal  rectus  of  one  eye 
and  the  external  of  the  other  and  usually  evades  the  pupil  and  levator 
palpebree  superior.  The  gait  is  atactic  from  involvement  of  the  corpora 
quadrigemina.  Speech  is  frequently  difficult.  Neuritis  is  observed  in 
the  optic  disk  and  sometimes  in  the  peripheral  nerves,  as  evidenced  by 
the  absent  patellars,  ataxia,  tender  muscles,  etc.  Sometimes  there  is 
hemiparesis  or  facial  paresis.  The  temperature  is  usually  normal  or 
subnormal,  though  respiration  and  pulse  are  increased.  Death  occurs 
within  two  weeks  after  these  violent  symptoms.  Some  cases  thought 
to  be  nuclear  have  been  proved  pohTieuritic. 

2,  Encephalitis  or  Poliexcephalitis  Hemorrhagica. — Striimpell 
(1884)  described  cases  causing  infantile  paralysis  (q.  v.) .  In  1885  Leichten- 
stern  saw  cases  following  certain  infections.  Foci  in  the  cortex,  subcortex 
or  central  ganglia,  contained  pus  cocci  and  influenza  bacilli.  The  disease 
occurs  mostly  between  the  fifteenth  and  thirtieth  years.  After  an  in- 
fluenza (q.  V.)  there  may  be  (a)  general  symptoms,  as  headache,  vomiting, 
delirium,  mental  obscuration,  convulsions,  high  fever,  slow  pulsie,  irreg- 
ular breathing,  stiff  neck  or  optic  neuritis;  (h)  focal  symptoms  appear 
after  a  few  days,  as  hemi-  or  monoplegia,  aphasia,  conjugate  deviation, 
focal  convulsions  or  hemichorea.  The  reflexes  are  affected  as  in  apoplexy. 
The  course  lasts  one-half  to  three  weeks  and  is  often  fatal.  This  form 
may  resemble  hemorrhage,  syphilis  or  softening,  but  the  paralysis  is 
preceded  by  fever,  enlarged  spleen,  somnolence  or  convulsions.  ]\Ienin- 
gitis  is  usually  differentiated  with  ease. 

3.  Subtypes. — These  consist  of  the  following:  (a)  poliencephalitis 
inferior  acuta,  involving  the  pons  or  medulla  and  giving  acute  bulbar 
symptoms;  there  is  paralysis  of  the  sixth  or  seventh  to  twelfth  nerves 
when  it  occurs  in  various  combinations  or  with  types  (V)  and  (2).  Con- 
fusion is  possible  with  softening,  hemorrhage,  the  late  hemorrhage  of 
trauma  or  tumors.  (6)  With  poliencephalomyelitis,  inflammation  and 
paralysis  of  the  anterior  spinal  roots  may  coexist.  Hutchinson's  facies 
is  observed,  viz.,  fixed  eyes,  fallen  lids,  prominent  eyebrows,  obliterated 
nasolabial  folds  and  atrophic  paralysis  of  the  arms.  Differentiation  from 
multiple  neuritis  is  usually  possible. 

Prognosis. — The  peracute  cases  may  die  in  two  days;  acute  cases  last 
one-half  to  three  weeks  and  death  is  most  frequent;  Oppenheim  instances 
recoveries.  ^Nluch  involvement  of  the  mind,  decubitus,  alcoholic  delirium, 
chlorosis,  sinus  thrombosis  and  weak  pulse  are  unfavorable  elements. 


ABSCESS  OF   THE  BRAIN  799 

In  children  recovery  is  common,  but  epilepsy,  paralysis  and  mental 
alteration  are  sequences. 

Treatment. — This  is  symptomatic.  The  causal  factor  must  be  elimi- 
nated, cerebral  congestion  avoided  and  the  skin,  bowels  and  bladder, 
delirium  and  convulsions,  diet  and  patient's  rest  must  be  cared  for  as  in 
brain  hemorrhage.  Mercurial  inunctions  and  potassium  iodide  give  the 
best  results.     Electricity  is  indicated  in  the  chronic  stage. 

II.  Abscess  of  the  Brain. — Encephalitis  apostematosa  is  not  a  common 
disease.    Eichhorst  found  three  among  13,563  medical  cases. 

General  Etiology. — The  streptococcus  is  the  most  frequent  rhicro- 
organism,  the  staphylococcus  coming  next,  then  the  pneumococcus  and 
other  bacteria.  Mixed  infections  are  common;  old  abscesses  are  often 
sterile.  Sixty-six  to  75  per  cent,  occur  in  men.  Twenty  per  cent,  occur 
in  the  second  and  33  per  cent,  in  the  third  decade.  The  cerebrum  is 
in\'olved  in  75  and  the  cerebellum  in  25  per  cent. 

General  Pathology. — The  focus  is  single  in  80  per  cent,  of  cases.  The 
average  size  is  from  one  to  two  inches,  but  it  may  occupy  nearly  the  entire 
hemisphere.  The  surrounding  brain  may  be  inflamed,  or  edematous. 
The  right  side  of  the  brain  is  more  often  affected.  Pressure  is  less  common 
and  less  intense  than  in  tumor;  very  large  abscesses  may  produce  internal 
hydrocephalus.  The  abscess  consists  of  pus  of  variable  consistency, 
yellow  or  green,  acid;  flocculi  of  disorganized  brain  tissue  are  common. 
The  pus  cells  are  often  disintegrated  and  fatty  needles,  cholesterin 
crystals  and  sometimes  corpora  amylacea  are  found.  Putridity  is  due  to 
communication  with  the  nose  or  ear  or  embolism  from  putrid  lung  foci. 
Encapsulation  occurs  in  50  per  cent.,  chiefly  in  old  cases,  but  rarely 
completely  or  permanently  limits  the  abscess,  which  usually  grows  and 
often  ruptures. 

Special  Etiology  and  Pathology. — 1 .  Infective  Foci  near  the  Brain. — 
Infective  foci  near  the  brain  are  its  usual  causes,  and  for  this  reason  brain 
abscess  is  seen  by  internalists,  neurologists,  surgeons  and  otologists,  (a) 
Ear  disease  explains  at  least  25  per  cent,  of  brain  abscess.  Insurance 
companies  recognize  the  risk  in  these  cases.  Jansen  found  one  abscess 
to  500  cases  of  chronic  and  one  to  2650  of  acute  otitis.  The  ear  disease 
may  date  back  thirty  or  forty-five  years  and  is  especially  dangerous 
when  it  recurs  and  when  granulations  and  polypi  exist.  The  acute 
infections  thus  indirectly  cause  brain  abscess.  Infection  traverses  the 
bone  to  the  dura  by  way  of  the  thin  tegmentum  tympani,  by  the 
roof  of  the  antrum,  sometimes  through  the  petrosquamous  suture  (in 
children),  mastoid  cells,  lateral  sinus,  labyrinth  or  aqueduct  along  the 
sheaths  of  the  seventh  and  eighth  nerves;  in  42  per  cent,  there  is  a  fistule 
between  the  abscess  and  the  causal  focus;  in  15  per  cent,  the  dura  inter- 
poses between  the  two  foci;  in  15  per  cent,  there  are  dural  adhesions 
and  in  17  per  cent,  the  intervening  substance  is  softened  brain  tissue. 
Toynbee  remarked  that  disease  of  the  roof  caused  temporosphenoidal 
abscess,  but  disease  of  the  mastoid  cells  chiefly  produced  cerebellar 
abscess.  Of  otitic  abscess,  temporosphenoidal  constitutes  67  per  cent. 
(75  per  cent,  under  ten  years)  and  cerebellar  abscess  33  per  cent.;  the 
latter  is  rarely  due  to  any  cause  other  than  otitis  and  almost  invariably 


SOO  DISEASES  OF   THE  BRAIX 

occur-  in  the  anterior  part  of  its  hemispheres.  Otitic  abscess  infrequently 
involves  the  occipital,  frontal  ftwo  personal  observations)  or  parietal 
lobes.  The  smaller  the  abscess  the  nearer  it  lies  to  the  cortex,  (h) 
Traumatism  produces  2.5  per  cent,  of  cases.  Punctured  wounds  are  more 
dangerous  than  open,  compound  fractures.  Fractures  of  the  base  (by 
infecting  the  middle  ear),  splintering  of  the  inner  table  (areas  becom^ing 
infected  through  the  blood)  and  operations  on  the  brain  are  possible 
causes;  80  per  cent,  occur  over  ten  years  of  age.  Ninety-three  per  cent. 
are  solitary  abscesses.  Infection  travels  along  the  perivascular  and 
perineural  hTiiph  sheaths  but  may  pass  "retrograde"  by  the  valveless 
veins,  (c)  Other  contiguous  disease  is  rarer,  causing  but  4  per  cent,  of 
brain  abscess.  Disease  of  the  nose  and  communicating  sinuses  may  cause 
abscess  of  the  frontal  lobes  and  in  antrum  disease  sometimes  of  the 
parietal  lobes.  Disease  of  the  orbit,  as  phlegmon  or  penetrating  wounds, 
and  still  more  rarely  cranial  osteomyelitis,  ulcerative  tuberculosis  or 
s^'philis  may  cause  abscess  by  contiguity. 

2.  Metastatic  Abscesses. — Metastatic  abscesses  constitute  25  per 
cent,  of  brain  abscess.  The  abscesses  may  number  from  2  to  over  100; 
they  are  multiple  in  66  per  cent.  They  are  cortical  or  subcortical,  less  fre- 
quently in  the  central  ganglia  and  almost  never  in  the  cerebellum  alone. 
The  causal  embolus  is  seldom  found,  la)  Lung  lesions:  "pulmonal  cere- 
bral abscesses""  are  due  to  empyema,  putrid  bronchitis  and  bronchiectasis 
'45  per  cent.i,  gangrene,  abscess  and  sometimes  tuberculous  cavities. 
This  form  rarely  encapsulates,  (h)  Ulcerative  endocarditis,  pyemia, 
osteomyelitis,  etc.,  are  less  common  causes;  paradoxical  embolisfn  may 
occur  through  a  patent  foramen  ovale,  whereby  the  clot  escapes  the 
lungs. 

Symptoms. — Symptoms  are  absent  in  h)  per  cent,  of  cases. 

1.  Symptoms  of  Sepsis. — (a)  Fever  is  the  most  important  general 
symptom;  Eichliorst  describes  cases  closely  resembling  typhoid;  it  is 
present  in  acute  cases  and  during  the  last  stages  when  the  abscess 
spreads  or  meningitis  or  sinus  thrombosis  develops.  Macewen's  cases 
showed  normal  or  subnormal  temperature,  (h)  Chills  are  not  frequent, 
(c)  The  pulse  is  often  accelerated,  but  may  later  become  slowed  to  30 
or  40,  the  compression  pulse. 

2.  DiFFU-SE  Braix  S"mPTOMS. — These  are  due  to  increased  intra- 
cranial tension,  inflammation,  meningitis  or  internal  hydrocephalus 
and  include  (a)  headache,  which  is  most  common  and  severe,  though 
less  so  than  in  brain  tumor;  even  the  stiff,  painful  neck  and  headache 
are  general  rather  than  focal  symptoms.  It  is  frequently  associated  with 
(6)  vomiting  and  'cj  vertigo,  (d)  Mental  symptoms  are  those  of  slow 
cerebration,  ie)  General  convulsions  are  frequent  only  in  the  last  stages, 
in  cases  of  extensive  abscess  or  rupture  into  the  ventricle,  (f)  The 
pulse  is  often  slowed,  even  with  coexistent  fever,  to  40  (even  10)  and 
sometimes  with  slow  or  irregular  respiration,  (g)  Optic  iieuritis  is  more 
common  than  choked  disk;  it  occurs  in  53  per  cent,  and  may  produce 
amaurosis  and  atrophy. 

3.  Focalizing  Symptoms. — Focalizing  symptoms  are  often  absent 
and  when  present  are  less  conspicuous  than  in  tumor  because  they  are 


ABSCESS  OF   THE  BRAIN  801 

obscured  by  the  primary  affection  or  the  general  symptoms  and  occur 
in  areas  of  less  physiological  dignity.  They  usually  signalize  advance  of 
the  abscess,  softening  or  increased  brain  tension. 

Frontal  or  mental  symptoms  may  occur  (see  Tilmor),  but  foci  as 
large  as  the  fist  may  remain  latent.  They  may  impinge  on  the  motor 
cortex.  The  symptoms  are  those  of  a  cortical  lesion,  which  extends 
more  rapidly  than  tumor  and  is  attended  by  Jacksonian  fits,  rigidity 
and  increased  tendon  and  decreased  skin  reflexes  on  the  contralateral 
side;  in  subcortical  lesions  from  traumatic  and  metastatic  abscess,  hemi- 
paresis  occurs  in  50  per  cent.,  is  sometimes  progressive,  usually  incomplete 
and  at  times  is  apoplectiform  in  onset  (three  personal  observations). 
If  hemiparesis  is  early  it  indicates  involvement  of  the  internal  capsule, 
which  also  causes  hemiliypesthesia.  Conjugate  de^'iation  is  not  common. 
Temporosphenoidal  lesions  are  largely  otitic,  frequently  latent  and 
subcortical,  whence  the  centres  are  less  involved  than  the  deeper  associa- 
tion fibers.  The  more  important  left-sided  lesions  lead  (in  42  per  cent.) 
to  sensory  aphasia,  partial  word-deafness,  alexia,  agraphia,  amnestic 
and  optic  aphasia.  The  right  side  concerns  the  memory  for  letters  and 
figures.  Occipital  lesions  or  those  deeper  in  Gratiolet's  optic  radiation, 
produce  hemianopsia  (more  in  traumatic  or  metastatic  than  in  otitic 
abscess).  Cerebellar  abscess  results  almost  exclusively  from  ear  disease 
and  is  often  latent.  Occipital  headache  and  stiff  neck  occur;  there  may 
be  a  tendency  to  fall  forward  or  backward  and  hemiparesis  or  yawning 
may  residt  from  compression;  cranial  nerve  paralyses  are  not  frequent 
and  result  from  coincident  meningitis.  Paralyses  of  the  seventh  and 
eighth  nerves  are  often  due  to  bone  disease.  Abscess  of  the  pons,  medulla 
(of  which  Gassier,  in  1903,  found  onh'  16  cases)  and  cms  is  exceptional. 
(See  Cerebeal  Localization.) 

SYMPTOMS  BY  Stages. — (i)  The  initial  stage  is  observed  mostly  in 
acute  traumatic  or  metastatic  abscess.  Pus  formation  usually  requires 
ten  to  thirty  days.  The  causal  septic  and  general  brain  symptoms 
appear  rapidly;  death  may  occur  from  coma,  fever  and  meningitis 
or  the  next  stages  appear,  (ii)  The  latent  stage  has  no  fever,  is  seen  in 
chronic  abscess,  probably  corresponds  Tvdth  encapsulation  and  lasts  for 
months  or  even  decades,  (iii)  In  the  "manifest"  stage  septic,  general 
or  focal  brain  symptoms  appear  continuously  or  remittently,  Avith 
evidence  of  extension.  Most  cases  are  seen  in  this  stage.  Gowers  esti- 
mates that  after  nervous  symptoms  once  develop,  (iv)  the  next  or  terminal 
stage,  appears  in  five  days  (20  per  cent.),  in  ten  days  (33  per  cent.), 
fourteen  days  (50  per  cent.)  and  in  thirty  days  (75  per  cent.). 

Diagnosis. — Recognition  is  impossible  in  latent  cases  affecting  "silent'' 
areas,  whence  "no  brain  disease  of  equal  severity  so  often  escapes 
recognition."  Few  cases  can  be  detected  without  consideration  of  the 
etiology,  which  is  definitive  in  75  per  cent.,  the  sepsis,  general  and  focal 
brain  symptoms. 

Otitic  abscess  may  be  confused  with  the  otitis  itself,  especially  in 

children;  otitis   may   produce  headache,   vomiting,   convulsions,   ODtic 

neuritis,  nystagmus  and  diplopia,  but  all  symptoms   disappear  under 

surgical  care;  otitic  brain  abscess  runs  an  acute  course;  temperature 

51 


802  ,        DISEASES  OF   THE  BRAIN 

is  often  lower  than  in  other  forms,  the  headache  may  be  local  and 
edema  may  be  seen  over  the  temporal  region,  with  tenderness  on  per- 
cussion and  a  higher  percussion-note  (Macewen). 

Serous  meningitis  is  often  mistaken  for  the  suppurative  form  and  is 
very  important  in  ear  disease.  It  is  attended  by  slight  temperature, 
internal  hydrocephalus,  paralysis  of  the  basal  nerves  and  gives  a  serous 
fluid  on  lumbar  puncture.  Extradural  abscess  was  found  in  78  per  cent,  of 
cases  of  brain  suppuration  by  Jansen,  sinus  thrombosis  in  18  per  cent, 
and  brain  abscess  in  barely  3  per  cent.  Local  symptoms,  as  edema  and 
tenderness,  are  commoner  than  diffuse  and  focal  symptoms.  Sinus 
thrombosis  {q.  v.)  is  more  often  attended  by  pyemic  symptoms,  foci  in 
the  lungs,  choked  disk  and  external  signs  of  altered  brain  circulation. 

Traumatic  abscess  is  often  suspected  because  of  delayed  healing  of  the 
wound.  It  is  usually  cortical  (whence  its  focal  symptoms)  and  often 
provokes  fever  and  other  general  symptoms.  It  must  be  differentiated 
from  traumatic  hemorrhage,  which  occurs  days  or  weeks  after  the  injury 
and  often  in  the  corp.  quadrigemina,  pons  or  medulla;  from  acute 
encephalitis,  whose  course  is  more  rapid;  from  concussion,  in  which  the 
symptoms  are  more  diffuse  and  may  involve  the  brain  nerves  or  arouse 
fever,  though  cortical  symptoms  are  absent.  The  late  traumatic  abscess 
is  subcortical  (affecting  the  conduction  or  association  fibers).  Cerebral 
tumor  (g.  v.). 

Abscess  by  metastasis;  localization  is  largely  in  the  hemispheres,  thus 
obeying  the  topography  of  embolism.  The  Sylvian  district  and  occipital 
lobes  are  most  often  affected  and  the  multiplicity  of  localization  should 
be  remembered.    The  course  is  usually  precipitate. 

Prognosis. — Spontaneous  recovery  by  demarcation,  inspissation,  calcifi- 
cation or  external  rupture  is  very  unusual.  Without  operation,  death 
is  practically  inevitable,  from  (a)  rupture  into  the  lateral  ventricles, 
chiefly  in  metastatic  and  otitic  abscess  and  into  the  membranes 
(cerebellar  abscess),  (b)  hydrocephalus  internus,  (c)  sinus  thrombosis, 
(d)  pressure  on  the  medulla,  or  (e)  brain  edema.  Sudden  death  may 
occur  without  adequate  postmortem  explanation. 

Treatment. — (a)  Prophylactic  therapy  concerns  the  etiological  factor. 
Adequate  drainage  is  always  necessary,  although  granulations  in  the 
middle  ear  are  protective  and  should  not  be  curetted  in  any  routine 
manner  (precisely  as  uterine  curettage  is  discountenanced  in  puerperal 
sepsis).  (6)  Palliative  treatment  is  that  of  brain  tumor  and  meningitis. 
Special  care  regarding  vomiting  is  indicated,  lest  it  rupture  the  abscess. 
(c)  Surgical  intervention.  Successful  cases  were  those  of  Morand  1868, 
Roux  1848,  and  Schede  1866.  The  contra-indications  are  metastatic 
abscess,  a  fatal  etiological  disease,  ventricular  rupture  and  diffuse 
meningitis,  although  in  the  last  2  cases  isolated  recoveries  are  recorded. 
Sinus  thrombosis,  circumscribed  meningitis  and  incipient  pyemia  do 
not  contra-indicate  operation.  In  Korner's  otitic  abscesses,  51.6  per 
cent,  recovered,  Wheeler's  series  gave  87.5  per  cent,  and  Macewen's 
96  per  cent. 

III.  Dementia  Paralytica. — It  is  also  known  as  paretic  dementia,  pro- 
gressive paralysis  of  the  insane  and  among  the  laity  as  softening  of  the 


DEMENTIA   PARALYTICA  803 

brain.  Bayle,  1822,  and  Calmeil,  1826,  first  accurately  described  the 
affection.  It  is  so  important  in  every-day  practice  and  constitutes  such 
a  large  proportion  (10  to  25  per  cent.)  of  all  insanities  that  its  description 
is  in  place. 

Definition. — Dementia  paralytica  is  a  chronic  inflammation  or  degen- 
eration of  the  brain,  characterized  by  progressive  vasomotor,  motor 
and  psychical  disturbances. 

Etiology. — (a)  Syphilis  is  the  cause,  Noguchi  and  Moore  finding  the 
spirochete  in  25  per  cent,  of  cases;  dementia  is  syphilis  and  not  a  para- 
syphilitic  affection.  (6)  Other  causes  are  modern  life,  with  its  strenuous- 
ness,  competition,  hurry,  worry,  short  sleep,  dissipation,  overwork  and 
city  life;  Krafft-Ebbing  summarized  the  etiology  as  " syphilization  and 
civilization."  These  causes  may  cooperate  with  heredity  and  alcoholism. 
Generally  speaking,  the  higher  classes  and  certain  occupations  (officers, 
artists  and  actors)  are  more  subject  to  it.  Kraff't-Ebbing  found  no 
clergymen  among  his  2000  patients.  It  occurs  between  the  thirtieth 
and  fiftieth  years,  and  is  7  to  10  times  as  frequent  in  men  as  in  women. 

Pathogenesis. — Lues  probably  produces  (a)  vasomotor  paresis  in  the 
forebrain,  followed  by  (6)  lymph  stasis  in  the  cortex  and  pia,  (c)  degen- 
eration and  atrophy  of  the  brain  and  cord,  and  (d)  interstitial  inflam- 
mation. All  cases  end  in  brain  atrophy  but  some  regard  chronic 
meningo-encephalitis  as  primary,  and  others  hold  that  it  is  secondary 
to  encephalitis  parenchymatosa. 

Pathology. — (a)  The  calvarium  is  thickened  in  33  per  cent,  (b)  The 
dura  in  50  per  cent,  is  thick,  opaque,  vascular  and  adherent  to  the  skull 
{ijachymeningitis ,  which  is  often  hemorrhagic).  In  attempting  to  strip 
off  the  pia  it  is  found  adherent  to  the  brain  cortex  (in  80  per  cent.), 
especially  over  the  frontal  and  motor  areas,  supplied  by  the  internal 
carotid  artery,  (c)  Gross  brain  changes  are  constant.  The  brain  in  the 
early  stages  is  swollen  and  hyperemic,  in  the  later  stages,  toasted;  it 
may  weigh  but  a  third  or  quarter  of  the  normal  (1260  gm.) ;  atrophy 
affects  largely  the  zones  supplied  by  the  internal  carotid  artery,  especi- 
ally the  frontomotor  cortex  and  island  of  Reil.  The  gray  matter  is 
yellowish-gray,  soft  and  wasted,  but  the  atrophied  white  substance  is 
firm.  The  convolutions  are  greatly  narrowed  and  the  sulci  are  widened,  the 
degree  of  atrophy  corresponding  to  the  6  or  8  ounces  of  serum  which  fills 
the  deficit  (hydrops  ex  vacuo).  In  80  per  cent,  granulations  are  seen  on 
the  ependyma  of  the  lateral  ventricles,  resembling  the  back  of  a  "  cat's 
tongue,"  and  the  ventricles  contain  hydrops  ex  vacuo,  (d)  The  minute 
alterations  in  the  brain  are  as  follows:  the  ganglion  cells  are  early  swollen 
and  cloudy;  the  later  findings  are  vacuolated  and  atrophied  ganglion 
cells;  wasting  of  the  medidlary  sheaths  and  axis-cylinders,  especially  the 
association  or  tangential  nerve  fibers  running  parallel  to  the  cortex  which 
waste  before  any  inflammation  can  be  seen;  corpora  amylacea  repre- 
sent what  is  left  of  them;  the  same  changes  occur  in  the  cranial  nerves; 
the  bloodvessels  show  mural  proliferation,  exudation,  colloid  or  hyaline 
metamorphosis,  thickening,  atrophy  and  obliteration;  the  lymph  vessels 
show  proliferation,  transudation  and  compression  of  the  cortex,  where 
cystic  degeneration  occurs  from  snaring  off  of  lymph  vessels;  the  neuroglia 


804  DISEASES  OF   THE  BRAIN 

increases  even  sevenfold  (sclerosis),  (e)  Alteration  of  the  spinal  cord 
is  present  in  90  per  cent.;  the  lateral  columns  often  show  descending 
degeneration,  but  more  commonly  changes  like  those  of  tabes  (g.  v.) ;  the 
cerebrospinal  fluid  contains  globulin  and  mononuclear  cells  and  exhibits 
the  Wassermann  reaction. 

General  Symptoms.- — x4s  a  rule,  the  symptoms  are  vasomotor,  psychical 
and  motor,  in  the  order  of  their  usually  slow  development.  The  leading 
symptoms  are  referable  to  alteration  in  the  frontomotor  cortex.  (1)  In 
the  prodromal  stage,  the  first  symptoms  are  equivocal  or  point  to  ia)  neu- 
rasthenia because  of  the  "irritable  weakness,"  ready  fatigue  in  mental  pro- 
cesses, headache,  cephalic  pressure,  introspection  and  ^'rheumatic"  pains. 
Again,  the  initial  symptoms  are  (6)  congestive,  as  headache,  migraine  or 
attacks  similar  to  petit  mal.  (c)  Most  important  are  mental  changes.  The 
patient  is  "not  himself"  but  "he  does  not  remark  his  o^\m  alteration" 
(Schulej.  "The  patient  is  confused  as  to  time,  and  comes  too  early  to 
work  or  remains  after  time;  he  confuses  places  and  may  smoke  in  church; 
his  observation  is  faulty  as  well  as  his  judgment;  he  confuses  dreams  with 
actualities  and  he  forgets  entire  epochs,  especially  recent  impressions. 
Esthetic  and  social  lapses  are  common;  the  subject  becomes  vulgar, 
careless,  neglects  duties,  disregards  amenities  and  from  lack  of  will-power 
may  steal  or  dissipate  most  openly.  Emotional  outbreaks  occur,  as  violent 
or  brutal  conduct  or  maudlin  sentiment  over  soon-forgotten  incidents" 
(Kraff t-Ebbing) .  The  patient  is  often  perniciously  active,  id)  Focal 
symptoms,  especially  amnestic  aphasia,  may  appear,  (e)  General  findings 
are  noted  after  a  time,  as  small  and  unequal  pupils  or  other  tabes-like 
findings,  double  vision,  fibrillary  contractions  of  the  tongue,  tremor,  pains, 
headache,  vertigo,  congestiA'e  attacks,  slow  pulse,  unmodulated  voice,  skip- 
ping of  words  in  reading  and  incorrect  writing.  This  stage  covers  months 
or  years.  In  rare  instances  the  symptoms  follow  tabes,  "the  ascending 
form  of  general  paralysis."  (2)  At  the  height  of  the  disease,  (a)  the 
psychical  symptoms  take  various  types,  as  maniacal  exaltation,  melan- 
cholia or  simple  dementia,  (h)  Congestive,  apoplectiform  attacks  are 
frequent  and  immobile  and  unequal  pupils,  hesitant  speech  with  elision 
of  syllables,  altered  expression,  trembling  or  paresis  of  the  face,  inco- 
ordination of  the  hands  and  gait,  disturbances  in  writing  and  reading 
become  more  distinct.  (3)  The  terminal  stage  is  characterized  by  total 
dementia  (the  final  type  of  all  initial  varieties),  complete  disorder  of 
speech,  incoordination  so  extreme  as  to  necessitate  feeding  the  patient 
and  keeping  him  in  bed,  sensory,  vasomotor  and  trophic  complications 
and  death  from  pyelonephritis,  bed-sores  or  bulbar  symptoms. 

Symptoms  in  Detail.- — 1.  Psychical  Symptoms. — ^The  weakness,  alter- 
ation in  character,  loss  of  memory  and  reason  and  the  ethical,  esthetic 
and  moral  deficit  have  been  described.  During  the  height  of  the  disease 
there  is  one  of  three  main  mental  manifestations:  (a)  megalomania, 
which  classical  expansive  type  occurs  in  GO  per  cent.,  associated  anatom- 
.ically  with  the  characteristic  meningo-encephalitis,  and  characterized  by 
ideas  of  grandeur,  the  patient  believing  he  is  a  king,  God,  a  millionaire, 
an  athlete,  etc.  He  makes  ridiculously  large  plans,  buys  extravagantly, 
lacks  will-power,  indulges  himself  excessively,  changes  with  great  "facil- 


DEMENTIA   PARALYTICA  805 

ity"  from  one  thing  to  another,  is  optimistic,  friendly,  even  philanthropic 
and  rapidl}'  runs  through  his  capital.  He  loses  himself,  forgets  names 
and  confuses  the  real  with  the  unreal.  Periods  of  acute  mania,  with  fever 
and  grinding  of  the  teeth  are  expressions  of  brain  congestion;  complete 
dementia  is  the  final  outcome,  though  remissions  occur.  (6)  The  melan- 
cholic or  h^^ochond^iacal  form  is  thought  to  occur  with  cystic  degenera- 
tion of  the  cortex.  It  may  be  of  the  dull  or  agitated  type.  The  patient 
may  dwell  on  the  condition  of  his  bowels  and  think  they  would  "burst 
and  flood  the  world."  There  is  often  micromania,  characterized  by 
"  self-belittlement,"  in  which  the  individual  fears  everything  and  thinks 
himself  a  "dot,  nothing,  or  denies  his  existence."  These  cases  may 
commit  suicide,  (c)  Simple  primary  dementia  may  be  present  from  the 
beginning;  this  type  is  increasing  in  frequency,  while  megalomania 
is  decreasing.  It  is  anatomically  simple  cortical  atrophy  in  which  in- 
flammation is  absent  or  late.  These  subjects  are  often  deceptive  in  the 
early  stage,  being  quiet,  urbane  and  optimistic.  In  the  ultimate  dementia 
of  all  types,  "there  is  no  sense  of  time,  place  or  identity,"  and  the  patient 
babbles  or  is  speechless. 

2.  ]MoTOR  Disorder. — This  usually  occurs  with  mental  changes,  is 
constant,  though  variable  in  its  expression,  incomplete  in  degree,  exten- 
sive as  to  parts  involved  and  progressive,  (a)  Speech  is  pathognomonic- 
ally  disturbed  as  a  result  of  mental  change,  wasting  of  association  fibers 
and  later  bulbar  atrophy.  It  is  incoordinate,  involving  letters  ("  literal" 
ataxia)  or  syllables.  In  pronouncing  such  words  as  "electricity"  the 
patient  characteristically  stutters  over  syllables.  Loss  of  word-memory 
is  the  primary  trouble;  the  patient  forgets  expressions,  speaks  ungram- 
matically and  "does  not  notice  it."  Speech  becomes  atactic,  there  is 
paraphasia,  the  voice  is  unmodulated,  gives  out  suddenly,  is  sometimes 
hoarse,  nasal  or  slow,  but  never  scanning.  Later,  speech  is  disturbed 
from  bulbar  alteration,  causing  dysarthria  from  disease  of  the  facial  and 
hypoglossal  nuclei;  it  is  ultimately  unintelligible  (absolute  aphasia). 
Closely  associated  with  speech  disturbance  is  (b)  disordered  reading 
(paralexia)  (c)  Writing  is  disturbed  first  because  of  the  mental  alteration; 
the  patient  has  difficulty  in  collecting  his  thoughts,  although  he  does  not 
realize  the  cause  (the  ataxia  by  which  he  drops  syllables,  repeats  words 
or  sentences — paragraphia);  and  it  is  disturbed  secondly  because  of 
tremor.  The  writing  is  uneven,  up  and  dowai  or  zig-zag.  These  changes 
are  diagnostic,  (d)  Paralysis  of  the  eye  muscles  (in  6  per  cent.)  is  usually 
partial  and  transitory.  When  total,  syphilis  or  tabes  is  the  probable 
cause,  (e)  The  pupils:  Myosis  may  occur,  often  just  before  maniacal 
outbursts.  Mydriasis  is  frequently  unilateral  and  results  from  sym- 
pathetic irritation.  In  60  per  cent,  of  cases  the  pupils  are  now  large, 
now  small,  which  is  considered  especially  sinister.  They  are  often 
irregular  or  triangular.  The  Argyll-Robertson  pupil,  responding  to 
accommodation  but  not  to  light,  is  marked  in  47  per  cent.,  partial  in  20 
per  cent,  and  absent  in  33  per  cent.;  it  is  due  to  degeneration  in  Bech- 
terew's  column  (between  that  of  Goll  and  of  Burdach).  (/)  The  facial 
nerve:  The  paresis  of  the  lips  is  cortical,  as  are  fibrillary  twitchings, 
automatic  chewing  movements  and  almost  constant  grinding  of  the  teeth. 


806  DISEASES  OF .  THE  BRAIN 

The  "fatuous"  or  "masked"  expression  is  psychical.  Sahvation  results 
from  cortical  irritation.  There  may  be  difficulty  in  swallowing,  (g) 
The  limhs:  (i)  The  cortical  changes  cause  the  small-waved,  rapid,  con- 
stant tremor,  the  ataxia,  loss  of  muscle  sense  and  the  uncertain, 
awkward,  tripping  paralytic  gait,  (ii)  The  gait  may  be  tabetic,  with 
absent  knee-jerks,  immobile  pupils  and  vesical  symptoms;  or  it  is 
more  often  spastic  with  early  increased  patellars,  ankle-clonus,  con- 
tractures and  arthropathies,  (iii)  Neuritic  atrophy  of  the  cranial  nerves 
may  occur  as  in  tabes.  (A)  Apoplectiform  and  epileptiform  attacks,  (i) 
Apoplectiform  seizures  result  from  vasomotor  paralysis  and  brain  edema 
and  differ  from  apoplexy  in  their  incompleteness,  evanescence,  increased 
temperature  and  increased  reflexes.  They  last  part  of  an  hour  and  may 
produce  temporary  hemiplegia,  but  especially  aphasia  with  paresis  of 
the  right  arm.  (ii)  Epileptiform  attacks  occur  later,  result  directly 
from  cortical  disease,  are  usually  partial  (involving  the  face  or  arm), 
and  either  Jacksonian  or  attended  by  partial  loss  of  conscious- 
ness. 

3.  Sensation  and  Special  Senses. — Coincident  tabes  and  pachy- 
meningitis may  emphasize  the  sensory  manifestations,  as  lancinating 
pains.  Sensation  is  often  dulled  and,  like  the  analgesia,  is  cortical  in 
origin.  Perhaps  the  hypochondriacal  complaint  that  certain  organs,  as 
the  bowels,  arie  absent,  is  due  to  visceral  anesthesia.  Migraine,  first 
appearing  late  in_life,  may  indicate  an  organic  origin;  Charcot  described 
a  form  with  hemianopsia  and  symptoms  like  glaucoma.  Migraine  is 
cortical  when  associated  with  paresis  of  the  face,  tongue  or  arm.  There 
may  develop  optic  neuritis  and  atrophy  (4  per  cent.),  optic  hallucinations 
and  psychical  blindness. 

4.  Other  Symptoms. — (a)  Vasomotor  changes  occur  in  the  skin 
(lividity,  edema  and  sweating)  and  in  the  brain,  lungs,  bladder,  intestines 
and  stomach  (resembling  the  so-called  bilious  attacks).  (6)  Trophic 
symptoms  are  sweating  of  blood,  rough  skin,  phosphaturia,  perforating 
ulcer  of  the  foot  (3  per  cent.),  bed-sores  and  friability  of  the  bones,  which 
may  be  broken  without  the  patient  knowing  it.  The  "insane  ear"  is 
frequent. 

5.  General  Symptoms. — The  pulse  is  often  slow  and  monocrotic, 
the  temperature  low,  although  the  heat  centres  may  be  involved  in 
congestive  seizures  with  great  febrile  elevation,  and  the  body  weight 
is  often  reduced  in  the  early  and  late  stages,  though  at  the  height  of 
the  disease  it  often  increases,  especially  before  the  congestive  seizures. 
The  sexual  instinct,  at  first  increased  and  sometimes  perverted,  later 
declines.    Insomnia  may  be  severe,  protracted  or  absolute. 

Diagnosis. — The  diagnosis  depends  upon  (a)  the  etiology,  as  syphilis 
with  mental  strain  or  excesses ;  (6)  the  grouping  of  the  psychical  symptoms, 
as  character,  esthetic  or  ethical  changes  with  (c)  viotor  symptoms,  as  the 
speech,  writing  or  tremor;  (d)  vasomotor  symptoms,  as  migraine  or 
apoplectiform  insults,  and  (e)  the  progressive  course. 

The  Wassermann  test  {v.  page  219)  of  the  blood  is  positive  in  80  to 
98  per  cent.;  the  spinal  fluid  shows  lymphocytosis,  globulin  and  the 
Wassermann  reaction. 


DEMENTIA   PARALYTICA  807 

DifEerentiation. — 1.  Diffuse  Brain  Disease. — (a)  Cerebral  syphilis 
may  be  confused  with  diffuse  meningo-encephalitis.  (6)  Senile  dementia 
seldom  occurs  under  sixty  years  of  age.  Its  course  is  longer,  the  symp- 
toms more  gradual  and  less  intense,  memory  is  maintained  longer  and 
there  is  less  megalomania  than  fear  of  persecution  and  poisoning. 
(c)  Multiple  sclerosis  occurs  earlier,  is  complicated  by  late  and  mild 
mental  symptoms  and  an  intention  tremor,  which  is  wider  in  amplitude 
and  ceases  during  repose.  The  speech  is  scanning,  staccato,  and  there 
is  no  literal  ataxia.  Nystagmus  is  common,  while  it  is  rare  in  general 
paralysis.  jNIotor  symptoms  are  largely  referable  to  lateral  column 
disease. 

2.  Focal  Brain  Disease. — (a)  Although  migraine,  headache,  apop- 
lectiform attacks  and  sensory  or  motor  irritation  of  the  Jacksonian  t}"pe 
may  occur  in  brain  tumor,  it  does  not  cause  diflficulty  in  pronouncing 
syllables,  peculiar  mental  alteration  or  immobile  pupils;  it  is  character- 
ized by  general  symptoms,  as  choked  disk  or  vomiting  and  focal  symptoms, 
which  are  foreign  to  general  paralysis.  In  tumor  there  is  dementia  only 
with  marked  internal  hydrocephalus.  (6)  Hemorrhagic  pachymenin- 
gitis complicates  20  per  cent,  of  cases  of  dementia  paralytica;  when  it 
exists  as  an  independent  affection,  it  often  leads  to  intense  local  headache, 
vomiting,  recurrent  hemiplegia  or  monoplegia,  cortical  irritation  .and 
more  rapid  course,     (c)  Softening  usually  produces  focal  symptoms. 

3.  Psychoses  and  Neuroses. — (a)  Every  case  of  mania  or  hypo- 
chondriasis between  the  twenty-fifth  and  fort>-fifth  years,  not  due  to 
alcoholism  or  to  acute  somatic  disease  should  arouse  suspicion  of  general 
paralysis  (Mendel),  (b)  In  neurasthenia  the  onset  is  more  acute;  the 
memory  is  fatigued  but  never  lost  and  the  patient  recognizes  his  in- 
capacity. In  dementia  paralytica  there  are  hypochondriasis  with  absurd 
conceptions,  changes  in  the  pupils,  disk  and  field  of  vision,  alterations 
in  character,  speech  and  intellect  which  are  never  seen  in  neurasthenia. 

4.  Intoxications. — These  may  cause  the  forms  known  as  general 
pseudoparalysis,  (a)  Chronic  alcoholism  is  not  progressive,  recovery  is 
frequent,  delirium  tremens  and  convulsions  are  common,  the  course  is 
acute  and  the  alcoholic  tremor,  headache,  hallucinations  and  neuritis 
are  found,  (b)  Chronic  plumbism  (saturnine  encephalopathy)  is  often 
progressive,  and  in  its  last  stages  almost  indistinguishable  from  dementia 
paralytica.  It  is  more  acute  and  80  per  cent,  of  cases  recover.  There  are 
headache,  cardiac  distress,  anemia  and  a  gingival  lead  line,  (c)  Chronic 
bromism  is  distinguished  by  its  dementia,  bromide  acne,  fetid  breath, 
coated  tongue,  pharyngeal  anesthesia,  weak  heart  and  acute  and  usually 
favorable  course. 

Prognosis. — The  disease  is  fatal  in  66  per  cent,  of  cases  within  two 
years,  though  remissions  may  occur.  Krafft-Ebbing  saw  no  recoveries 
in  2500  cases;  recovery  indicates  an  incorrect  diagnosis,  pseudoparalysis 
generalis.  The  following  courses  are  distinguished:  (a)  acute  or  galloping 
form,  which  lasts  months  to  a  year;  (6)  classical,  expansive  type,  three 
or  four  years;  {c)  the  depressive  type,  two  or  three  years;  {d)  dementia 
forms,  four  or  five  years;  {e)  circular  form,  in  which  depression  alternates 
with  mania;  (f)  female  variety  which  has  a  longer  course  than  in  males; 


808  DISEASES  OF   THE  BRAIN 

(g)  spinal  form,  with  a  relatively  long  course;  (/?)  juvenile  or  adolescent; 
and  (i)  senile  form.  Death  results  in  50  per  cent,  from  the  disease  itself, 
by  apoplectiform  seizures,  suicide,  inanition  or  bulbar  symptoms.  In 
50  per  cent,  it  results  from  complications,  tuberculosis  (18  per  cent.), 
bed-sores,  with  sepsis  (10  per  cent.),  lung  gangrene  (6  per  cent.),  pneu- 
monia (5  per  cent.),  choking  (10  per  cent.)  and  cystitis. 

Treatment. — Hygienic  treatment,  as  rest,  protection  from  heat,  and 
quiet  surroundings,  is  indicated.  The  patient  should  be  committed  to 
an  asylum,  for  suicide  or  other  violence  is  always  possible.  In  simple 
dementia  alone,  may  the  patient  be  treated  at  home.  Hydrotherapy 
is  valuable  within  limits;  cold  rubs  lessen  excitation;  full  cold  baths  are 
contra-indicated.     Medicinal  treatment  (v.  S\^hilis). 


CHRONIC  BULBAR  PARALYSIS. 

First  thoroughly  described  by  Duchenne  (1860),  as  labioglossopharyn- 
geal  (laryngeal)  paralysis.  Trousseau  made  the  first  autopsies,  Charcot 
and  V.  Leyden  demonstrated  alteration  in  the  bulbar  nuclei. 

Etiology.— ]Most  cases  occur  in  maJes  between  fijty  and  seventy  years 
of  age.  Heredity  is  a  factor  only  when  the  disease  is  associated  with 
progressive  muscular  atrophy. 

Pathology. — To  the  naked  eye  the  medulla  usually  appears  normal. 
iMicroscopically,  (a)  the  motor  nuclei  are  symmetrically  and  bilaterally 
wasted.  The  h}T)oglossal  nucleus  suffers  most  and  few  normal  cells 
remain;  its  accessory  nucleus  is  usually  normal.  The  spinal  accessory 
nucleus  is  next  most  frequently  affected,  but  the  vagus  nucleus  suffers 
less.  Atrophy  may  invade  the  glossopharyngeal  or  exceptionally  the 
facial  and  fifth  nuclei.  In  some  cases  perivascular  exudation  occurs 
within  the  nuclei  and  the  nerve  elements  are  degenerated  (the  parench}^- 
matous  form),  but  in  others  increase  of  connective-tissue  or  vascular 
thickening  may  be  seen.  (6)  The  respective  nerve  tninl:s  in  their  course 
or  in  their  terminal  endings  show  parenchymatous  and  interstitial  change, 
even  within  the  medulla,  and  the  posterior  longitudinal  fibers  waste  in 
direct  ratio  to  the  hypoglossal  nuclear  atrophy,  especially  those  which 
form  the  anterior  fundamental  fibers  of  the  spinal  cord.  Sometimes  the 
loop  of  the  seventh  nerve  wastes,  (c)  The  muscles  supplied  by  the  above 
nerves  waste,  as  those  of  the  lips,  tongue,  palate  and  larynx  (the  process 
sometimes  extends  to  the  neck  and  arms).  The  greatest  change  is  in  the 
tip  of  the  tongue.  The  changes  are  those  of  progressive  muscular  atrophy 
{q.  v.).  (d)  In  all  cases  pyramidal  trad  degeneration  may  be  traced  down 
into  the  cord  or  up  into  the  crus. 

Ssmaptoms. — LabioglossopharjTigeal  paralysis,  the  name  proposed  by 
Duchenne,  designates  the  parts  paralyzed  by  the  wasting  of  the  motor 
nuclei.  It  is  bilateral,  but  one  case  showing  unilateral  disease.  It  is  slow 
in  onset,  afebrile  and  painless.  The  first  symptom  is  usually  paresis 
of  the  tongue  (hypoglossus)  which  first  shows  fatigue  and  much  later 
actual  paralysis.  It  is  difficult  to  protrude  or  move  up,  down  or  trans- 
versely.   The  Unguals,  L,  X,  Pt  and  S  are  formed  with  difficulty  and  also 


CHRONIC  BULBAR  PARALYSIS  809 

later  the  lingual  palatines,  as  T  and  D.  The  tongue  is  wriukled  and 
wasted.  The  lips  become  weak  and  whistling  and  formation  of  the  labials 
(O,  U,  P,  B,  M)  become  impossible.  The  tongue  and  lips  are  more 
closely  associated  than  any  other  muscles  of  the  body;  anatomically  the 
facial  fibers  for  the  orbicularis  oris  probably  originate  in  the  hypoglossus 
nucleus.  Later  the  mouth  cannot  be  closed,  the  lower  lip  sags  and  the 
zygomatic  muscles  overcome  the  weak  fibres  of  the  upper  lip  and  accen- 
tuate the  nasolabial  furrow.  The  lips  are  frequently  thin.  The  expression 
is  peculiar,  the  forehead  is  corrugated,  the  eyebrows  somewhat  lifted, 
but  the  mouth  is  "dead"  and  laughing  and  emotional  displays  produce 
a  strange  effect,  which  Trousseau  compared  to  the  mask  of  the  Greek 
actors.  The  original  descriptions  picture  the  patient  constantly  holding 
a  handkerchief  before  the  lips  to  collect  the  free  flow  of  saliva  from  the 
open  mouth;  the  salivary  secretion  is  probably  also  increased  from  disease 
of  its  bulbar  centre.  Swallowing  becomes  difficult  from  the  inability  of  the 
tongue  to  propel  the  food  to  the  pharynx  so  that  the  subject  must  push 
the  food  back  with  the  finger,  and  again  the  palate  (controlled  by  the 
spinal  accessory  and  vagus  nerves)  is  weakened,  producing  a  nasal 
voice  and  allowing  food  to  regurgitate  into  the  nose.  The  pharynx  is 
paretic  (glossopharyngeal  and  vagus  nerves).  Semisolid  food  can  best 
be  swallowed,  because  fluid  more  easily  regurgitates  into  the  nose  and 
solids  more  easily  reach  the  larynx.  The  larynx  is  often  involved  (spinal 
accessory  and  vagus  nerves).  The  adductors  are  more  often  affected 
than  the  abductors.  Talking  and  coughing  are  difficult  or  impossible. 
Fibrillary  fwitchings  are  very  common,  sensation  is  normal,  but  the 
reflexes  of  the  skin  and  mucosa  are  usually  lost.  There  is  sometimes 
a  partial  reaction  of  degeneration.  The  intellect  is  normal.  Forced 
laughing  and  weeping  are  not  uncommon.  The  general  nutrition  suffers 
from  the  dysphagia.  In  some  cases  the  eyes  may  be  involved,  as  in  pro- 
gressive nuclear  ophthalmoplegia  (an  identical  process  in  the  pons); 
occasionally  the  cervical,  facial,  masseteric,  temporal  and  pterygoid 
muscles  are  involved.  Bulbar  paralysis,  frequently  coexists  with  pro- 
gressive muscular  atrophy  of  spinal  origin,  affecting  the  limbs  or  trunk, 
and  Kussmaul  pointed  out  that  the  two  processes  are  identical  in  nature. 
The  spinal  disease  may  progress  upward  to  the  medulla,  causing  secondary 
bulbar  palsy,  or  the  bulbar  palsy  may  be  primary.  In  typical  forms, 
there  are  wasting,  paralysis  and  absence  of  the  reflexes;  in  some  atypical 
forms  there  is  no  wasting;  at  times  the  reflexes  are  increased  (clonus 
in  the  muscles  of  mastication),  probably  from  a  supranuclear  lesion,  "the 
bulbar  analogue  of  amyotrophic  lateral  sclerosis  of  the  cord." 

In  the  progressive  course  of  the  malady  the  pulse  becomes  rapid  and 
irregular  and  the  heart  tones  run  together,  which  Duchenne  compared 
to  the  "heart  beating  in  water."  Dyspnea  develops  and  the  expiration 
is  weak. 

Diagnosis. — This  is  based  on  (a)  the  distribution  of  the  process  in 
the  motor  nuclei;  (6)  its  bilateral  symmetry;  (c)  gradual  onset,  and 
(d)  chronic  progression.  Neuritis  of  the  bulbar  nerves  is  very  rare; 
the  lips  escape,  because  the  nerve  fibers  to  the  orbicularis  oris,  arising 
in  or  near  the  hypoglossus  nuclei  run  to  the  pons  and  leave  it  by  the 


810  DISEASES  OF   THE  BRAIN 

facial  nerve  fibers;  there  is  more  atrophy,  more  rapid  course,  more 
sensory  disturbance  and  the  reaction  of  degeneration  is  present.  It 
occurs  in  acute  infections.  Brain  tumor  within  the  medulla,  growths 
without  the  medulla  and  multiple  sclerosis  and  syringomyelia  rarely 
produce  bilateral  or  symmetrical  paralyses.  Pseudobulbar  paralysis; 
bilateral  disease,  more  often  in  or  near  the  internal  capsule,  especially 
when  due  to  arterial  lesions,  may  cause  dysarthria  (Joffroy,  1872). 
One  lesion  may  be  in  the  cortex  and  the  other  in  the  lenticulostriate 
area.  Pseudobulbar  palsy  causes  mental  change,  aphasia,  hemiplegia, 
double  facial  paralysis  and  hemianopsia;  one  side  is  involved  after  the 
other  and  it  is  attended  by  no  wasting,  no  loss  of  reflex  action  and  no 
reaction  of  degeneration. 

Prognosis. — The  disease  is  fatal  in  one  to  three  years,  especially  in 
advanced  life  or  with  coexistent  spinal  muscular  atrophy.  In  the  rarest 
instances  the  disease  may  be  arrested.  Death  results  from  inanition, 
inhalation  pneumonia,  intercurrent  disease  or  paralysis  of  the  cardiac 
or  respiratory  centre. 

Treatment. — Treatment  is  discouraging.  Nutrition  must  be  main- 
tained by  feeding  with  the  nasal  catheter.  Iron  and  strychnine  may  be 
given.     Electrotherapy  is  of  little  value. 

Asthenic  Bulbar  Palsy;  Myasthenia  Gravis. — Chronic  bulbar  palsy 
without  anatomical  lesion  was  first  described  by  Wilkes  (1877),  Erb 
(1879),  Goldflam  (1891)  and  Oppenheim.  It  is  also  known  as  the  Erb- 
Goldflam  syndrome.  Starr  collected  250  cases.  It  most  often  occurs  in 
person's  under  the  thirtieth  year.  The  cardinal  feature  is  extreme  exhaustion 
(myasthenia)  after  the  slightest  exertion.  Weakness  develops  in  the  eyelids, 
face,  palate,  masseters,  pharynx,  vocal  cords  and  tongue,  although  but 
slightly  expressed  by  ptosis  (the  first  symptom  in  33  per  cent,  of  cases), 
dysphagia,  dysarthria  and  difficult  mastication,  and  disappears  after 
rest,  to  return  anew  after  a  few  muscular  efforts.  Myasthenia  may  be 
confined  to  the  eyes.  From  these  bulbar  symptoms  the  afl^ection  is 
called  asthenic  bulbar  paralysis.  In  some  cases  the  arms,  legs  and  trunk 
are  similarly  involved,  so  that  walking  or  arm  movements  become  im- 
possible after  short  exertion — myasthenia  gravis  pseudoparalytica.  The 
symptoms  are  symmetrical.  The  myasthenic  reaction  of  Jolly  consists 
of  normal  tetanic  response  to  faradic  stimulation,  becoming  weaker 
with  each  repetition,  until  at  last  no  reaction  is  elicited.  The  reflexes 
soon  become  exhausted.  Some  atonicity  of  the  digestive  tract  is  common. 
Collins  noted  a  rapid  exhaustion  of  the  special  senses  and  Buzzard  re- 
remarked  sensory  alterations.  Remissions  are  usual,  sixteen  years  being 
the  maximum  clinical  duration.  About  Ifi  per  cent,  of  cases  die  from 
exhaustion  of  the  cardiac  and  respiratory  centres  but  the  autopsy  findings 
are  negative  (in  66  per  cent.)  or  doubtful;  Kalisher  found  hemorrhages 
in  the  medulla,  and  C.  Mayer  found  vascular  and  nuclear  alterations. 
Lymphoid  cells  were  found  in  the  heart  and  between  the  muscle  bundles 
(Weigert,  1901),  and  Weigert,  Hun  and  Blumer  describe  lymphoid  and 
glandular  hyperplasia  in  the  thymus  gland.  The  diagnosis  is  based  on 
(a)  absence  of  atrophy,  of  the  reaction  of  degeneration  and  of  twitch- 
ings  and  sensory  phenomena;   (6)  the  presence  of  muscular  adynamia 


HYDROCEPHALUS  811 

recurring  remittently ;  (c)  Jolly's  myasthenic  reaction  and  (d)  the  slight 
involvement  of  the  hypoglossus. 

Treatment. — Rest  and  massage  are  helpfnl;  iodides,  calcium,  adrenalin 
and  strychnine  are  less  useful.  Galvanization  is  recommended  by  Gold- 
flam,  who  reported  recovery  under  its  use. 

Apoplectiform  Bulbar  Paralysis. — Sudden  bulbar  paralysis  deserves 
discussion  in  this  place  for  the  sake  of  topical  differentiation.  Its  usual 
causes  are  hemorrhage,  embolism,  thrombosis  and  less  frequently  bulbar 
encephalitis  or  neuritic  traimia. 

Symptoms. — (a)  The  oji-set  is  apoplectiform  with  s\Taptoms  which  are 
rarely  focal,  as  vertigo,  vomiting,  dyspnea,  yawning,  slowed  heart,  and 
often  without  coma,  (b)  Motor  symptoms  are  frequent,  as  double  hemi- 
plegio;  monoplegia  is  possible,  or  if  the  lesion  occurs  at  the  pyramidal 
decussation  there  may  be  hemiplegia  cruciata,  i.  e.,  paralysis  of  one  arm 
and  the  opposite  leg.  A  unilateral  focus  may  produce  bilateral  symptoms 
rarely,  however,  symmetrical.  The  pyramidal  tracts  in  the  medulla 
are  supplied  by  the  inferior  cerebellar  artery,  (c)  Sensory  symptoms 
may  develop,  as  hemiataxia  or  hemianesthesia  (d)  The  bidbar  nerves  may 
be  affected ;  parah'sis  of  the  tongue,  pharynx,  masseters,  larynx  and, 
because  of  the  vascular  supply,  frequently  of  the  eyes,  face  and  other 
pons  centres  may  result.  The  reflexes  of  these  parts  are  often  suspended, 
though  in  the  extremities  they  are  increased.  The  lesion  may  be  at  the 
\e\e\  of  the  nuclei  or  supranuclear.  The  hypoglossal  and  spinal  acces- 
sory nerves  are  supplied  by  the  anterior  spinal  and  vertebral  arteries; 
the  vagus,  glossopharyngeal  and  auditory  nerves  by  the  vertebral;  the 
fifth,  seventh  and  eye  nerves  (third,  fourth  and  sixth)  by  the  basilar 
artery.  There  may  be  hemiplegia  with  paralysis  of  the  opposite  side 
of  the  tongue  if  the  lesion  is  in  the  anterior  part  of  the  medulla. 

Diagnosis. — Chronic  bulbar  palsy  is  excluded  by  the  acuity  of  onset 
and  the  asymmetry  and  irregularity  of  the  bulbar  symptoms,  as  double 
hemiplegia,  which  is  unequal  on  the  two  sides,  or  dysphagia  without 
paralysis  of  the  tongue  or  lip.  Dift'erentiation  between  hemorrhage, 
embolism  and  thrombosis  is  frequently  impracticable.  Pseiidobidbar 
paralysis  of  cerebral  origin  {t.  s.). 

Prognosis  and  Treatment. — ^The  prognosis  is  most  grave  at  the  onset. 
Improvement  and  even  recovery  are  possible.  Treatment  concerns  chiefly 
the  underlying  vascular  disease. 

Progressive  Nuclear  Ophthalmoplegia. — An  atrophy  of  the  oculomotor 
nuclei,     {r.  Affections  of  the  Third  Nerve.) 


HYDROCEPHALUS. 

Acute  hydrocephalus  is  an  acute  accumulation  of  fluid  between  the 
dura  and  the  brain  (acute  external  hydrocephalus)  or  in  the  ventricles 
(acute  internal  hydrocephalus).  In  some  cases  the  fluid  is  a  transudate, 
lieing  part  of  a  general  edema,  resulting  from  cardiac  or  renal  disease, 
or  due  to  local  causes,  as  sinus  thrombosis.  In  most  cases  it  is  an  exudate. 
Acute  meningitis,  the  only  certain  cause,  is  tuberculous  in  80  per  cent.; 


812  DISEASES  OF  THE  BRAIN 

it  is  less  often  serous  meningitis.  Quincke  thinks  some  cases  are  angio- 
neurotic. 

I.  Chronic  External  Hydrocephalus. — Fluid  between  the  dura  and 
brain  is  caused  by  (a)  compensatory  hydroys  ex  vacuo,  occurring  where 
brain  development  is  arrested  (congenital  form)  or  when  the  brain  wastes 
(paretic  dementia,  softening,  hemorrhage,  senile  atrophy,  porencephaly). 
(6)  Stasis,  as  in  sinus  thrombosis;  and  (c)  chronic  diseases,  as  cancer, 
nephritis  or  alcoholism.     The  symptoms  are  indeterminate. 

n.  Chronic  Congenital  Internal  Hydrocephalus. — ^Etiology. — Possible 
causes  are  fetal  meningitis,  obstruction  of  the  choroid  plexus,  branches 
of  the  vena  Galeni,  lymphatics,  lateral  apertures  of  the  fourth  ventricle 
near  the  glossopharyngeal  roots,  aqueduct  of  Sylvius  or  in  the  foramen 
of  Magendie  or  Luschka. 

Symptoms  and  Pathology. — The  large  head  may  be  an  obstacle  to 
labor.  It  may  measure  167  cm.  in  circumference.  If  it  appears  after 
the  seventh  year  the  head  is  not  enlarged,  and  in  cretins  the  head  may 
be  undersized.  Often  the  head  cannot  be  held  upright.  The  skull  is 
even  membranous  and  translucent  to  the  candle  test.  If  the  disease  halts, 
the  bones  may  thicken  and  Wormian  bones  develop.  The  head  projects 
beyond  the  base,  the  sphenoid  is  luxated  forward  and  downward,  the  ear 
meatus  points  downward,  the  occiput  is  forced  back,  the  sella  turcica 
is  flattened  and  widened,  the  roof  of  the  orbit  may  be  pushed  down  so 
as  to  become  palpable,  the  fontanelles  are  large,  the  fissures  gape  and 
fluctuation  may  be  felt.  The  hair  is  thin,  the  veins  are  large  and  a  systolic 
murmur  may  be  heard,  the  cause  of  which  is  doubtful.  The  brain  is 
pale  and  may  be  flattened  almost  beyond  recognition.  The  ependyma 
are  thick,  granular  and  sclerotic.  The  average  amount  of  fluid  is  1 
quart,  the  maximum  13  quarts.  The  ventricles,  especially  the  lateral, 
are  enlarged;  the  enlarged  third  ventricle  easily  compresses  the  optic 
chiasm.  The  foramen  of  Monroe  is  often  very  large.  The  fluid  is  usually 
clear,  and  rarely  blood-stained.  It  is  neutral  or  alkaline,  its  specific 
gravity  is  1.001  to  1.009;  and  the  albumin  is  0.2  to  2  per  mille;  more 
than  1.009  or  2.5  per  mille  of  albumin  indicates  inflammation. 

The  face  is  small,  triangular,  and  the  eyes  are  prominent.  Much 
of  the  sclera  is  shown  and  the  upper  lid  is  small.  The  brain  may  be 
reduced  to  a  small  fraction  of  an  inch  in  thickness  and  is  a  mere  flask 
for  the  fluid.  The  demarcation  between  gray  and  white  matter  is  lost 
and  in  marked  cases  the  convolutions  and  sulci  are  obliterated,  the  basal 
ganglia  flattened,  the  cerebellum  forced  into  the  spinal  canal  and  many 
structures,  such  as  the  fornix  or  corpus  callosum  have  disappeared. 
Mentality,  as  a  rule,  is  impaired  or  abolished,  speaking  is  learned  late 
if  at  all,  and  irritability,  epileptiform  attacks,  psychoses,  headache  and 
vomiting  are  fairly  common.  Eye  symptoms  are  frequent,  as  diminished 
vision  or  blindness  from  optic  atrophy,  strabismus,  nystagmus  and  wide, 
possibly  reactionless,  pupils.  The  limbs  often  present  spasticity,  con- 
tractures, paresis  and  increased  reflexes.  The  child  walks  late,  if  at  all. 
Sensation  is  normal.  Puberty  may  be  delayed  or  the  infantile  testes  may 
persist.  Lumbar  puncture  shows  increased  intraspinal  pressure  (36  mm. 
of  mercury). 


HYDROCEPHALUS  813 

Complications. — Complications  are  largely  anomalies  of  development, 
as  syringomyelia,  hydromyelia,  meningocele,  microcephaly,  porencephaly, 
anencephaly  and  encephalocele. 

Course. — Some  subjects  die  during  or  after  birth.  Many  die  in  the  first 
three  years  from  increase  of  brain  pressure  with  coma  or  intercurrent 
disease.  In  some  cases  temporary  remissions,  and  in  still  rarer  instances 
permanent  arrest  of  the  process  occurs,  the  mind  improves,  the  speech 
shows  some  defects  or  the  gait  remains  paretic  and  spastic.  In  very 
exceptional  cases  rupture  externally  is  observed  after  head  trauma  or 
spontaneous  breaking  into  the  ear  or  nose  occurs,  as  in  Lebert's  case, 
which  "leaked"  for  five  years.  Golis  reported  a  case  which  lived  seventy- 
one  years. 

in.  Acquired   Chronic   Hydrocephalus. — Etiology. — The  causes  are 

(a)  stasis,  general  (cardiac  or  pulmonary)  or  local  (tumor  or  sinus  throm- 
bosis); (b)  cachectic  transudation,  as  in  carcinoma  or  nephritis;  and 
(c)  inflammation,  beginning  as  acute  meningitis  of  the  sporadic  or  epi- 
demic type,  or  as  slowly  beginning  chronic  basal  meningitis,  especially 
in  young  children.  The  same  points  of  obstruction  may  exist  as  in  the 
congenital  variety,  (d)  Rickets  is  a  frequent  associate.  Some  forms  may 
be  angioneurotic. 

Symptoms. — Meningitic  symptoms  usher  in  some  cases  in  which 
after  weeks  new  evidences  of  brain  pressure  appear,  as  alteration  in  the 
pulse  and  breathing,  unequal  pupils  or  coma.  Headache,  vomiting, 
visual  disturbance,  spastic  paresis,  epilepsy,  altered  mentality,  idiocy  and 
involvement  of  the  cranial  nerves  are  seen,  as  in  the  chronic  congenital 
form.    The  shape  of  the  head,  however,  is  not  altered. 

Diagnosis. — Differentiation  between  chronic  congenital  and  acquired 
forms  is  very  difficult,  without  an  accurate  history,  (a)  From  rhachitis: 
The  two  aiTections  are  often  associated.  The  rhachitic  head  is  square 
rather  than  globular,  it  protrudes  more  in  front  and  laterally  than 
behind,  the  sutures  are  less  widely  separated,  the  fontanelles  are  wide 
but  do  not  bulge,  and  there  are  no  signs  of  brain  tension.  The  rhachitic 
head  should  be  measured,  because  it  seems  larger  than  it  actually  is. 

(b)  From  brain  tumor:  The  two  conditions  may  be  coincident.  The 
congenital  form  is  the  more  easily  distinguished  by  the  history  and  its 
slower  course,  but  focal  symptoms  are  less  common,  and  spinal  symptoms 
are  more  common  than  in  tumor,  (c)  Hyperostosis  of  the  skull,  brain 
hypertrophy  and  acromegaly  enlarge  the  head,  but  are  separable  by  the 
same  arguments  as  in  rhachitis. 

Treatment. — Few  therapeutic  results  can  be  obtained.  Bandaging  the 
head  is  sometimes  helpful,  but  it  may  aggravate  the  brain  compression. 
Puncture  of  the  lateral  ventricles  dates  from  the  time  of  Hippocrates. 
Isolated  recoveries  are  recorded,  but  the  evacuation  must  be  slow. 
Permanent  drainage  is  usually  fatal.  Attempts  to  effect  anastomosis 
between  the  ventricles  and  the  subdural  space  are  sometimes  successful. 
Lumbar  puncture  in  acquired  forms  may  be  useful,  but  may  cause  death. 


814  DISEASES  OF   THE  CEREBRAL  MENINGES 


DISEASES  OF  THE  CEREBRAL  MENINGES. 

Inflammation  of  the  dura  is  termed  pachymeningitis,  and  inflam- 
mation of  the  arachnoid  and  pia,  leptomeningitis  or  meningitis. 

PACHYMENINGITIS. 

External  pachymeningitis  is  secondary  to  skull  disease,  infections  and 
cerebral  atrophy.  Its  symptoms  are  indefinite,  as  pain,  headache,  possibly 
hemiplegia,  or  are  those  of  the  primary  lesion.  Surgery  in  Macewen's 
22  cases  gave  100  per  cent,  recovery. 

Internal  yachymeningitis  is  divided  into  (a)  the  purulent  form,  which 
follows  bone  disease  or  leptomeningitis;  and  (6)  the  pseudomembranous 
or  serous  type,  seen  chiefly  in  general  paralysis  or  in  children  with  peri- 
splenitis. More  important  is  (c)  'pachymeningitis  hemorrhagica  interna, 
described  by  Heschl  (1855). 

Etiology. — (a)  Fifty  per  cent,  occur  in  persons  over  fifty  years  of  age 
and  40  per  cent,  over  sixty.  (&)  Seventy-seven  per  cent,  of  cases  occur 
in  males,  (c)  Paretic  dementia  causes  19  per  cent.  Pachymeningitis  is 
common  in  other  dementias  and  chronic  psychoses,  whence  its  great 
frequency  in  asylums  and  poor-houses.  It  also  occurs  in  arteriosclerosis 
and  encephalomalacia.  {d)  Chronic  alcoholism,  frequently  with  cardiac 
and  renal  disease,  is  a  frequent  cause,  {e)  Trauma,  as  during  birth, 
from  forceps  delivery  or  from  small  pelvis.  (/)  Hemorrhagic  diathesis 
(scurvy,  hemophilia,  pernicious  anemia),  chronic  nephritis,  {g)  Infective 
diseases,  as  typhoid,  puerperal  fever  (9  per  cent.),  heart  disease  (18  per 
cent.),  hereditary  syphilis  (11  per  cent.),  and  tuberculosis  (23  per  cent.) 
are  also  causes. 

Pathology. — 1.  Gross  Pathology. — The  inner  surface  of  the  dura  is 
cloudy,  yellow  or  brown  from  punctate  hemorrhages  or  hematoidin 
deposits.  In  pronounced  cases  the  dura  shows  membranous  laminae, 
maybe  a  quarter  of  an  inch  thick,  which  are  adherent  by  proliferation  of 
bloodvessels  and  by  organization.  Those  layers  nearest  the  brain  are 
the  most  newly  formed.  Repeated  hemorrhage  into  the  layers  of  the 
newly  formed  tissue  or  between  them  may  be  an  inch  thick  or  reach  the 
size  of  an  egg.  The  free  hemorrhage  may  spread  over  the  entire  surface 
of  the  brain,  even  reaching  the  retina.  Corresponding  to  the  most  fre- 
quent seat  of  pachymeningitis,  the  convexity  of  the  brain  is  compressed, 
especially  over  the  motor  areas  and  bilaterally  in  56  per  cent. 

2.  Minute  Examination.— The  fresh  fibrin  and  the  exudation  contain 
red  cells  and,  nearest  the  brain,  a  covering  of  endothelial  cells.  Later  the 
exuded  fibrin  develops  capillaries,  organizes  and  again  hemorrhage  occurs 
from  the  newly  formed  vessels.  This  organizes  in  turn,  so  that  successive 
laminae  develop. 

3.  Pathogenesis. — lores  proved  that  two  classes  of  cases  exist: 
(a)  The  hemorrhage  is  primary  and  the  simple  clot  organizes  into  firm 
connective  tissue;  this  variety  is  called  regressive  and  occurs  in  cases 
due  to  trauma,  blood  diseases,  infections  and  arteriosclerosis.     (&)   In 


PACHYMENINGITIS  815 

chronic  pachymeningitis  proper,  the  inflammation  is  primary,  the  pro- 
cess is  progressive,  the  connective  tissue  formed  in  layers  is  looser,  more 
vascular,  and  its  inner,  successively  formed  layers  are  the  seat  of  repeated 
hemorrhages. 

Symptoms. — Generally  there  are  no  symptoms,  because  the  hemorrhage 
is  slight  or  overshadowed  by  the  original  disease. 

1.  General  Syiviptoms. — The  most  frequent  is  headache,  which  is  of 
little  differential  value,  diffuse  and  most  marked  in  alcoholics.  There 
may  be  prodromal  delirium,  slow  and  irregular  pulse,  choked  disk, 
moderate  albuminuria  or  some  fever, 

2.  Focal  Signs. — The  most  important  is  hemiplegia,  which  is  pre- 
ceded for  some  time  by  coma  (Fiirstner) .  The  paralysis  is  contralateral, 
rarely  complete,  varies  with  increase  or  decrease  of  the  clot,  often  involves 
the  cortical  facial  and  hypoglossal  centres,  is  sometimes  bilateral  and 
associated  with  aphasia  (33  per  cent.),  hemihypesthesia  (hemiataxia), 
hemiamblyopia,  contractures  in  the  paretic  members  and  Jacksonian 
epilepsy.  Conjugate  deviation  of  the  head  and  eyes,  nystagmus  and 
forced  postures  may  be  observed.  The  patient  may  grasp  at  his  clothes 
or  at  his  hair  or  beard.  The  pupil  contralateral  to  the  lesion  is  usually 
larger;  the  pupils  react  poorly  and  later  both  are  wide.  The  tendon 
reflexes  are  increased,  but  the  skin  reflexes  are  decreased  or  abolished 
during  the  coma.  Basal  nerve  involvement,  trismus  and  rigidity  of  the 
neck  are  uncommon. 

Course  and  Prognosis. — Death  may  occur  in  the  first  seizure  or  the 
symptoms  may  subside  for  months,  possibly  permanently.  Residual 
signs  include  headache,  ataxia,  psychical  alteration,  paresis  and  aphasia. 
Recurrence  is  frequent,  with  stupor,  coma  and  hemiplegia  until  death 
occurs  from  the  fundamental  disease,  hemorrhage  or  intercurrent  affec- 
tions. 

Diagnosis. — A  correct  diagnosis  is  rare.  A  patient  with  paretic 
dementia  may  die  from  a  pseudo-apoplectic  shock  or  pachymeningitis; 
a  nephritic  may  succumb  to  pachymeningitis,  apoplexy,  uremia,  brain 
edema  or  heart  failure.  A  presumptive  diagnosis  can  be  made  from 
the  age,  causal  disease,  preceding  dulness  or  coma,  hemiplegia,  small 
pupils  and  convulsions,  and  recurrences. 

In  pachymeningitis  there  is  more  cortical  irritation  than  in  cerebral 
hemorrhage,  the  coma  and  paralysis  are  more  variable  and  temperature, 
narrow  pupils  and  optic  neuritis  are  more  common.  In  encephalomalacia, 
the  hemiplegia  is  more  often  attended  by  aphasia  and  hemianesthesia, 
and  there  is  less  cerebral  irritation.    Brain  tumor  is  easily  distinguished. 

Treatment. — Treatment  relates  to  prophylaxis  and  the  seizure.  The 
use  of  the  ice-cap,  quiet,  elevation  of  the  head,  application  of  leeches 
back  of  the  ear,  and  possibly  venesection  are  indicated.  Nourishment 
should  be  given  by  rectum.  Morphine  and  chloral  relieve  the  headache, 
excitement  or  convulsions.  Lumbar  puncture  has  not  proved  beneficial. 
Operation  was  first  performed  by  Ceci  in  traumatic  and  Annandale, 
Jaboulai,  Monroe  and  Ballard  in  other  varieties. 


816  DISEASES  OF  THE  CEREBRAL  MENINGES 

MENINGEAL  HEMORRHAGE. 

Etiology  and  Pathology. — (o)  Trauma  may  rupture  the  anterior,  middle 
or  posterior  meningeal  arteries,  with  or  without  fracture  of  the  skull, 
usually  at  the  site  of  trauma,  but  sometimes  by  contre-coup.  The  cor- 
responding veins  may  rupture,  also  the  sinuses  or  the  pial  vessels,  from 
the  latter  of  which  blood  may  percolate  to  the  base  of  the  brain  or  cord. 
The  internal  carotid  may  be  ruptured  and  death  then  occurs.  External 
hemorrhage  results  most  frequently  from  middle  meningeal  rupture. 
The  blood  clot  may  weigh  3  to  17  ounces  or  reach  the  size  of  the  fist, 
compressing  the  brain  and  dislocating  the  falx.  During  birth  (see  In- 
fantile Cerebral  Paralysis)  trauma  may  be  a  factor;  large  sym- 
metrical hemorrhage  of  the  convexity  is  common,  (b)  Arteriosclerosis 
and  rupture  of  cerebral  aneurysms;  (c)  acute  infections,  hemorrhagic 
diathesis,  sinus  thrombosis  and  rarely  heart  and  lung  disease;  (d)  50 
per  cent,  of  cases  occur  under  forty  years  of  age.  Small  clots  may  be 
absorbed  or  microgyria,  porencephalia,  cysts  or  brain  sclerosis  may 
result. 

Symptoms. — Clinical  latency  is  not  rare  in  the  newborn.  Small  hemor- 
rhage in  the  adult  may  produce  no  symptoms.  Very  large  effusions 
result  in  early,  sudden  death.  In  rupture  of  the  middle  meningeal  artery 
there  are  (a)  symptoms  of  brain  pressure  with  those  of  brain  concussion 
or  contusion,  as  loss  of  consciousness,  irritative  symptoms,  increased 
breathing,  slowed  pulse,  pallor,  vomiting  and  fever  of  100°  to  101°.  Either 
death  or  improvement  may  result,  (b)  In  other  cases  improvement  from 
the  concussion  and  contusion  occurs,  but  after  an  interval  of  hours  or 
days,  hemorrhage  occurs  or  recurs,  with  coma,  pressure  symptoms,  mono- 
or  hemiplegia  and  convulsions,  as  in  pach\Tiieningitis.  Rigidity  is  less 
frequent  than  in  meningitis.  Hemorrhage  of  the  sinuses  and  pia  are  said 
to  cause  monoplegia. 

Prognosis  and  Treatment. — Ninety  per  cent,  of  cases  die  from  ex- 
pectant treatment;  33  per  cent,  die  in  twenty-four  hours  and,  when  the 
hemorrhage  is  due  to  aneurysmal  rupture,  30  per  cent,  die  in  ten  hours. 
Early  surgical  treatment  is  indicated. 


ACUTE  SUPPURATIVE  LEPTOMENINGITIS. 

In  1768,  Whytt  noted  the  acute  hydrocephalic  symptoms  of  meningitis, 
but  failed  to  recognize  the  meningitis,  which  Quinn  (1779)  described. 
In  1855  Rilliet  and  Barthez  distinguished  the  suppurative,  secondary, 
tuberculous  and  other  forms. 

Etiology. — Suppurative  meningitis  is  generally  a  secondary  process. 

1.  Trauma. — Microorganisms  from  the  ear  or  nose  may  find  ready 
access  to  the  brain  when  its  resistance  is  lessened  by  trauma. 

2.  Regional  Extension. — {a)  Disease  of  the  middle  ear,  antrum  or 
petrous  bone  may  result  in  suppurative  or  serous  inflammation  (see 
Brain  Abscess).  (6)  Extension  from  the  nose  is  less  common.  The 
disease  may  be  spontaneous  or  operative,  syphilitic,  tuberculous,  menin- 


ACUTE  SUPPURATIVE  LEPTOMENINGITIS  '        817 

gococcic,  neoplastic  or  suppurative,  of  the  nasal  mucosa  or  of  the  eth- 
moidal, sphenoidal  or  antral  cells.  Infection  may  travel  through  the 
bone,  along  the  veins  to  the  dura  or  along  the  olfactory  nerve  endings. 

(c)  From  the  eye,  the  avenues  to  the  brain  are  numerous,  and  yet  disease 
of  the  eye  itself,  even  panophthalmitis  is  less  important  than  orbital 
cellulitis  or  enucleation,  which  exposes  the  sheath  of  the  optic  nerve. 

(d)  Extension  may  result  from  parotitis,  carbuncles  of  the  face,  whose  veins 
communicate  with  the  cavernous  sinus;  scalp  affections;  erysipelas,  etc. 

3.  Metastatic  or  Secondary  Extension. — (a)  SexAicopyemia,  from 
lung  suppuration,  empyema,  arthritis,  endocarditis  and  kindred  affections ; 
(b)  pneumonia  and  rarely  exanthemata  may  produce  it;  in  this  group 
there  is  an  intermediate  link,  as  otitis  media  in  scarlatina  and  empyema 
or  lung  infarct  in  typhoid. 

Bacteriology. — (a)  The  ijneumococcic  is  the  most  frequent  variety, 
being  primary  or  secondary  to  pneiunonia.  (6)  Pyogenic  organisms, 
especially  the  Streptococcus  pyogenes  and  the  Staphylococcus  pyogenes 
aureus;  (c)  the  typhoid,  colon  and  influenza  bacilli,  pneumobacillus,  actino- 
mycomata,  and  many  other  organisms  have  been  found. 

Pathology. — 1.  MacroscopicaUy  a  purulent  exudate  effuses  between 
the  dura  and  leptomeninges  and  in  the  meshes  of  the  arachnoid.  The 
dura  is  tense.  The  leptomeninges  are  reddish,  cloudy  and  often  dotted 
with  punctate  hemorrhages.  The  exudate  is  purulent,  yellow  or  whitish- 
green  and  succulent.  The  infection  spreads  rapidly,  follows  the  peri- 
vascular lymphatics,  as  streaks  of  pus,  imbeds  the  vessels  and  nerves 
in  its  meshes,  obliterates  the  sulci  and  involves  the  brain  and  cord  mem- 
branes. The  brain  is  always  swollen,  springs  out  as  the  membranes 
are  cut,  is  vascular  and  sometimes  locally  anemic  from  compression  by 
the  exudate;  its  surface  is  most  affected  by  small  abscesses,  punctate 
hemorrhages  or  minute  islets  of  encephalitis,  particularly  in  the  meta- 
static form  (convexity  meningitis) :  the  base  is  most  frequently  concerned 
in  ear  disease.  There  may  be  primary  or  secondary  sinus  thrombosis. 
The  ventricular  fluid  is  increased,  cloudy,  purulent  or  sometimes  serous. 
The  apertures  of  the  ventricles  may  be  occluded;  inflammation  may 
be  noted  in  the  velum  interpositum,  choroid  plexus  or  ependyma.  In 
the  spinal  membranes  the  changes  are  similar  and  are  most  marked  over 
the  posterior  part  of  the  dorsal  region.  The  process  is  usually  diffuse. 
On  incising  the  membranes  the  swollen  cord  bulges  out  and  the  same 
changes  are  seen  as  in  the  brain. 

2.  Microscopically  there  are  perivascular  exudation  of  red  and  white 
cells  and  fibrm  formation,  even  in  those  cases  in  which  the  membranes 
appear  normal  to  the  naked  eye.  Exudation  is  most  marked  over  the 
cortex  and  near  the  ventricles,  but  may  also  occur  deeper  in  the  medullary 
substance.  The  ganglionic  cells  show  degeneration.  Analogous  findings 
are  present  in  the  cord,  on  its  surface  or  about  the  central  canal.  In  the 
optic  nerve,  exudation,  hemorrhage  and  edema  are  seen,  possibly  also 
in  other  cranial  and  spinal  nerves.  Various  bacteria  are  found,  as  the 
pyogenic  organisms,  the  pneumococcus  and  the  meningococcus;  patho- 
logically (though  not  bacteriologically),  the  suppurative  and  epidemic 
forms  are_identical. 
52    "" 


818  DISEASES  OF   THE  CEREBRAL  MENINGES 

Symptoms. — Prodromal  phenomena  are  ambiguous;  otitis,  pneumonia 
or  pyemia  may  overshadow  or  totally  obscure  meningeal  manifestations. 
Complete  latency  is  possible,  as  in  a  convalescent  pneumonia  patient, 
who  while  dining,  felt  dizzy  and  died  in  a  few  minutes.  The  autopsy 
revealed  a  massive,  purulent  cerebrospinal  meningitis,  which  had  not 
produced  a  single  sign  or  symptom.  The  onset  may  be  sudden  with  chill 
and  fever.  Headache  is  usually  the  first  and  most  prominent  symptom, 
and  is  often  associated  with  vomiting.  The  sensorium  is  disturbed, 
delirium  is  succeeded  by  stupor  and  finally  by  coma,  in  which  headache 
still  persists.  Convulsions  are  particularly  equivocal  in  children.  Oytic 
neuritis  may  develop  if  the  course  of  the  disease  is  not  too  precipitate. 
Rigidity  of  the  neck  and  spine  is  soon  noted,  as  well  as  hypei-esthesia, 
hyperalgesia  and  muscular  rigidity.  Fever  is  usually  present.  It  is 
usually  higher  than  in  other  t^^pes,  perhaps  104°  to  105°,  and  more  con- 
tinuous. Toward  the  end  it  may  be  107°  or  may  drop  to  subnormal. 
The  pulse  is  faster  and  irregular.  Irritation  and  paralysis' oi  the  cerebral 
nerves  develop  and  are  manifested  by  ocular  paralysis,  pupillary  inequality 
and  tardy  reaction  to  light,  if  the  inflammation  is  basal.  If  the  process 
invade  the  convexity,  cortical  irritation  may  be  manifested  by  Jacksonian 
epilepsy  and  mono-  or  hemiplegia.  Lumbar  puncture  reveals  purulent 
fluid  and  the  organisms  of  suppuration.  Kernig's  sign  is  present.  The 
abdomen  is  often  retracted,  there  may  be  vomiting,  the  urine  is  febrile 
and  frequently  contains  albumin  and  peptone.  The  course  is  generally 
rapid;  it  lasts  a  few  hours  or  more,  usually  two  to  ten  days,  and  almost 
invariably  results  fatally  in  coma.  The  diagnosis,  differentiation  and 
treatment  are  considered  under  Cerebrospinal  Fever. 

SEROUS  MENINGITIS. 

This  is  more  frequently  seen  at  the  bedside  than  at  autopsy.  It 
is  often  tuberculous.  The  membranes  are  glistening,  clear  or  flocculent 
fluid  is  seen  in  the  arachnoid  meshes  and  ventricles,  which  may  be  the 
sole  seat  of  the  disease,  and  the  pia  especially  shows  exudation.  It  is 
often  mistaken  for  edema  of  the  brain.  The  microscope  may  be  necessary 
to  demonstrate  inflammation. 

Symptoms. — No  definite  symptoms  can  be  outlined.  The  disease  is 
too  frequently  diagnosticated.  Headache  is  common;  vomiting,  rigidity, 
fever,  slow  and  labile  pulse,  optic  neuritis,  hyperesthesia,  spasms  and 
paralyses  of  the  cerebral  nerves  are  much  less  frequent  than  in  the 
other  forms  of  meningitis.  The  symptoms  resemble  those  of  brain 
tumor.  Lumbar  puncture  in  some  instances  gives  absolute  relief;  the 
prognosis  is  most  favorable  in  this  type. 

CHRONIC  LEPTOMENINGITIS. 

Etiology. — It  maj^  result  from  (a)  acute  leptomeningitis;  (b)  trauma, 
atrophic  and  sclerosing  brain  diseases,  as  paretic  dementia,  hydrocephalus 
and  softening  and  in  alcoholism,  nephritis  or  plumbism  or  (c)  suppuration, 
syphilis  and  tuberculosis. 


GENERAL  ANATOMICAL  CONSIDERATIONS  819 

Pathology  and  Symptoms. — The  leptomeninges  are  diffusely  or  locally 
dense,  opaque  and  fibrous.  In  the  chronic  suppurative  form  the  pus 
loculi  are  situated  in  a  firm,  fibrous  tissue.  The  symptoms,  if  cortical, 
are  like  those  of  the  chronic  tuberculous  form;  if  basal,  nerve  paralysis 
and  optic  neuritis  are  common.  In  the  chronic  simple  form  (Gee  and 
Barlow)  the  process  may  begin  acutely  and  may  persist,  especially  at 
the  base  and  in  the  posterior  fossa.  Possibly  it  is  a  sequel  of  a  locahzed 
epidemic  or  tuberculous  type.  This  "simple  meningitis  of  children" 
occurs  in  76  per  cent,  in  the  first  year  of  life.  Rigid  neck  is  the  leading 
symptom.  Paralyses,  convulsions  and  rigidity  are  rare.  Fifty  per  cent, 
of  patients  die.  The  alcoholic  form  is  slight,  diffuse  and  cortical;  menin- 
gitic  symptoms  are  obscured  by  alcoholic  disease  of  the  liver,  kidneys, 
heart  or  peripheral  nerves.  Diagnosis  is  difficult,  and  therapy  wholly 
etiological. 


DISEASES  OF  THE  SPINAL  CORD. 

GENERAL  ANATOMICAL,  PHYSIOLOGICAL  AND  SYMPTOMATIC 
CONSIDERATIONS. 

The  nervous  system  is  made  up  of  numerous  similarly  constituted 
units,  called  neurones  (Waldeyer).  Each  neurone  comprises  (a)  a  central 
nerve  cell;  (b)  protoplasmic  processes  or  dendrites  from  the  cell  which 
conduct  (cellulipital)  impulses  to  the  cell;  (c)  an  axis-cylinder  or  axone 
arising  from  the  cell  and  conducting  impulses  (cellulifugal)  from  the 
cell;  and  {d)  the  terminal  ramifications  of  the  axis-cylinder,  known  as 
arborizations.  The  axis-cylinder  often  gives  off  collateral  branches  or 
yaraxones.  The  nutrition  of  the  nerve  cell  probably  depends  upon  the 
integrity  of  its  nucleus,  and  the  nutrition  of  the  cell  governs  that  of  its 
neurone.  Disease  of  the  cell  causes  degeneration  of  the  entire  neurone; 
division  of  a  process  or  axis-cylinder  results  in  its  degeneration  below 
the  point  of  separation  from  the  nutrient  cell.  The  neurones  are  mostly 
independent  of  each  other;  at  times,  especially  in  the  retina,  some  degree 
of  anastomosis  between  the  dendrites  of  different  systems  exists  (Dogiel). 
The  nerve  cells  are  closely  grouped  in  the  gray  cortex,  gray  substance  of 
the  cord  and  ganglia  of  the  peripheral  nerves.  The  axis-cylinders  largely 
course  through  their  white  substance.  To  comprehend  localization  in 
spinal  diseases,  we  must  recognize  that  pathological  processes  are  in 
general  of  two  varieties:  (a)  those  involving  certain  neurones,  or  system 
diseases  and  (b)  those  not  involving  given  neurones,  non-system  diseases. 

The  functions  of  the  cord  are  (1)  conduction  of  motor  impulses  to 
the  muscles;  (2)  conduction  of  sensory  impressions  to  the  brain;  (3) 
certain  reflexes;  (4)  centres  governing  the  bladder,  rectum,  etc.,  and 
(5)  trophic  influences. 

1.  The  motor  tract  is  composed  of  two  sets  of  neurones  or  segments. 
The  upper  segment  has  its  origin  in  the  cells  of  the  motor  cortex  (Fig. 
61,  A),  runs  through  the  corona  radiata,  internal  capsule,  crus,  pons 


820 


DISEASES  OF   THE  SPINAL  CORD 


and  anterior  pyramids  of  the  medulla  (whence  the  name  pyramidal 
tracts),  and  crosses  to  the  opposite  side  (Fig.  61,  5),  running  down  in  the 
lateral  columns  of  the  cord  (C)  and  giving  off  branches  {D,  D)  to  the 
anterior  horns,  where  the  tract  ends  in  fine  terminal  filaments,  which 
surround  the  motor  ganglion  cells  in  the  anterior  horn.  (See  Fig.  56.) 
The  lotver  segment  begins  with  the  motor  cell  in  the  anterior  horn  (E), 
the  dendrites  of  which  connect  with  the  terminal  ramifications  of  the 


Fig.  61." — Illustrating  the  course  of  the  two  motor  neurones:  A,  cortical  cell  of  origin  of 
motor  tract;  B,  decussation  in  medulla;  C,  course  in  lateral  columns  of  cord:  D,  D,  branches 
to  anterior  horns  in  cord;  in  second  (lower)  neurone,  E,  cells  of  anterior  horns,  E",  cells 
in  pons;  F,  nerve  trunks;  G,  motor  end  plates;  H,  muscles. 


axis-cylinder  of  the  upper  segment  hy  contact  (Ramon  y  Cajal)  or  by 
concrescence  (Held);  it  extends  along  its  own  axis-cylinder  into  the 
anterior  nerve  roots  and  nerve  (F),  and  ends  in  terminal  ramifications 
{G,  motor  end  plates)  in  a  muscle,  e.  g.,  of  the  arm  or  leg,  which  is  on  the 
side  opposite  to  the  origin  of  the  cortical  motor  centre.  From  the  cells  of 
both  segments  the  motor  impulse  travels  downward  (cellulifugal  con- 
duction). About  75  per  cent,  of  the  upper  motor  neurones  cross  as 
above  described,  are  called  the  crossed  lyyramidal  tracts  {C.P.T.,  in  Tigs. 


GENERAL  ANATOMICAL   CONSIDERATIONS 


821 


61  and  62)  and  lie  in  the  lateral  columns  of  the  cords;  25  per  cent,  of  the 
motor  fibers  do  not  cross  in  the  medulla,  but  pass  down  in  the  anterior 
columns  of  the  same  side — the  anterior  or  direct  pyramidal  tracts  (D.P.T., 


GANGLION  CELL  OF 

CORTEX.    BEGINNING 

OF  1st  neurone 


TERMINAL  FILAMENTS 
END  OF  FIRST  NEURONE- 


GANGLION  CELL  OF  ANT.   HORN 
BEGINNING  OF  2ND  NEURONE 


-END  OF  2N0  NEURONE 
IN  MUSCLE  PLATES 


Fig.  G2. — Illustrating  the  general  outlines  of  the  upper  and  lower  neurones  and  of  the  direct 
(D.P.T.),  and  crossed  {C.P.T.),  pyramidal  tracts. 


noo-rs 


Fig.  63. — Showing  the  different  tracts  of  the  cord.     (Gowers.) 


822 


DISEASES  OE  THE  SPINAL  CORD 


c  1. 


Dl. 


ID 


in  Figs.  61  and  62).  The  direct  pyramidal  tract  probably  crosses  to  the 
anterior  horn  of  the  opposite  side  by  way  of  the  white  portion  of  the 
commissure  of  the  cord.    The  upper  segment  is  largely  crossed,  but  the 

lower  segment  (or  neurone)  is  a  direct  tract, 
the  cells  in  the  anterior  horns  supplying 
muscles  of  the  same  side  of  the  body. 

The  cord  therefore  contains  parts  of  both 
neurones,  the  course  of  which  has  been  ascer- 
tained by  the  secondary  descending  degneration 
which  follows  neurone  lesions.  Tiirck  first 
fully  described  its  occurrence  and  Flechsig 
and  Bechterew  added  information  from  em- 
bryological  studies.  After  a  lesion,  as  hemor- 
rhage in  the  internal  capsule,  the  fibers  of  the 
upper  neurone  below  the  lesion  degenerate; 
granule-bearing  cells  appear  and  the  axis- 
cylinders  swell,  degenerate  and  stain  poorly 
by  the  Marchi  method,  because  the  axones 
are  separated  from  the  nutrient  cortical  cells. 
The  neuroglia  increases  and  corpora  amylacea 
develop.  Degeneration  is  seen  in  the  opposite 
lateral  pyramidal  tract  and  in  the  anterior 
column  on  the  same  side  as  the  brain  lesion. 
Sometimes  slight  degeneration  occurs  in  the 
lateral  pyramidal  tract  of  the  same  side,  which 
probably  has  some  connection  with  the  anterior 
uncrossed  pyramidal  tract  of  the  same  side 
(see  Broadbent's  theory,  page  770).  Since 
the  vitality  of  the  neurone  fibers  decreases  as 
their  distance  from  their  trophic  cell  increases, 
the  degeneration  is  greatest  in  the  most  per- 
ipheral part  of  the  axone.  The  degeneration 
usually  stops  at  the  end  ramifications  of  the 
axone  (see  page  766  and  Plate  XX). 

Degeneration  in  the  Lower  Segment. — Dis- 
ease of  the  anterior  horns  or  the  nerve  trunk 
causes  degeneration  of  the  nerve  toward  the 
periphery  and  trophic  muscle  changes.   The  re- 
action of  degeneration  is  elicited.  (See  Neuritis.) 
The  two  neurones  do  not   correspond  in 
number,    because  one  neurone  of  the  upper 
segment    is    connected    with    several    lower 
neurones,  i.  e.,  various  cells  in  the  anterior 
horns  at  different  levels  are  probably  excited 
by    a  single  pyramidal  fiber.    For  complex 
movements,  as  of  the  hands,  there  are  more 
Fig.  64.  —  Diagram  from     pyramidal  fibers  than  for  simple  movements, 
Gowers    showing  relation  of     as  of  the  intercostal    muscles.     The  anterior 

vertebral  spines  to  their  bodies  ,  .    .  •  i       r^i 

and  to  the  nerve  roots.  spmal    root    ncrvcs    30m    With    fibers    trom 


9  .. 
10.... 


12.. 


\ 


i 


•12 


s... 


-IS 


PLATE  XX 


B 


A.  Aseending  degeneration  in  the  posteron:iedian  eolun-in  and  anterolateral 

ascending  tracts  from   lumbar  lesion.     (After  Gowers.) 

B.  Ascending  degeneration  after  injury  to  eauda.     (After  Sehultze.) 

C.  Descending  degeneration    of  pyramidal    tracts  from   right-sided  cerebral 

hemorrhage.     (After  Mott.) 


OENMAL  ANATOMICAL  CONSIDERATIONS  §23 

the  posterior  roots,  and  passing  downward,  leave  the  spinal  cord 
between  the  vertebrae,  thus  forming  the  spinal  nerves,  whose  area  of 
origin  in  the  cord  is  called  a  segment.  The  peripheral  nerves  often  arise 
from  several  segments,  which  are  sometimes  considerably  separated; 
muscles  with  siniilar  function  have  similar  spinal  localization,  because 
momments  rather  than  muscles  are  localized  in  the  cord,  as  well  as  in  the 
brain.  The  table  on  page  824  gives  the  localization  of  the  muscles,  with 
special  regard  to  their  cells  (the  beginning  of  the  second  neurone),  as 
well  as  of  the  skin  and  reflexes.  The  cord  is  shorter  than  the  spinal  canal, 
reaching  only  to  the  second  lumbar  vertebra.  The  nerve  roots  descend 
and  therefore  their  level  at  the  point  of  exit  does  not  correspond  with 
their  level  of  origin.     Fig.  64  shows  this  relation. 

2.  The  sensory  tract  conducts  upward  and  is  more  complicated  and 
less  clearly  understood  than  the  motor  tract,  because  the  interpretation 
of  experiments  on  animals  is  confusing.  It  is  composed  of  three  or  more 
neurones.  The  cells  of  the  first  neurone  are  in  the  intervertebral  ganglia, 
whose  cells  end  in  an  axis-cylinder  dividing  into  a  branch  to  the  skin 
and  another  to  the  cord  by  the  posterior  root;  the  branches  from  the 
skin  (peripheral  sensory  nerves)  represent  the  dendrites  of  the  ganglion 
cells  and  the  branch  to  the  cord  represents  the  axis-cylinder.  All  per- 
ipheral sensory  fibers  originate  in  the  ganglia  and  almost  all  fibers  of 
the  posterior  nerve  roots  come  from  these  ganglia.  From  the  posterior 
roots  the  fibers  reach  the  cord,  where  (a)  some  pass  into  the  posterior 
column,  (6)  some  into  the  gray  matter  and  (c)  others  run  to  the  cells 
of  the  anterior  horns  (reflex  arcs) . 

(a)  The  fibers  entering  the  white  substance  (the  ^posterior  columns) 
divide  into  a  short  descending  branch  (probably  concerned  in  reflex 
processes,  giving  off  some  collaterals  and  ending  in  the  gray  matter) 
and  into  a  more  important  long  ascending  branch;  by  the  entrance  of 
new  fibers  at  higher  levels  they  become  more  centrally  located  in  Goll's 
posterior  median  column  in  which  the  lowest  fibers  {e.  g.,  the  sciatic) 
are  most  posterior  and  the  highest  {e.  g.,  the  cervical)  are  most  anterior. 
The  posterior  columns  convey  fibers  for  muscle  sense  (sense  of  posture 
and  movement  association)  and  possibly  also  for  simple  tactile  sensation. 
"Sensations  we  do  not  feel"  travel  in  these  columns  (Gowers).  Goll's 
posterior  median  column  ends  in  the  nucleus  gracilis  of  Goll  (postero- 
median nucleus)  in  the  medulla.  It  is  uncrossed,  i.  e.,  direct.  Burdach's 
posterior  external  column  ends  in  the  nucleus  cuneatus  of  Burdach 
(posterior  external  nucleus)  in  the  medulla.  It  is  likewise  uncrossed 
or  direct.  The  first  neurone  ends  in  these  nuclei.  The  second  neurone 
crosses  above  the  motor  decussation  in  the  medulla  (interior  arcuate 
fibers)  to  the  opposite  side  and  unites  with  fibers  that  have  already  crossed 
in  the  cord,  thus  forming  the  fillet  (see  below,  b).  This  neurone  is  crossed. 
The  posterior  nuclei  communicate  with  the  opposite  cerebral  cortex, 
with  the  cerebellum  of  the  same  and  opposite  side  and  with  the  external 
arcuate  fibers. 

(6)  The  fibers  entering  the  gray  matter  of  the  posterior  horns  also  divide 
into  ascending  and  descending  branches.  Some  lie  at  the  zona  terminalis, 
the  most  posterior  part  (Lissauer's  zone)  of  the  posterior  horn.    All  these 


824 


DISEASES  OF  THE  SPINAL  CORD 


Segment. 


Muscles. 


Skin:  Sensation. 


Reflexes. 


1  Lumbar. 


2  Lumbar. 


3  Lumbar. 


4  Lumbar. 


5  Lumbar. 


1-2  Sacral. 


3-5  Sacral. 


2-3  Cervical. 

4  Cervical. 
.'>  Cervical. 

G  Cervical. 
7  Cervical. 


8  Cervical. 


1  Dorsal. 


2-12  Dorsal. 


Sternocleidomastoid,  trape- 
zius, soaleni,  neck  mus- 
cles. Diaphragm  (3,  4,  5, 
6  cerv.). 

Lev.  ang.  scapulse,  rhom- 
boideus,  supra-  and  infra- 
spinatus, deltoid,  supin- 
ator longus,  biceps. 

Supinator  brevis,  serrat. 
mag.,  clavicular  portion 
of  pectoralis  maj.,  teres 
minor. 

Pronators,  coracobrachi- 
alis,  brachialis  ant.,  tri- 
ceps, long  extensors  of 
hand  and  fingers.  Lower 
neck  muscles  and  middle 
part  trapezius,  6,  7,  8,  C 
and  1  D. 


Costal  portion  of  pectoralis 
maj.,  latissimus  dorsi, 
teres  maj. 

Long  flexors  of  the  hand 
and  fingers. 


Extens,  poll.  long,  et  brev. 
Small  muscles  of  hand. 


Neck  and  occiput. 


Shoulder     (anterior     part, 
Dana). 


Radial  side  of  arm  (volar 
and  dorsal  surfaces)  to 
the  insertion  of  deltoid. 
Post,  surface  of  shoulder? 

Dorsal  and  volar  surfaces  of 
radial  side  of  hand  to  mid- 
line of  middle  finger,  and 
up  to  base  of  hand,  nar- 
row strip  on  volar  and 
dorsal  surfaces  up  to 
axilla,  connecting  with 
above  area. 

Ulnar  part  of  hand  (dorsal 
and  volar)  from  middle 
of  the  fourth  to  middle  of 
third  finger  and  connect- 
ing with  it,  a  moderate 
strip  on  volar  and  dorsal 
surfaces  of  arm. 

Dorsal  and  volar  surfaces  of 
hand  to  middle  of  fourth 
finger,  narrow  strip  on 
dorsal  and  volar  siirfaces 
of  arm  up  to  axilla. 

Narrow  strip  on  ulnar  sur- 
face of  arm  and  forearm 
down  to  base  of  hand. 
(The  upper  part,  perhaps, 
belongs  to  the  second 
dorsal  segment.) 


Muscles  of  back  (also  low-  Chest,  back,  abdomen  and 
est  part  of  trapezius)  and  upper  gluteal  region, 
abdomen.  Intercostals D,  (Umbilicus,  tenth  dorsal; 
1-10.  ensiform,  sixth  to  seventh 

dorsal) . 


Abdominal  muscles,  quad- 
ratus  lumborum.  Ileo- 
psoas. 

Sartorius  (or  third  lumbar), 
flexors  of  hip.  Quadri- 
ceps femoris  (extensors 
of  knee) ,  cremaster. 

Internal  rotators  of  thigh. 


Adductors  of  hip. 
Sartorius  (?). 
Abductors   of   hip. 
Tibialis  anticus. 
Calf  muscles. 

Flexors  of  knee  (?),  gluteals 
(extensors  of  hip). 

External  rotators  of  hip. 
Flexors  of  foot  (?). 
Extensors  of  toes. 
Peronei. 

Flexors  of  foot  and  toes. 
Small  muscles  of  foot. 


Muscles  of  perineum. 


Pubic  area,  anterior  aspect 
of  scrotum. 


Anterior  and  inner  side 
of  hip,  inner  side  of  leg 
to  malleolus,  inner 
side  of  foot,  external 
surface  of  hip,  lumbar 
regions. 

1  Posterior  surface  of  hip, 
I       thigh,   external  surface 
of  leg  and  foot. 


Back  of  foot. 


1  Skin  of  sacrum,  anus,  peri- 
I      neum,     genitalia. 


Sudden  inspiration  by 
sharp  pressure  below  the 
ribs. 

Widening  of  pupil  from 
irritation  of  neck,  4-7 
cervical. 

Scapular  reflex  (fifth  cerv. 
to  first  dorsal).  Tendon 
reflexes  of  this  group  of 
muscles. 

Tendon  reflexes  of  muscles 
named. 


Volar  reflex  of  hand,  peri- 
osteal reflexes  of  radius 
and  ulna.  Tendon  re- 
flexes of  muscles  named. 


Corresponding  tendon  re- 
flexes. 


Tendon  reflexes. 


Abdominal  reflex.  Epi- 
gastric reflex  (according 
to  Dinkier,  is  at  the  ninth 
dorsal,  the  middle  and 
lower  abdominal  at  the 
tenth  and  twelfth,  respec- 
tively) . 


Cremasteric 
lumbar) . 


reflex     (1-3 


Patellar  reflex  (2-4  lum- 
bar). Erection  (lumbar 
cord) .  Uterus  (lumbar 
cord) . 


Gluteal    reflex   (4-5    lum- 
bar) . 


Plantar  reflex;  ejaculation 

(3^  sacral). 
Achilles  tendon  reflex. 

Bladder  and  rectum  reflex. 


The  brackets  to  the  left  concern  only  the  muscles,  and  indicate  the  origin  of  the  muscles  from  several 
nuclei. 


PLATE   XXr 


Selieme  of  Sensory  Conduction.     (Strunipell.) 

A. — Entrance  of  posterior  sensory  roots  into  lumbar  cord:  g.i.,  intervertebral  ganglion; 
r.p.,  posterior  root;  part  of  the  fibers  end  in  the  posterior  horns,  from  whose  cells  other  fibers 
arise  and  enter  the  lateral  columns,  partly  on  the  same  and  partly  on  the  opposite  side ;  other 
fibers  from  the  posterior  roots,  course  upward  in  the  posterior  columns  and  form  in: 

B  (the  cervical  cord). — GoU's  columns  (G) ;  B.C.,  Burdach's  columns. 

C. — Medulla  oblongata,  G  and  B  are  the  nuclei  wherein  Goll's  and  Burdach's  columns  end. 
From  these,  new  fibers  arise  which  decussate  and  form  the  fillet  (lemniscus,  L)  in: 

D. — L,  lemniscus;  Py,  pyramidal  tract;  O,  the  olive;  C.R.,  corpus  restiforme. 

E. — Pons;  IV,  fourth  ventricle. 

F. — L,  lemniscus  of  fillet;  n.r.,  nucleus  ruber;  Py,  pyramidal  tract  in  crus  cerebri;  nL, 
nucleus  lenticularis;  Th,  optic  thalamus  (beginning  of  new  neurone  to  cortex?). 


GENERAL  AX  ATOMIC  AL   CONSIDERATIONS  825 


fibers  end  with  terminal  ramifications  about  ganglion  cells  in  the  gray 
matter;  they  form  the  beginning  of  a  second  neurone  which  crosses  in  the 
commissure  of  the  cord  and  courses  upward  in  the  anterolateral  column 
and  anterior  ground  fibers  of  the  opposite  side  (just  anterior  to  the  lateral 
pyramidal  tracts)  and  they  unite  in  the  medulla  with  the  fibers  of  the 
second  neurone  of  (a)  {v.  s.).  (See  Plate  XXI.  j  The  fibers  entering  the 
posterior  horn  convey  teviperature  and  pain  conduction  and  travel  between 
the  posterior  median  column  and  the  central  canal.  Tactile  sensation 
is  probably  conveyed  in  the  anterolateral  cohmm,  which  conveys  most 
of  the  upward  sensory  impulses,  since  their  division  causes  anesthesia 
(Gowers).  Both  (a)  and  (h)  then  run  in  the  median  lemniscus  of  the 
fillet  and  in  part  of  the  longitudinal  bundles  of  the  formatio  reticularis 
of  the  pons,  tegmentum  of  the  cms  and  posterior  limb  of  the  internal 
capsule,,  beyond  which  some  fibers  run  directly  to  the  motor  cortex  or 
parietal  lobes,  while  others  end  in  the  optic  thalamus,  whence  perhaps 
by  a  third  neurone  to  the  cortex. 

The  sensory  tracts  degenerate  upicard  (ascending  degeneration).  Plate 
XX,  Fig.  A,  shows  degeneration  in  the  posterior  and  anterolateral 
columns.  Most  ascending  degenerations  stop  in  the  medulla.  The 
direct  cerebellar  tract,  which  begins  at  the  first  lumbar  nerve,  also  de- 
generates upward;  most  of  its  fibers  come  from  the  lower  dorsal  and 
first  lumbar  nerves;  some  of  them  come  from  the  gray  substance  of  Clark's 
columns  to  which  collaterals  are  sent  from  the  posterior  fibers;  Flechsig 
believes  that  it  conveys  muscular  impressions  from  the  lower  part  of  the 
trunk  and  the  legs;  its  destination  is  the  middle  lobe  of  the  cerebellum 
by  way  of  the  restiform  body. 

The  spinal  sensory  nerves  descend  lower  than  do  the  corresponding 
motor  nerves  and  skin  sensation  for  a  given  area  is  often  supplied  by 
two,  three  or  more  nerves,  whence  anesthesia  results  only  when  all  of 
them  are  diseased  (Sherrington).     (See  Plate  XXII.) 

Lesions  of  the  conns  meduUaris  down  to  the  fourth  sacral  nerve  pro- 
duce paralysis  of  the  bladder  and  rectum  and  simultaneously  saddle- 
shaped  anesthesia  on  the  anus,  gluteal  region,  perineum,  genitalia, 
imdersurface  of  the  thigh  (pudendal  and  coccygeal  plexuses),  but  the 
scrotum  escapes  because  the  spermatic  plexus  and  external  spermatic 
ner^'e  connect  with  the  lumbar  plexus.  Motor  paralysis  is  absent  because 
the  limbs  receive  their  supply  from  the  lumbar  and  upper  sacral  segments. 
The  cremaster  reflex  is  normal.  If  sexual  desire  and  erection  are  preserved 
with  loss  of  vesical  and  rectal  function,  a  conns  localization  is  probable. 
Sensory  dissociation,  trophic  changes  and  rapid  advance  of  the  disease 
argue  for  conus  disease.  Lesions  of  the  cauda  equina  (where  the  roots  lie 
closely  together)  are  usually  symmetrical.  The  onset  is  insidious  and  the 
progression  slow;  pain  is  prominent  and  usually  the  first  symptom; 
then  the  leg  reflexes  are  lost,  followed  considerably  later  by  paralysis, 
atrophy  and  anesthesia  (especially  in  the  perineum,  ext.  genitalia  and  a 
narrow  zone  about  the  anus).  For  caudal  lesions  speak  remission  and 
improvement  in  the  vesical  and  rectal  functions  and  the  slow  appearance 
of  muscular  wasting,  reaction  of  degeneration  and  trophic  alteration. 
In  its  upper  part,  the  above  symptoms  with  paralysis  of  both  legs  are 


m 


DISEASES  OF   THE  SPIXAL   CORD 


noted;  paraplegia  dolorosa  is  frequent  (see  Plate  XX,  Fig.  B).  A 
lesion  beloAv  the  third  lumbar  vertebra  is  usually  limited  to  the  pudendal 
and  sciatic  distributions. 

3.  In  the  gray  matter  there  are  reflex  centres  enumerated  in  the  table 
above.  The  reflex  arc  comprises  the  aft'erent  sensory  fiber  with  its 
termination  in  the  gray  matter  and  the  motor  nucleus  with  its  efferent 
motor  fiber.  The  fibers  of  the  oculoxmijUlary  reflex  run  by  way  of  the 
sympathetic  nerve  (rami  communicantes)  to  the  cord.  Irritation  of  its 
centre  produces  mydriasis,  especially  in  spinal  caries.  Paralysis  from 
disease  of  the  centre  produces  myosis,  narrowing  of  the  eye  fissure, 
sometimes  retraction  of  the  eye-ball  and  flattening  of  the  cheek;  this 
paralysis  is  produced  by  section  of  the  eighth  cervical  and  first  dorsal 
segments,  i.  e.,  the  same  localization  as  for  paralysis  of  the  forearm  and 


Fig.  65. — Lesion  at  the  level  of  the 
second  lumbar  segment  (StriimpeU  and 
Miilier,  from  whom  also  follomng  figures 
are  borrowed). 


Fig.  66. — Lesion  at  third  lumbar  segment. 


anesthesia  of  the  ulnar  surfaces  of  the  hand  and  arm.  It  occurs  more 
often  in  disease  of  the  nerve  roots  than  of  the  cord  itself.  The  tendon 
reflexes  will  be  considered  under  the  individual  cord  diseases.  They  are 
inhibited  from  the  brain  and  probably  also  from  the  cord.  There  are 
muscular  fibers  to  evacuate  the  bladder  and  rectum  and  sphincters  to 
retain  their  contents.  The  former  are  stimulated  by  distention  and  the 
latter  relax;  they  are  controlled  normally  by  the  will.  If  inhibition  fails, 
the  bladder  or  rectum  is  evacuated,  sometimes  with  the  knowledge  of  the 
patient,  as  in  disease  of  the  p^Tamidal  tracts,  or  unconsciously,  as  in 
coma  or  when  the  sensory  nerves  of  these  parts  are  diseased.  As  to  the 
rectum,  disease  of  the  centre  discloses  itself  by  continuous  evacuation 
and  relaxation  of  the  sphincter  on  digital  examination;  disease  above 
the  centre,  by  normal  tonicity  of  the  sphincter. 


GENERAL  ANATOMICAL  CONSIDERATIONS 


m7 


In  the  above  considerations,  the  leading  points  are  given  regarding 
the  level  of  the  lesion  and  the  course  of  the  chief  systems.  Total  transverse 
disease  of  the  cord  produces  paralysis  of  the  muscles  at  and  below  that 


Fig.  67. — Lesion  at  fifth  lumbar  segment.  Fig.  68. — Lesion  at  first  sacral  segment. 

level,  and  sensory  interruption;  it  might  be  difficult  to  decide  whether 
the  cord  were  affected  through  a  narrow  horizontal  level,  or  whether  all 
the  cord  below  it  were  diseased,  unless  the  reflexes  below  were  noted. 
Hyperesthesia  usually  discloses  the  level  of  the  lesion.     Lesions  of  the 


Fig.  69. — Lesion  at  second  sacral  segment.       Fig.  70. — Lesion  at  third  sacral  segment. 


'pyramidal  tract  (first  neurone)  produce  motor  paralysis  at  the  level  of 
the  lesion,  increased  reflexes  and  spasticity  (hypertonic  muscular  rigidity) 
but  with  no  muscular  atrophy,  reaction  of  degeneration  or  sensory  dis- 


828 


DISEASES  OF   THE  SPIXAL   CORD 


turbance.  Lesions  of  the  anterior  horns  or  anterior  roots  produce  a  flaccid 
paralysis,  atrophy  and  the  reaction  of  degeneration  if  the  process  is 
acute,  flf  it  is  chronic  the  atrophy  is  more  marked  than  the  paralysis 
and  the  reaction  of  degeneration  is  absent  or  atypical.  The  trophic 
cells  are  not  specialized  in  the  horn,  but  all  cells  are  probably  trophic.) 
The  motor  nerve  (Xasse,  1839)  and  the  muscle  degenerate;  the  reflexes 
are  abolished;  the  muscle  tension  (myotatic  irritability)  is  lost,  there  is 
vasomotor  paralysis  (since  the  fine  fibers  of  the  anterior  roots  are  vaso- 
motor) and  contractures  result  (from  sensory  irritation).  If  the  lesion 
is  in  the  anterior  horn  there  may  be  fibrillary  muscular  contractions. 
Irritation  of  the  anterior  horns  may  increase  the  reflexes  and  induce 
contractures.  In  lesions  of  the  posterior  columns  the  chief  alteration  is 
sensory  disturbance,  especially  in  the  muscle  sense,  and  therefore  inco- 


FiG.  71. — Lesion  at'foiirth  sacral  segment. 


ordination  or  ataxia.  The  reflex  arc  may  be  interrupted.  In  lesions 
of  the  posterior  horns  there  are  disturbance  of  the  temperature  and  pain 
sense  and  some  alteration  of  the  tactile  sense;  the  reflexes  may  be  dis- 
turbed. In  lesions  of  the  posterior  roots  the  reflexes  are  disturbed  and 
there  are  anesthesia  and  ataxia.  Irritation  of  these  roots  causes  pain, 
hyperesthesia  in  the  form  of  a  girdle  sensation  around  the  trunk  or  lancin- 
ating pains  in  the  extremities  and  reflex  contractures.  The  importance 
of  the  spinal  ganglion  as  the  trophic  centre  must  be  remembered 
("Waller,  1852).  Vasomotor  fibers  lea^-e  the  cord  through  the  anterior  roots 
by  the  rami  communicantes  and  course  down  in  the  lateral  columns  or 
in  the  intermediolateral  tract  from  the  centre  in  the  medulla.  Most 
of  the  vasoconstrictor  fibers  leave  the  cord  between  the  third  dorsal  and 
second  lumbar  segments,  while  the  vasodilator  fibers  are  much  more 
rliffuselv  scattered  through  the  cord. 


PLATE    XXII 


5d 

6d 


V      7d 


1 2d 


---v: 


5&-/ 


^ 


4H 


5  s 


Hi 


These  figures  have  been  aevised  by  Wichmann  in  order  to  show  the  distribution  of  the  sensory  areas 
corresponding  to  the  segments  of  the  spinal  cord.  The  colors  used  correspond  to  those  of  the  normal  spec- 
trum, red,  orange,  yellow,  green,  blue,  indigo,  and  violet,  with  brown;  respectively — the  first,  second,  third, 
fourth,  etc.,  segments  in  each  portion  of  the  spinal  cord- -cervical,  dorsal,  lumbar,"  and  sacral.  The  last  four 
segments  in  the  dorsal  region  are  left  white.  The  advantage  of  the  plate  is  that  it  shows  very  clearly  the 
overlapping  of  the  segments  that  has  been  demonstrated  by  Sherrington.  The  dark  heavy  black  lines 
on  the  arms  indicate  the  division  between  the  two  sides  of  innervation — that  from  the  upper  portion  of 
the  cervical  enlargement  and  that  from  the  lower  portion.  The  heavy  black  lines  of  the  legs  indicate  the 
clm.sions  between  the  sacral  and  lumbar  areas  of  innervation.  The  figures  and  letters  indicate  the  seg- 
ments m  which  the  supply  has  been  drawn  and  have  been  introduced  for  the  sake  of  making  the  diagram 
more  available  for  ready  reference.  C— cervical,  D— dorsal,  L— lumbar,  and  S— sacral.  The  horizontal 
bands  ot  color  without  dividing  hnes  between  them  indicate  that  both  segments  innervate  the  areas 
involved.      (Musser.) 


DISEASES  OF   THE  SPINAL  MENINGES  829 

DISEASES  OF  THE  SPINAL  MENINGES. 

Most  diseases  of  the  vertebrae  and  cord  affect  the  meninges,  but 
generally,  meningeal  symptoms  excite  little  clinical  interest.  ^ 

I.  Hemorrhage. — (a)  Between  the  vertebrae  and  dura,  hemorrhage  is 
frequent  from  rupture  of  the  subdural  plexus  of  veins.  It  surrounds 
the  nerve  roots  and  is  most  severe  over  the  posterior  cord;  it  results 
mostly  from  trauma  and  to  a  lesser  extent  from  vertebral  disease  or 
aneurysmal  rupture.  (b)  Arachnoid  hemorrhage  (hematorrhachis) 
results  from  the  above  causes,  dystocia,  or  hemorrhagic  diseases.  The 
entire  spinal  canal  may  be  filled  with  blood  from  brain  hemorrhage, 
especially  at  the  base. 

Symptoms. — Small  hemorrhages  cause  no  symptoms  and  meningeal 
apoplexy  may  be  overshadowed  by  brain  or  traumatic  cord  symptoms. 
Pain  in  the  back,  rigidity,  radiating  pains  from  root  compression,  hyper- 
esthesia, painful  reflex  spasms,  motor  weakness,  anesthesia,  sphincter 
disturbance  and  abolition  of  the  tendon  reflexes  are  the  common  symp- 
toms. They  affect  the  lower  more  than  the  upper  cord,  increase  for  a  day 
or  so,  produce  inflammatory  reaction  for  a  few  days  and  subside  in  from 
four  to  eight  weeks.  Physical  signs  vary  with  the  location;  brachial 
paraplegia  is  present  in  cervical,  and  involvement  of  the  legs  in  lumbar 
or  dorsal,  hemorrhage. 

Diagnosis  and  Treatment. — In  diagnosis  the  most  important  symptom 
is  irritation,  while  in  hemorrhage  of  the  cord  (hematomyelia)  paralysis 
prevails  and  pain  is  less  frequent.  In  non-traumatic  cases,  diagnosis  is 
impossible.  The  treatment  is  symptomatic.  Absolute  rest  in  the  lateral 
decubitus  or  on  the  face  should  be  enjoined. 

II.  Pachymeningitis. — (a)  This  may  be  external  (peripachymeningitis) 
and  follows  caries,  penetrating  bed-sores,  deep  cellulitis,  psoas  or  retro- 
pharyngeal abscess.  Its  symptoms  are  those  of  compression.  Root 
symptoms  and  fever  are  frequent.  The  prognosis  is  unfavorable  and  the 
treatment  is  etiological,  expectant  or  surgical.  (6)  Internal  pachymenin- 
gitis hemorrhagica.  Its  causes  are  those  of  the  cerebral  form  (q.  v.). 
(c)  Charcot  (1871)  and  Joffroy  described  a  pachymeningitis  cervicalis 
hypertrophica,  in  which  the  inner  surface  of  the  dura  is  thickened  by 
annular  concentric  fibrous  deposits.  The  dura  adheres  to  the  vertebrae 
and  leptomeninges  and  compresses  the  nerve  roots,  which  indurate. 
Several  cervical  segments  are  involved.  The  process  is  most  marked  on 
the  dorsal  aspect  of  the  cord,  which  is  flattened  anteroposteriorly  and 
shows  peripheral  induration  by  extension  of  the  process  to  it  through  the 
pial  vessels  (meningomyelitis) ;  this  causes  ascending  and  descending 
degeneration.  Cold,  syphilis,  alcoholism  and  trauma  are  probable 
causes. 

Symptoms.— Charcot  described  three  stages:  (a)  the  neuralgic  stage, 
which  corresponds  to  involvement  of  the  posterior  roots,  in  which  pains 
radiate  from  the  neck  into  the  ulnar  and  median  nerve  supply.  They  are 
continuous,  with  paroxysmal  exacerbations,  with  localization  at  times 
in  the  arm-joints,  with  rigidity,  paresthesia  in  the  arms  and  some  motor 
weakness.     (6)  The  second  stage  is  atrophic  paralysis  of  the  arms,  the 


830  DISEASES  OF   THE  SPINAL  CORD 

process  involving  the  anterior  roots.  The  pains  are  replaced  by  atrophy 
and  paralysis  in  the  ulnar  and  median  nerve  areas,  while  the  radial  area 
is  usuallj^  unaffected;  this  produces  flexor  paralysis  in  the  forearms 
^nd  hands,  and  the  claw-hand  {main  en  griff e)  results  from  contracture; 
the  wrist  is  overextended,  the  first  phalanges  are  extended,  the  second 
and  third  are  flexed;  ulnar  and  median  anesthesia  and  the  reaction  of  de- 
generation are  found.  The  shoulder  and  elbow  muscles  may  be  involved. 
Deviations  from  Charcot's  complex  are  at  times  noted,  as  absence  of 
atrophy  and  contracture,  (c)  In  the  third  stage  the  legs  exliibit  sjMstic 
yaralysis  without  atrophy;  the  bladder  and  rectal  functions  and  some- 
times the  sensory  conduction  are  disturbed  from  secondary  changes  in 
the  cord. 

Diagnosis. — The  process  is  easily  localized  to  the  cervical  region. 
jNIarked  pain  also  occurs  in  tumors,  cervical  spondylitis,  syphilitic  meningo- 
myelitis  and  at  times  in  syringomyelia.  Amyotrophic  lateral  sclerosis 
{q.  V.)  and  progressive  spinal  muscular  atrophy  cause  no  such  severe 
pains  and  syringomyelia  (g.  r.)  is  characterized  by  dissociated  anesthesia, 
muscular  atrophy,  painless  felons  and  trophic  changes  in  the  joints. 
Tumors  iq.  r.)  are  difficult  to  differentiate.  Neuritis  causes  symptoms 
limited  to  the  limbs. 

Prognosis. — ^This  is  usually  unfavorable  and  chronic  progression, 
cystitis,  etc.,  usually  develop.    Instances  of  recovery  are  recorded. 

Treatment. — Warm  baths,  counter-irritation,  sedatives,  narcotics, 
mercury,  iodides  and  care  of  the  skin  and  bladder  are  indicated. 


TUMORS  OF  THE  SPINAL  CORD  AND  ITS  MEMBRANES. 

Of  Schlesinger's  400  cases  126  were  intramedullary  and  239  extra- 
medullary  (151  intradural  and  88  extradural). 

I.  Tumors  of  the  Membranes. — These  may  arise  from  the  dura  or 
leptomeninges.  In  Horsley's  extradural  tumors  there  were  sarcoma, 
lipoma,  tubercle,  echinococcus  cysts,  mjTfoma,  fibrochondroma,  car- 
cinoma and  fibrosarcoma.  Cysticercus  often  causes  no  symptoms. 
Intradural  tumors  include  myxoma,  sarcoma,  fibroma,  psammoma, 
tubercle,  parasitic  and  syphilitic  tumors.  Lipomata,  echinococci,  cysti- 
cerci,  neuromata  and  angiomata  are  rarer.  Usually  single,  multiple 
occurrence  may  be  noted  in  sarcomata,  parasitic  tumors  and  neuromata. 
This  group  compresses  the  cord  or  its  nerve  roots.  There  are  edema 
of  the  cord,  flattening,  peripheral  hardening,  central  softening  and 
ascending  and  descending  degenerations.    The  nerve  roots  atrophy. 

Symptoms. — Extradural  gro^i:hs  produce  more  vertebral  than  cord 
symptoms.  The  first  symptoms  are  usually  those  of  compression  of 
the  nerve  roots,  e.  g.,  radiating  pains,  first  on  one  side,  then  on  both, 
which  run  into  the  arms,  trunk  or  legs  and  advance  from  one  root  to 
another;  hyperesthesia;  paresthesia;  anesthesia,  which  is  less  common 
since  it  implies  involvement  of  at  least  three  roots;  atrophic  paralysis; 
rigidity;  and  spontaneous  muscular  contractions.  Local  tenderness  is 
rare.    The  symptoms  recall  those  of  carcinoma  of  the  spine  aside  from  its 


TUMORS  OF   THE  SPINAL  CORD  AND  ITS  MEMBRANES     831 

vertebral  signs.  Later,  evidences  of  compression  of  the  cord  appear,  as 
paresis,  perhaps  of  one  side  first  (Brown-Sequard's  type,  v.  i.)  or  para- 
paresis with  atrophy  if  the  anterior  horn  is  involved  at  that  level,  with 
increased  reflexes  (unless  the  arc  is  broken),  with  spasticity  and  contract- 
ures; and  with  sensory  changes.  As  in  carcinoma  of  the  vertebrae,  the 
paraplegia  dolorosa  of  Cruveilhier  is  common,  as  is  anesthesia  dolorosa 
(the  "eccentric  projection"  or  reference  of  pain  to  the  anesthetic  areas). 
Finally,  there  are  total  paraplegia,  anesthesia  and  bladder  and  rectal 
paralysis. 

n.  Tumors  in  the  Cord  Substance. — They  are  less  common  than 
tumors  in  the  membranes,  and  include  glioma  (cervical  and  upper  dorsal 
regions),  sometimes  gumma,  sarcoma  (pia),  tubercle  (gray  substance  or 
posterior  horn)  and  cysticercus.  Most  are  circumscribed,  though  glioma 
tends  to  vertical  diffusion.  Unlike  meningeal  tumors,  they  are  rarely 
metastatic. 

Symptoms. — In  intramedullary  growths,  root  symptoms  are  absent, 
especially  in  gliomata  and,  since  there  is  gradual  compression  of  the 
cord,  the  clinical  picture  may  resemble  chronic  myelitis  and  syringo- 
myelia. The  cord  symptoms  are  disturbed  conduction;  spastic  para- 
plegia; marked  increase  of  reflexes  (unless  the  arc  is  broken  or  absolute 
cord  compression  develops);  bilateral  symptoms,  or  if  unilateral,  they 
soon  reach  the  other  side;  extensive  muscular  atrophy,  if  the  cervical 
or  lumbar  enlargement  is  diseased,  often  then  with  the  reaction  of  de- 
generation; and  sensory  changes  involving  all  \'arieties  of  sensation  or 
certain  varieties  only,  as  pain  or  temperature  (dissociated  or  partial 
anesthesia).  Bruns  maintains  that  the  lesion  and  symptoms  are  at  first 
unilateral,  followed  by  the  Brown-Sequard  complex  {q.  v.).  As  the  tumor 
grows,  total  paraplegia  and  anesthesia  may,  in  rare  cases,  develop  below 
the  level  of  the  lesion. 

Localization. — Accurate  localization  is  most  important  but  rarely 
possible  until  the  cord  itself  is  compressed.  The  most  common  error 
is  in  locating  the  tumor  too  low.  Atrophic  pajalysis,  in  the  cervical 
or  lumbar  region,  is  the  most  certain  aid.  Sensory  changes  are  less 
reliable;  the  actual  lesion  is  two,  three  or  four  segments  higher  than 
the  anesthesia  because  anesthesia  results  only  from  involvement  of  at 
least  three  roots  (Sherrington's  law).  The  hyperesthesia  usually  repre- 
sents the  level  of  the  lesion  and  local  spinal  tenderness,  though  rare, 
is  very  important.  Finally,  the  spinal  segments  involved  must  be  con- 
sidered in  terms  of  the  corresponding  vertebrse  (v.  s.,  page  822),  (a) 
In  a  tumor  of  the  upper  cervical  cord  there  are  pains  in  the  cervical  plexus 
and  perhaps  anesthesia ;  at  first  there  may  be  a  spinal  hemiplegia  differing 
from  cerebral  hemiplegia  in  that  the  face  and  hypoglossus  escape  and  the 
anesthesia  is  contralateral  to  the  paralysis;  then  there  is  spastic  paralysis 
of  all  four  extremities,  which  rarely  lasts  long,  since  affection  of  the 
phrenic  nerve  causes  early  death.  (6)  In  tumor  of  the  cervical  enlarge- 
ment there  are  atrophy,  flaccid  paralysis  and  pain  in  one  arm,  spastic 
paresis  in  the  leg  of  the  same  side,  anesthesia  of  the  entire  opposite  half 
of  the  body  and  opposite  limbs;  and  then  paralysis  of  both  arms  and 
legs  with  anesthesia,     (c)  Localization  in  the  dorsal  cord  often  produces 


832  DISEASES  OF   THE  SPINAL  CORD 

unilateral  signs,  as  paresis  of  one  leg  with  its  half  of  the  trunk,  and 
anesthesia  of  the  corresponding  parts  of  the  other  side;  spastic  paraplegia 
of  legs  and  abdomen,  retention  of  urine  and  later  incontinence;  and 
then  girdle  pains,  (d)  In  tumors  of  the  lumbar  enlargement  there  are 
unilateral  pains  in  the  lumbar  plexus  and  atrophic  paralysis  in  the 
ileopsoas,  quadriceps  and  adductors;  there  is  total  anesthesia  when  the 
cord  is  involved  in  the  region  of  the  lumbar  plexus ;  later  partial  anesthesia 
(affecting  the  sense  of  temperature  and  pain)  develops  in  the  region  of 
the  sacral  plexus;  still  later  there  is  complete  paralysis  and  anesthesia 
in  the  region  of  the  lumbar  plexus,  with  atrophy,  absence  of  the  patellar 
reflexes,  the  reaction  of  degeneration,  spasticity  of  the  legs  and  feet, 
and  Achilles  clonus,  (e)  If  the  localization  is  in  the  sacral  cord  there  is 
atrophic  paralysis  of  the  leg  and  foot,  posterior  muscles  of  the  thigh, 
gluteal  and  perineal  muscles,  anesthesia,  total  paralysis  of  the  bladder 
and  rectum,  impotence,  loss  of  the  Achilles  reflex  (while  the  patellars 
may  persist),  early  decubitus  and  cystitis.  (/)  If  the  tumor  is  in  the 
Cauda,  the  symptoms  are  usually  bilateral  from  the  beginning;  para- 
plegia is  rarely  as  symmetrical  as  in  cord  lesions;  there  is  the  reaction 
of  degeneration;  pain  is  violent,  since  many  sensory  fibers  are  in  close  con- 
tact; Minor  described  bilateral  and  even  unilateral  sciatica  as  an  early 
symptom.  The  sacral  plexus  is  chiefly  or  first  involved,  while  growths 
of  the  lumbar  enlargement  affect  both  the  sacral  and  lumbar  plexuses. 

Diagnosis. — The  diagnosis  of  meningeal  tumor,  always  difficult,  is 
based  on  (a)  local  pain  and  rigidity,  which  are  especially  marked  in 
the  extradural  type;  (6)  hyperalgesia;  (c)  radiating  pains,  i.  e.,  root 
symptoms  which  later  gradually  give  way  to  (d)  cord  symptoms,  often 
unilateral  at  first  and  then  bilateral,  as  interrupted  sensory  and  motor 
conduction  and  increased  reflexes.  Carcinoma  of  the  vertebrae  produces 
more  pain  on  movement  than  other  tumors.  In  caries  there  is  less  pain, 
local  vertebral  changes  eventually  appear,  and  the  course  is  usually  more 
rapid.  In  myelitis  the  arms  are  less  often  paralyzed;  radiating  pains 
are  much  rarer  than  in  tumor  and  a  girdle  sensation  is  more  common. 
The  local  pain  sometimes  suggests  aneurysm,  lung  disease  or  peripheral 
neuralgias  but  the  tender  points  of  Valleix  are  absent.  Root  symptoms, 
early  interruption  of  cordal  conduction  and  absence  of  trophic  disturb- 
ance in  the  bones  and  of  dissociated  anesthesia  argue  against  syringo- 
myelia. A  diagnosis  of  tuhercidosis  or  syphilis  is  fortified  by  its  presence 
in  other  organs.  In  youth,  tubercle;  at  puberty,  sarcoma  and  glioma; 
in  the  third  and  fourth  decades,  glioma,  tubercle  or  sarcoma;  and  in 
advanced  years  gummata  are  most  frequent.  Diffuse  sarcomatosis  is 
usually  cerebrospinal,  rarely  invades  the  cord  substance,  affects  the 
posterior  cordal  surface  most  frequently  and  generally  in  the  lumbar  and 
lower  dorsal  regions;  it  occurs  largely  in  the  young  and  its  course  is 
rapid.  Tabes  in  one  remarkable  case  was  simulated  by  multiple  tumors 
of  the  posterior  roots.  Tumors  of  the  cord  are  more  diflricult  of  differen- 
tiation, for  root  symptoms  are  often  lacking. 

Course  and  Prognosis. — Slow  development,  progression  either  steady 
or  "by  starts,"  sometimes  remissions  and  eventual  compression  of  the 
roots  or  cord  are  usual,  with  death  from  cvstitis  or  decubitus.    Sudden 


CIRCULATORY  DISTURBANCES  833 

paralysis  is  less  common.  The  average  duration  is  one  to  three  years, 
but  a  longer  course  is  possible  (even  fifteen  years). 

Treatment. — 1.  Thera.peutics. — Narcotics  are  employed  sparingly  in 
the  early  stages,  lest  their  efl^ect  fail  later  if  the  course  is  protracted. 
Syphilis  is  always  a  possible  factor. 

2.  Surgical  Treatment. — Gowers  first,  1887,  localized  a  fibromyxoma 
which  Horsley  removed  successfully.  Tumors  of  the  cord  are  less  favor- 
able than  those  of  the  meninges.  Intramedullary  tumors  may  only  crowd 
the  nerve  paths,  but  in  their  removal  the  attendant  laceration  or  acute 
myelitis  results  in  damage  equal  to  that  of  the  tumor.  Accurate  locali- 
zation is  most  important.  Death  may  result  from  shock,  escape  of  cere- 
brospinal fluid  and  infection.  The  operative  mortality  is  47  per  cent.  In 
Stursberg's  126  cases,  30  per  cent,  recovered. 


CIRCULATORY  DISTURBANCES.     HEMORRHAGE.     TRAUMA  OF 

THE  CORD. 

I.  Anemia  of  the  Spinal  Cord. — Paralyses  referred  to  anemia  of  the 
cord  are  mostly  due  to  neuritis,  hemorrhages  in  the  cord  or  nerve  sheaths, 
and  to  degeneration.  Paralysis  following  profuse  hemorrhage  from  the 
stomach  or  uterus  may  be  properly  referred  to  cord  anemia.  Stenson 
(1667)  demonstrated  experimentally  that  compression  of  the  aorta  pro- 
duced paraplegia  due  to  anemia  of  the  cord,  the  motor  cells  of  which 
appear  to  be  especially  susceptible  to  ischemia. 

II.  Embolism  and  Thrombosis  (Myelomalacia) . — Embolism  of  the  spinal 
arteries  is  extremely  rare,  though  observed  in  endocarditis.  No  separate 
clinical  symptoms  can  be  recognized.  Thrombosis  is  very  rare.  Venous 
thrombosis  is  secondary  to  other  lesions  of  the  cord.  Arterial  thrombosis 
is  rather  more  common;  it  has  been  found  in  syphilis,  multiple  sclerosis, 
senility  and  perhaps  bears  some  relation  to  acute  disseminated  myelitis. 
It  is  often  impossible  to  decide  whether  an  area  of  softening  is  ischertiic 
(myelomalacia)  or  inflammatory  (myelitis). 

III.  Hemorrhage  (Hematomyelia). — Etiology  and  Pathology. — Most 
cases  of  this  rare  lesion  occur  in  men  between  20  and  40  years  of  age. 
Trauma  causes  90  per  cent,  (a)  Capillary  hemorrhages  occur  in  foci 
of  softening,  inflammation,  etc.  {h)  The  larger  hemorrhagic  focus  from 
trauma,  muscular  effort,  caisson-disease,  etc.,  compresses  and  destroys 
the  cord  substance;  it  rarely  exceeds  the  size  of  a  hazel-nut  but  may 
extend  the  entire  length  of  the  cord  (tubal  form  of  Levier),  following 
exactly  the  less  resistant  gray  matter,  while  the  firmer  pyramidal  tracts 
usually  resist  its  lateral  diffusion;  if  it  invades  the  white  matter,  hemor- 
rhage usually  occurs  in  the  posterior  columns;  it  occurs  mostly  in  the 
cervical  cord;  all  large  non-traumatic  hemorrhages  occur  in  the  gray 
matter.  The  nervous  tissue  is  disorganized  by  large  hemorrhages,  which 
result  eventually  in  a  pigmented  apoplectic  scar  or  cyst. 

Symptoms. — (a)  In  the  accessory  form  there  is  bleeding  into  a  tumor, 
cavity,  softening  or  inflammation;  punctate  hemorrhage  may  accompany 
purpura,  stasis  or  convulsive  disorders,  and  few  or  no  symptoms  develop. 
53 


834  DISEASES  OF  THE  SPINAL  CORD 

(b)  The  traumatic  form  is  less  important  in  spinal  fracture  than  concussion 
(see  Trauma);  it  may  develop  during  dystocia  or  fetal  extraction,  (c) 
The  spontaneous  form  is  rarer  than  it  is  in  the  brain,  because  the  cord  is 
firmer,  subject  to  lower  blood-pressure,  and  most  rarely  the  seat  of  miliary 
aneurysm;  it  results  from  sudden  exertion  in  man  (and  more  often  in 
the  horse),  repeatd  coitus  or  rarely  arteriosclerosis. 

The  onset  is  sudden,  without  prodromes  or  loss  of  consciousness. 
Local  symptoms  must  vary  with  the  structures  involved  and  their 
level;  they  embrace  paraplegia,  monoplegia,  the  Brown-Sequard  syn- 
drome, paralysis  with  or  without  atrophy  or  spasticity,  anesthesia  either 
total  or  partial ;  pain  at  the  level  of  the  lesion ;  less  often  eccentric  pain, 
girdle  sensation  and  muscular  rigidity.  In  general  the  reflexes  are  in- 
creased in  small  and  abolished  in  large  hemorrhages.  The  symptoms 
advance  rapidly  and  may  be  aggravated  by  secondary  myelitis.  Late 
death  from  cystitis  or  decubitus  is  more  common  than  early  death. 
Recovery  is  rare  compared  with  cerebral  apoplexy;  it  occurs  most  often 
in  the  punctate  type;  it  is  rarely  absolute. 

Diagnosis. — The  diagnosis  is  usually  only  probable,  based  on  the 
sudden  paresis  and  anesthesia  and  their  rapid  advance.  For  differ- 
entiation from  hematorrhachis,  see  page  829.  From  acute  myelitis, 
differentiation  is  often  uncertain  and  of  only  academic  interest;  in 
myelitis  and  poliomyelitis  elevation  of  temperature  is  distinctive. 

rV.  Caisson  or  Divers'  Paralysis. — According  to  Pol  and  Watelle 
(1854),  this  occurs  in  workers  subject  to  pressure  of  at  least  2,  and  usually 
3  or  4,  atmospheres.  Symptoms  appear  when  the  individual  comes 
suddenly  into  the  open  air.  They  include  transient  pain  in  the  ears, 
sometimes  deafness,  vertigo,  headache  and  pains  in  the  limbs,  joints 
and  epigastrium ;  in  35  per  cent,  there  is  paraparesis  or  paraplegia,  some- 
times with  anesthesia,  and  usually  with  urinary  retention;  much  less 
often  there  is  hemiplegia  or  involvement  of  both  arms;  epistaxis,  mental 
symptoms;  loss  of  consciousness  and  symptoms  of  brain-pressure,  as 
vomiting  or  slowed  pulse.  Symptoms  are  not  severe  or  are  absent  if 
the  interval  of  work  in  the  caisson  does  not  exceed  five  hours. 

Pathology  and  Pathogenesis. — Hoppe-Seyler  (1885)  and  Bert  found 
that  lessened  atmospheric  pressure  liberated  nitrogen  in  the  blood  and 
tissues,  which  ruptured 'the  vessels  and  tissues.  In  the  first  autopsy 
V.  Leyden  found  clots  particularly  in  the  posterior  and  lateral  columns, 
surrounded  by  round  cells  (reactive  disseminated  myelitis) ;  most  changes 
were  in  the  less  compact,  dorsal  cord;  secondary  degeneration  is  found 
and  changes  in  the  gray  substance  from  hemorrhage;  Catsaris  saw 
gas  bubbles  in  the  blood.  Under  moderate  pressure  the  gas  is  given 
off  to  the  lungs,  while  in  extreme  instances  it  is  given  off  to  the  tissues 
(air  embolism). 

Prognosis. — A  few  subjects  die  at  once;  3-16  per  cent,  die  from 
cystitis,  as  in  myelitis;  about  50  per  cent,  recover  completely  and  the 
balance  partially,  with  spastic  paresis. 

Treatment. — The  return  to  normal  atmospheric  pressure  should  be 
made  gradually;  recompression  is  successfully  employed.  Ergot  and 
strvchnine  are  recommended. 


BROWN-SEQUARD'S  PARALYSIS 


835 


V.  Brown-Sequard's  Paralysis. — According  to  Brown-Sequard's  orig- 
inal statement  (1850),  on  the  side  of  section  (cervical  cord)  there  occur 
(a)  paralysis  of  voluntary  motion,  muscle  sensibility  and  vasomotor 
tonus;  (b)  hyperesthesia  of  trunk  and  limbs,  to  touch,  pain,  heat  and 
cold;  (c)  vasomotor  paralysis  of  face  and  eyes  (higher  temperature, 
narrow  pupils  and  contracture  of  certain  facial  muscles).  On  the  contra- 
lateral side  there  is  anesthesia  of  all  varieties  of  sensation,  except  muscle 
sensibility. 


Fig.  72. — Brown-Sequard's  par- 
alysis from  a  left-sided  focus :  a,  vaso- 
motor and  motor  paralysis;  b  and  d, 
cutaneous  anesthesia;  c,  hyperesthe- 
tic  zone.    (Erb.) 


VVS.Wi 


Fig.  73. — (Combined  from  Brown-Sequard.) 
F,  focus  in  left  side  of  cord;  V,  pyramidal  fibers 
having  crossed  in  medulla;  V,  vasomotor  fibers, 
not  crossing  in  cord;  S.M,  fibers  for  muscle  sense, 
not  crossing  in  cord;  iS  S  S' S',  other  sensory 
fibers  crossing  in  the  cord.  The  focus  explains 
the  classical  signs  and  also  how  few  of  the 
crossed  sensory  fibers  to  the  left  side  are  in- 
volved (merely  a  zone  of  anesthesia),  while  all 
sensory  fibers  to  the  right  side  are  severed 
(hemianesthesia) . 


Symptoms. — Exact  hemisection  of  the  cervical  cord  produces  a  spinal 
hemiplegia  on  the  side  of  the  section,  but  in  injuries  and  experiments 
the  trauma  is  rarely  complete  or  strictly  unilateral.  (In  some  cases 
decussation  of  the  uncrossed  pyramidal  tracts  may  occur  in  the  cord 
lower  down  than  the  usual  crossing  point  in  the  medulla  (Flechsig) 
and  spinal  hemiplegia  with  contralateral  monoplegia  may  result  from  uni- 
lateral lesion.)  The  characteristic  clinical  type  is  the  viid-dorsal  lesion, 
but.  in  cervical  section  or  in  pathological  foci,  paresis  of  the  arm  with 
paralysis  of  the  leg  is  more  usual,  because  the  cervical  motor  tracts 


836  DISEASES  OF   THE  SPINAL  CORD 

are  less  compact  than  tliey  are  in  the  lower  cord;  paralysis  of  the  leg 
may  be  incomplete,  while  that  of  the  arm  is  complete,  owing  to  the 
escape  of  fibers  for  the  leg  which  cross  lower  down  in  the  cord.  The 
paralysis  often  decreases  \\^th  surprising  rapidity,  and  if  the  anterior 
cells  are  intact  it  gradually  becomes  simple  weakness.  There  is  an 
inactivity  atrophy  of  the  muscles  without  abolition  of  faradic  irritability 
and  without  reaction  of  degeneration.  Respiration  is  rarely  affected. 
Involvement  of  the  thoracic  and  abdominal  muscles  usually  indicates 
a  bilateral  lesion.  Swelling  and  edema  in  the  paralyzed  members  and 
enlarged  joints  have  been  observed.  The  deep  reflexes  are  exaggerated 
on  the  side  of  lesion;  they  are  abolished  in  a  sudden  total  transverse 
lesion  of  the  lower  cervical  or  upper  dorsal  cord.  The  skin  reflexes  are 
abolished  or  decreased  on  the  side  of  paralysis  and  on  the  opposite 
anesthetic  side  they  may  be  normal,  absent  or  increased. 

Hyperesthesia  occurs  on  the  paralyzed  side  and  also  as  a  zone  above 
the  anesthetic  area,  near  the  level  of  the  lesion.  Hyperesthesia  or  hyper- 
algesia concerns  tactile,  pain  and  heat  and  cold  sensation  and  their 
absence  infers  incomplete  section.  It  usually  disappears  rapidly.  The 
fibers  involved  lie  in  the  lateral  tracts. 

The  zonular  anesthesia  on  the  side  of  the  injury  and  of  motor  paralysis 
is  explained  since  the  lesion  involves  not  only  the  sensory  fibers  (which 
are  ready  to  decussate  to  the  other  side  and  produce  the  crossed  hemi- 
anesthesia), but  also  sensory  fibers  from  the  contralateral  side,  which 
have  just  decussated  to  the  side  of  section.  Abolition  of  muscle  sensation 
on  the  side  of  the  lesion  is  in  accord  with  the  uncrossed  course  of  the 
muscle  sense  fibers  in  Burdach's  column,  entering  Goll's  column  higher 
up.  Muscle  sense  is  preserved  on  the  side  opposite  to  the  lesion.  Vaso- 
motor paralysis  occurs  on  the  side  of  section,  as  the  vasomotor  fibers 
course  in  the  anterolateral  columns.  "  Sensation  is  affected  on  the  opposite 
side,  but  not  quite  up  to  the  level  of  the  lesion,  because  the  decussation 
of  the  sensory  tract  is  not  immediate  but  occurs  somewhat  above  the 
entrance  of  the  nerve"  (Gowers).  Complete  crossed  hemianesthesia 
occurs  in  60  per  cent,  and  partial  anesthesia  (analgesia  and  thermo- 
anesthesia) in  40  per  cent,  of  cases. 

Prognosis, — Almost  complete  restitution  to  normal  is  possible;  it  is 
not  due  to  reestablishment  of  conduction  in  the  severed  tracts,  in  which 
ascending  and  descending  degeneration  occurs,  but  to  assumption  of 
function  by  the  uninjured  side  of  the  cord.  The  prognosis  and  treatment 
of  Brown-Sequard's  paralysis  vary  with  the  etiology  of  this  symptomatic 
syndrome,  which  may  be  s^-philis,  tumor,  sclerosis,  myelitis,  tuberculosis, 
trauma,  hematomyelia,  fracture  or  luxation. 


INFLAMMATION  OF  THE  CORD. 

Myelitis,  inflammation  of  the  cord,  was  described  by  Oliver  and 
Abercrombie  a  century  ago;  the  term  has  been  made  to  cover  many 
affections  not  inflammatory,  as  compression  paralysis.  Oppenheim  .and 
Marie  dispute  the  idea  that  myelitis  is  a  frequent  affection. 


ACUTE  MYELITIS  837 

I.  Acute  Myelitis. — Etiology.- — The  affection  occurs  largely  in  males 
between  ten  and  forty  years  of  age. 

1.  Acute  Infections.- — Experimental  myelitis  has  been  produced  by  the 
B,  pyocyaneus,  B.  diphtherise,  B.  coli,  B.  typhosus,  strepto-  and  staphyl- 
ococci, etc.  It  has  followed  epidemic  meningitis,  variola,  measles, 
rheumatism  and  other  infections,  caused  (a)  by  the  germs  themselves 
or  secondary  infection  (focal  myelitis  resulting)  or  (6)  by  their  toxins 
(disseminated  myelitis  resulting). 

2.  Intoxications. — These  include  poisoning  by  alcohol,  ergot  and  lead 
and  perhaps  auto-intoxications,  as  in  cancer  or  severe  anemia. 

All  other  causes  are  doubtful;  trauma  or  compression  by  caries  or 
cancer  causes  softening  or  hemorrhage,  to  w  hich  infection  may  be  added ; 
exposure  to  cold  and  dampness  reduces  the  physiological  resistance,  thus 
indirectly  favoring  bacterial  localization;  syphilis  (q.  v.)  may  initiate 
meningomyelitis,  but  syphilitic  myelitis  is  usually  ischemic  softening 
from  endarteritis. 

Pathology. — On  macroscopic  examination  we  find  redness  and  swelling; 
on  cross-section,  blurring  of  the  cord  tissues  and  decreased  consistency, 
even  to  fluidity;  "red  softening"  (hemorrhagic  myelitis)  and  in  older 
cases  "yellow  softening"  from  fatty  change,  or  "white  softening." 
After  hardening  in  Miiller's  solution,  the  normal  tissue  appears  green 
and  the  diseased,  yellow.  In  the  ultimate  stages,  atrophy,  cyst  forma- 
tion, induration  and  very  rarely  abscesses  are  found.  Microscopically 
there  are,  in  fresh  cases,  degenerated,  swollen  axis-cylinders;  disintegrating 
medullary  sheaths  from  which  myelin  drops  form;  granule  corpuscles 
(leukocytes  or  vessel  endothelial  cells);  extra vasated  red  and  white 
cells;  turgid  vessels  the  nuclei  of  which  proliferate;  choking  of  the  peri- 
vascular lymph  spaces  with  cells;  degeneration,  blurring  and  vacuole 
formation  of  the  nerve  cells,  the  processes  of  which  shrink  and  the  nuclei 
vanish;  amorphous  deposits  of  coagulated  albumin  in  and  about  the 
cells;  in  some  cases  the  parenchymatous  far  exceeds  the  interstitial 
alteration  (parenchymatous  myelitis,  or  better,  parenchymatous  de- 
generation). The  gray  matter  (poliomyelitis)  is  involved  much  more 
often  than  the  white  (leukomyelitis) .  In  older  cases  there  are  corpora 
amylacea,  empty  spaces  corresponding  to  destroyed  nerve  fibers;  Deiters's 
large  "spider"  cells  with  many  processes;  and  interstitial  proliferation 
is  substituted  for  the  destroyed  tissue.  In  rare  instances  bacteria 
are  found,  but  their  toxins  are  more  important.  The  microscope  differ- 
entiates between  inflammation  and  softening.  The  degree  and  the  extent 
of  inflammation  vary  greatly;  transverse  myelitis  may  destroy  an  entire 
cross-section;  or  disseminated  foci  may  involve  at  random,  various 
structures  at  different  levels.  Meningomyelitis  (perimyelitis,  annular  or 
cortical  myelitis)  chiefly  aiTects  the  periphery  of  the  cord,  whence  con- 
centric invasion  along  the  septa  may  split  up  the  cord  structures,  par- 
ticularly in  the  syphilitic  form.  Poliomyelitis  (inflammation  of  the  gray 
substance)  is  a  type  of  myelitis  classified  by  itself.  Degeneration  and 
inflammation  of  the  motor  and  sensory  roots  may  follow  myelitis  in  the 
cervical  or  lumbar  enlargement. 


838  DISEASES  OF  THE  SPINAL  CORD 

Symptoms. — The  symptoms  vary  with  the  extent,  form  and  local- 
ization. The  localized  form,  limited  to  a  small  segment,  is  called  trans- 
verse, while  the  diffused  form  is  known  as  disseminated  myelitis. 

Acute  transverse  myelitis  is  the  prototype.  The  cord  symptoms  are 
usually  first  in  time  and  always  first  in  importance  and  constitutional 
symptoms,  as  fever,  chills,  malaise  and  in  children  convulsions  sometimes 
precede  but  usually  attend  the  cord  symptoms.  Symptoms  resulting 
from  involvement  of  the  cord  are  (a)  paralysis,  which  is  usually  early, 
rapid  but  not  apoplectic  in  onset  and  is  prominent,  paraplegic,  progressive, 
flaccid  and  complete.  The  flexors  are  usually  weaker  than  the  extensors. 
The  toes  alone  may  be  moved;  twitching  of  the  paretic  muscles  or 
clonic  muscular  spasms  are  sometimes  present.  The  paralysis  is  often 
preceded  for  a  short  time  by  numbness,  or  moderate  darting  pains  in  the 
limbs,  joints  or  back.  The  paralyzed  limbs  show  a  transient  rise  of  tem- 
perature, followed  by  somewhat  subnormal  temperature.  The  limbs  are 
often  dry  and  may  not  sweat  even  after  injection  of  pflocarpin.  (6) 
Sensation  is  frequently  involved.  The  initial  tingling  pain  has  been 
considered.  Anesthesia  may  be  complete  but  more  often  incomplete 
(hypesthesia)  and  rarely  partial.  It  is  higher  anteriorly  than  posteriorly; 
a  zone  of  hyperesthesia  or  "girdle  pain"  marks  the  upper  level,  caused 
by  early  irritation  or  late  cicatrization.  Severe  pain  suggests  vertebral 
or  root  disease  rather  than  myelitis;  gastric  crises  like  those  of  tabes, 
dysesthesia,  i.  e.,  diffuse  vibrating  sensations  over  the  entire  limb  from 
local  stimulation,  and  ataxia  (usually  obscured  by  the  paraplegia)  are 
much  less  common,  (c)  At  the  onset  all  reflexes  may  be  lost,  but  they  are 
usually  increased  below  the  focus,  from  lessening  of  cerebral  inhibition 
(lateral  pyramidal  tracts).  (See  table.)  (d)  The  sphincters  are  affected 
almost  constantly  and  early;  ischuria  or  urinary  retention  and  later 
incontinence  are  usual;  when  the  bladder  is  full  it  may  dribble  from 
relaxation  of  the  sphincter,  known  as  ischuria  paradoxa  or  retention 
with  incontinence;  the  patient  may  or  may  not  be  conscious  of  the 
retention,  depending  on  whether  the  afferent  sensory  fibers  are  involved 
or  not.  The  urine  is  at  first  alkaline  and  later  ammoniacal  on  the  advent 
of  cystitis.  The  sphincter  ani  is  spasmodically  contracted  or  paralyzed 
(see  table);  the  paresis  of  the  bowel  and  abdomen  are  factors  in  con- 
stipation, (e)  Trophic  changes.  Muscular  atrophy  and  the  reaction 
of  degeneration  are  caused  by  disease  in  the  anterior  horns  and  the 
muscles  also  waste  from  inactivity.  The  skin  is  usually  dry,  sometimes 
glossy  or  vesiculated.  The  joints  are  sometimes  swollen  and  the  limbs 
edematous.  Bed-sores  are  frequent  over  the  sacrum,  trochanters,  heels, 
between  or  even  over  the  knees,  from  the  bed-covers;  they  result  from 
neglect  or  in  lumbar  myelitis  from  trophic  disturbance  (disease  in  the 
gray  matter  or  posterior  horns).  The  same  factors  cause  cystitis,  ulcera- 
tion in  the  bladder  or  urethra  and  the  tendency  to  cellulitis. 

Course  and  Prognosis. — The  onset  covers  a  few  hours  (the  apoplectic 
form),  or  several  days  to  a  week  (the  subacute  form).  Four  stages  are 
described:  the  acute  initial  stage;  the  advancing  degeneration;  the  resti- 
tution; and  the  stationary  stage.  Complete  paraplegia  and  anesthesia 
may  persist,  but  more  often  sensation  returns  after  some  weeks,  while 


ACUTE  MYELITIS 


839 


movement  returns  slowly,  incompletely  and  usually  with  some  residual 
spastic  paraplegia.  Contractures  may  develop,  especially  in  the  ad- 
ductors and  knee  flexors,  which  indicates  profound  disease.  Contractures, 
muscular  contractions  and  increased  reflexes  are  caused  by  secondary 

Cord  Symptoms  Gbouped  According  to  Localization. 


In  order  of 
frequency.    , 

Dorsal  myelitis  most 
frequent. 

Then  lumbar  myelitis. 

Lastly,  cervical  myelitis. 

Paralysis. 

Trunk,  back,  intercos- 

Trunk and  arms  nor- 

Neck     muscles,      dia- 

tal    and     abdominal 

mal.   Paraplegia  flac- 

phragm,  arms,  trunk 

muscles         (favoring 

cid  throughout  (ant. 

and    legs    paralyzed. 

mucous  stagnation  in 

horns    involved). 

Typically  but  rarely, 

lungs).  Arms  normal. 

atrophic   flaccid    par- 

Paraplegia, first  flac- 

alysis   of    arms    (ant. 

cid  then  spastic  (lat- 

horns involved),  with 

eral       columns       in- 

flaccid,   later    spastic 

volved)  . 

paralysis  of  legs  (lat. 
columns  involved). 

^trophy. 

In  trunk;     difficult  to 

None  in  arms  or  trunk. 

Atrophy  of  neck  mus- 

elicit.   In  legs;    only 

Atrophy  in  legs  (ant. 

cles     if     high     lesion 

from  inaction. 

horns    involved) . 

(rare) .  Usually  of 
arms  only  (ant.  horns 
involved  at  level  of 
lesion).  In  legs  only 
from  inaction. 

Reaction   of   de- 

Present in  trunk  mus- 

Present in  legs   or  in 

Present  in  arms  (rarely 

generation. 

cles;     absent  in  legs 

mild  cases  quantita- 

in neck). 

(or  only  quantitative 

tive  reduction. 

reduction) . 

Sensation. 

Girdle  pain  and  hyper- 

Pain in  loins  or  legs; 

Pain  and  hyperesthesia 

esthesia,  between  en- 

hyperesthesia           in 

in   arm  nerves   (with 

siform     and     navel. 

loins.     Anesthesia  of 

highest    localization) ; 

Anesthesia     corre- 

of legs. 

anesthesia     in     arms 

sponding  with  motor 

(lower     localization) ; 

paralysis. 

and  the  trunk  and 
legs. 

Reflexes. 

Superficial  reflexes,  ini- 

Lost. 

Superficial  reflexes;  ini- 

tial loss,  rapid  return 

tial  loss,  rapid  return 

and  increase. 

and  increase. 

Deep    reflexes,    initial 

Lost. 

Deep   reflexes;      initial 

loss,  slow  return  and 

loss,  slow  return  and 

increase. 

increase. 

Sphincters. 

Bladder,  initial  reten- 

Incontinence from  be- 

Same as  in  dorsal  mye- 

tion,   later   intermit- 

ginning      (sphincter 

litis. 

tent  overflow   or   in- 

paralysis). 

continence.     Cystitis 

common. 

Bowels;  usually  spasm 

Incontinence    (sphinc- 

Same as  in  dorsal  mye- 

of sphincter  ani;  con- 

ter    paralysis)      dis- 

litis. 

stipation. 

guised,    perhaps,    by 
constipation. 

Trophic  changes, 

Decubitus     from     ne- 

Decubitus, cystitis,  etc., 

As    in    dorsal    lesions. 

etc. 

glect,  etc. 

from     neglect     and 

(Occasionally        very 

trophic    alteration. 

high   temperature.) 

Pupils. 

Klumpke's      paralysis 

Absent. 

Paralysis  of  pupil  (low- 

of pupil  (if  in  upper 

est    cervical    region) . 

dorsal) . 

Optic  neuritis  in  iso- 
lated cases. 

Priapism. 

Often      present      and 
painful. 

None.    Impotence. 

Priapism  often  present. 

Mode  of  death. 

Cystitis,  decubitus. 

Decubitus,  cystitis. 

Medulla  symptoms;  in- 
volvement of  phrenic 

nerve  with  early  death. 

840  DISEASES  OF   THE  SPINAL  CORD 

degeneration.  The  immediate  outlook  is  uncertain  and  depends  (a) 
on  the  etiology,  the  prognosis  being  best  in  acute  infections;  (6)  on  the 
intensity  of  inflammation;  (c)  on  its  transverse  or  vertical  dimensions, 
and  (d)  on  the  rapidity  or  tardiness  of  improvement.  Complete  recovery 
in  circumscribed  forms  is  possible,  since  indirect  symptoms,  due  to 
collateral  edema,  may  disappear.  Death  results  from  extension  to  the 
medulla,  phrenic  nerve  phenomena,  and  sepsis  following  cystitis,  pyelitis 
or  pyelonephritis. 

Diagnosis. — The  early  onset  of  retention  of  urine,  paraplegia  and 
anesthesia,  is  especially  significant  after  acute  infections.  The  upper 
level  of  the  myelitis  corresponds  to  that  of  the  paralysis  or  anesthesia. 
The  lower  level  may  be  determined  by  the  condition  of  the  reflex 
centres.  Anterior  poliomyelitis  (q.  v.)  does  not  involve  sensation  as  it 
rarely  extends  back  of  the  anterior  horns.  In  compression  by  caries  or 
cancer  local  vertebral  and  root  symptoms  usually  precede  cord  symptoms. 
The  so-called  syphilitic  myelitis  (myelomalacia)  begins  acutely  without 
pain  and  is  rarely  relieved  by  antisyphilitic  remedies.  Hemorrhage  in 
the  cord  produces  most  sudden  symptoms  and  acute  spinal  pain  without 
prodromes.  For  differentiation  from  Landry's  paralysis,  see  page  842, 
and  from  multiple  neuritis,  see  page  872.  Meningeal  hemorrhage  and 
meningitis  produce  unmistakable  root  symptoms.  Of  abscess  of  the  cord, 
few  more  than  a  dozen  cases  are  reported;  its  symptoms  are  those  of 
myelitis  plus  meningeal  symptoms.  Hysterical  paraplegia  is  characterized 
by  motiveless  variability  of  the  symptoms,  little  myotatic  irritability, 
little  extensor  spasm  (and  then  both  legs  move  together  when  one  spas- 
modically extended  leg  is  lifted) ;  rarely  by  incontinence  of  urine  or  feces, 
no  trophic  changes,  no  cystitis,  no  reaction  of  degeneration  and  no 
decubitus. 

In  the  chronic  stage  the  diagnosis  is  usually  provisional  and  pachy- 
meningitis, tumor  and  multiple  sclerosis  should  be  considered. 

Treatment. — In  the  acute  stage  the  indications  are  (a)  absolute  rest 
in  bed  for  at  least  two  weeks,  keeping  the  patient  on  one  side  or  on 
the  face.  Blisters  should  be  avoided  lest  they  develop  decubitus,  (b) 
Gowers  recommended  spt.  etheris  nitrosi  with  digitalis  to  equalize  the 
circulation  and  promote  diuresis,  (c)  Mercury  and  iodides  are  usually 
without  effect  in  syphilitic  myelitis  (softening),  although  their  use 
is  rational,  (d)  Care  of  the  skin.  Though  bed-sores  may  be  trophic, 
care  greatly  reduces  their  frequency  and  extension.  Pressure  and  heat 
should  be  avoided  by  change  of  posture,  rubber  cushions,  soft,  thick  pads 
of  cotton  or  the  water  bed.  As  in  typhoid,  the  use  of  two  beds  is  very 
beneficial  and  the  sheets  should  be  stretched  smooth.  Alcohol  rubs  are 
antiseptic  and  harden  the  skin.  Moisture  and  filth  are  most  dangerous; 
the  bowels  should  be  irrigated  if  they  move  involuntarily;  incontinence 
of  urine  is  more  dangerous,  especially  in  women;  hard  urinals,  if  left 
between  the  legs,  may  cause  equal  damage;  the  urine  should  be  gathered 
in  bags  of  oiled  silk  filled  with  cotton;  in  women  mild  antiseptic  gauze 
and  impalpable  boric  acid  should  be  disposed  about  the  genitalia,  (e) 
Cystitis  develops  in  most  cases  in  which  the  catheter  is  used;  residual 
urine  is  easilv  infected,  infection  ascending  the  dribbling,  patent  urethra; 


CHRONIC  MYELITIS  841 

the  urethra  should  be  irrigated  before  the  absolutely  clean  catheter  is 
introduced;  lavage  with  Thiersch's  solution  in  cystitis  with  retention 
or  incontinence  and  grs.  v-x,  each  of  urotropin  and  salol,  t.  i.  d.,  are 
indicated. 

In  the  subacute  stage,  tonics,  massage  after  four  weeks,  mild  faradism 
of  the  bladder  and  rectum  are  indicated.  Contractures  are  modified 
by  warm  baths  and  massage.     Hot  baths  are  dangerous. 

II.  Acute  Multiple  Disseminated  Myelitis. — This  relatively  infrequent 
affection  is  subacute  in  onset;  foci  develop  irregularly,  together  or  succes- 
sively in  different  parts  of  the  cord  or  perhaps  of  the  brain  {disseminated 
encephalomyelitis) ,  with  acute  ataxia,  scanning  speech,  dysarthria,  tremor, 
nystagmus,  optic  neuritis,  spasticity  or  weakness  of  the  limbs.  Sensation 
and  the  sphincters  are  usually  not  affected.  The  clinical  picture  is 
necessarily  irregular,  because  the  inflammation  may  occur  anywhere; 
von  Leyden  distinguishes  the  atactic  and  the  paraplegic  forms.  Myelitis 
which  spreads  after  the  first  two  or  three  days  is  of  the  disseminated 
type;  once  thought  very  fatal,  numbers  of  recoveries  have  been  reported. 
Treatment  is  as  in  the  acute  transverse  variety. 

III.  Chronic  Myelitis. — This  may  be  the  stationary  stage  of  acute 
myelitis  or  in  very  rare  cases  myelitis  may  be  chronic  from  the  beginning, 
i.  e.,  a  gradual  onset  and  slow  progression.  Many  deny  the  existence  of 
this  form  and  classify  it  under  the  paraplegic  stage,  multiple  sclerosis  or 
chronic  system  disease. 

IV.  Subacute  and  Chronic  Poliomyelitis. — Etiology. — Metallic  poisons 
and  syphilis  are  important  factors.  Pathologiccdly,  two  main  types  are 
distinguished ;  in  the  larger  group  there  is  no  inflammation  but  a  primary 
atrophy  of  the  ganglionic  cells,  which  heightens  its  resemblance  to  spinal 
progressive  muscular  atrophy;  in  a  smaller  group  of  cases  there  is  early 
perivascular  exudation  in  the  anterior  horn  and  later  sclerosis,  wherein 
it  resembles  acute  poliomyelitis.  The  anterior  roots  are  involved  and  in 
most  cases  there  is  degeneration  in  both  pyramidal  tracts,  possibl,\'  also 
in  the  posterior  columns  or  roots,  in  Clarke's  columns  or  rarely  in  the 
medulla.  The  course  is  gradual;  one  extremity  becomes  slowly  affected 
(in  one  to  three  years),  sometimes  with  extension  to  others  after  months 
or  years.  There  are  paresis  with  atrophy,  fibrillary  tremors,  partial  or 
complete  reaction  of  degeneration,  decrease  or  absence  of  the  reflexes 
and  normal  sensation.  The  ultimate  outcome  is  unfavorable;  if  recovery 
occurs,  neuritis,  not  poliomyelitis,  is  the  actual  lesion.  Differentiation: 
(a)  Multiple  neuritis  (see  page  872) ;  (&)  from  progressive  spinal  muscidar 
atrophy,  even  an  anatomical  differentiation  is  not  easily  made.  As  a 
rule,  in  progressive  muscular  atrophy,  atrophy  precedes  and  exceeds 
the  muscular  weakness,  fiber  after  fiber  of  muscle  very  slowly  wastes, 
the  atrophy  is  especially  marked  in  the  distal  parts,  and  the  reaction 
of  degeneration  is  less  complete.  In  chronic  poliomyelitis,  an  outright 
atrophy  {atrophie  en  masse)  rapidly  follows  paralysis;  it  occurs  more  often 
in  the  proximal  parts,  as  in  the  shoulder,  and  the  reaction  of  degeneration 
is  marked,  {c)  In  amyotrophic  lateral  sclerosis  the  paralysis  is  spastic 
with  increased  reflexes,  contractures  and  often  with  bulbar  symptoms. 
Treatment  is  that  of  the  chronic  stage  of  acute  poliomyelitis. 


842  DISEASES  OP  THE  SPINAL  CORD 

V.  Landry's  Paralysis. — Acute  ascending  paralysis  was  described  by 
Landry  and  Kussmaul  in  1859.  Cuvier  died  of  this  disease  in  1832. 
Acute  ascending  paralysis  is  a  symptom-complex  rather  than  a  disease 
and  may  be  conveniently  classified  under  inflammatory  affections  of  the 
cord.  The  etiology  is  vague.  The  affection  occurs  mostly  between  twenty 
and  forty  years  of  age  and  three  times  more  frequently  in  males.  It 
has  followed  acute  infections,  as  diphtheria,  typhoid  or  influenza  and 
also  chronic  infections. 

Pathology. — In  many  cases  no  anatomical  findings  existed,  upon  which 
Westphal  (1876)  founded  his  three  criteria :  (i)  that  the  disease  is  a  progres- 
sive, ascending  fatal  affection,  (ii)  with  normal  electrical  reaction  and  (iii) 
negative  findings  at  autopsy.  Recent  cases  have  given  definite  though 
varying  postmortem  results,  as  structureless  exudation  in  the  cord,  dis- 
seminated foci  of  inflammation  in  the  cord,  medulla  and  pons,  changes  in 
the  pyramidal  tracts,  anterior  horns  and  in  the  spinal  or  cerebral  peripheral 
nerves.  Two  forms  are  distinguished :  (a)  the  bulbar  or  medullary  form, 
in  which  sensation  and  electrical  reactions  are  normal,  and  (6)  the 
peripheral  neuritic  form,  with  sensory  and  electrical  alterations.  The 
parenchymatous  swelling  of  the  liver,  spleen,  kidneys  and  lymphatics 
indicates  a  general  infection  or  toxemia.  Bacteriologically,  an  anthrax- 
like bacillus,  the  pneumococcus,  typhoid  bacillus,  bacilli  in  all  the 
peripheral  nerves  and  streptococci  have  been  found. 

Symptoms. — The  onset  is  acute  with  paralysis  in  one  foot,  then  in  the 
other,  and  in  the  legs,  thighs,  abdomen,  back,  arms,  even  in  the  face  or 
the  eyes,  possibly  with  optic  neuritis;  the  paralysis  is  progressive  and 
ascending;  when  the  medulla  is  invaded,  dysarthria,  dysphagia  and 
paralysis  of  the  tongue  occur,  finally  with  death  from  respiratory  par- 
alysis. The  proximal  parts  of  the  limbs  are  more  involved  than  the  distal 
and  some  muscles  may  escape.  Fever  is  usually  absent;  the  sensorium, 
sensation,  sphincters  and  electrical  reaction  are  usually  normal.  There 
are  no  tremors,  no  twitchings,  no  convulsions,  no  contractures,  no  trophic 
disturbance.  The  reflexes  are  usually  decreased  or  absent.  In  rare 
cases  there  may  be  partial  reaction  of  degeneration  (which  usually  has 
no  time  to  develop),  atrophy  and  moderate  disturbance  of  sensation  or 
the  sphincters.  The  paralysis  may  be  of  the  descending  type,  in  which 
event  the  bulbar  development  is  fatal  before  the  paralysis  in  the  legs  is 
well  developed. 

Course  and  Prognosis. — ^The  disease  lasts  two  days  to  two  weeks. 
Bulbar  symptoms  are  ominous,  but  not  necessarily  fatal.  The  central  form 
of  paralysis  is  fatal  and  the  peripheral  form  includes  most  of  the  recov- 
eries. In  rare  cases,  death  may  occur  in  a  few  hours  or  only  after  months. 
In  still  rarer  cases  of  recovery,  some  chronic  paralysis  may  remain.  If 
recovery  ensue,  the  paralysis  regresses  in  an  order  inverse  to  that  of 
development.  A  diagnosis  is  easily  made,  because  of  the  ascending  motor 
paralysis  with  loss  of  reflexes  and  without  marked  mental,  sensory, 
sphincter  or  electrical  alteration. 

Treatment. — The  treatment  is  that  of  myelitis  or  multiple  neuritis. 
Strychnine  and  other  stimulation  are  indicated  if  the  bulbar  symptoms 
are  manifested.  C.  L.  Greene  reports  a  case  which  was  kept  alive  by 
artificial  respiration  forty-one  days  after  respiratory  failure  set  in. 


MULTIPLE  SCLEROSIS  843 


MULTIPLE  SCLEROSIS. 

Insular  or  disseminated  sclerosis,  sclerose  en  ylaqnes  disseminees,  was 
described  pathologically  by  Cruveilhier  and  Carswell  (1838) ;  Frerichs,  in 
1849,  made  the  first  diagnosis,  and  Charcot  (and  Vulpian)  in  1863-64, 
gave  a  description  of  the  typical  case. 

Etiology. — In  fully  50  per  cent,  of  the  cases  no  cause  is  found.  It 
occurs  equally  in  either  sex  and  90  per  cent,  occur  under  the  fortieth 
year;  pseudosclerosis  occurs  after  the  fortieth  year  and  is  considered 
arteriosclerotic.  Three  main  factors  are  thought  to  exist:  (a)  Acute 
iiifections,  as  typhoid,  pneumonia,  measles,  smallpox,  etc.  (b)  Chronic 
intoxications  with  alcohol,  lead,  etc.  (c)  The  developmental  theory 
(Strtimpell) . 

Pathology. — Macroscopically,  the  sclerotic  foci  are  seen  as  irregular 
grayish-red  areas  as  large  as  a  pea  or  walnut;  they  are  multiple  (numbering 
even  over  100),  distributed  at  random  and  largely  in  the  white  substance 
but  also  in  the  gray  matter.  Their  distribution  is  cerebrospinal,  in  rarer 
cases  in  the  cord  alone,  and  most  rarely  in  the  brain  only;  the  cortex  is 
less  frequently  involved  than  the  centrum  ovale,  central  ganglia,  corpus 
callosum  and  the  undersurface  of  the  pons  and  crus.  The  medulla  is 
quite  often,  and  the  cerebellum  rarely,  involved.  The  white  matter  in 
the  cord  is  more  frequently  affected  than  in  the  brain.  On  section, 
the  focus  is  sunken  and  transparent,  well  demarked,  firm,  save  in  the 
freshest  foci,  and  on  hardening  in  Miiller's  solution,  appears  light  green 
while  the  normal  tissue  is  a  darker  green  color.  Microscopically,  the 
medullary  sheaths  in  the  white  substance  are  thinner  or  absent  and  though 
the  axis-cylinders  are  somewhat  wasted  and  at  times  varicose,  their 
remarkable  persistence,  first  noticed  by  Charcot,  causes  the  incomplete 
character  of  the  symptoms  and  the  usual  absence  of  ascending  and  descend- 
ing degenerations.  The  ganglion  cells  suffer  some  slight  atrophy  and 
pigmentation.  The  foci  show  corpora  amylacea,  granule-bearing  cells, 
increase  of  the  fine-meshed  neuroglia  fibrils  and  nuclear  proliferation. 
In  contrast  with  the  system-degenerations,  the  primary  change  is  inter- 
stitial with  secondary  changes  in  the  nervous  tissue.  The  cerebral 
nerves  suffer  often,  especially  the  optic  nerve,  in  which  proliferation  of 
connective  tissue  is  followed  by  loss  of  the  medullary  sheaths,  while  the 
axis-cylinders  are  unaffected.  The  nuclei,  roots  and  nerve  trunks  of 
the  other  cranial  nerves  may  suffer  similar  alteration.  The  spinal  roots 
are  not  infrequently  involved. 

Symptoms. — The  clinical  picture  is  so  variable  that  a  definite  descrip- 
tion cannot  be  made  to  cover  all  cases.  Charcot's  description  included 
the  intention  tremor,  the  nystagmus,  scanning  speech,  motor  weakness 
and  rigidity  and  apoplectic  insults. 

1.  Motor  Symptoms.- — These  are  the  most  important,  (a)  Muscular 
iveahiess  is  very  common.  Paresis  is  more  frequent  than  paralysis, 
since  some  axis-cjdinders  remain  intact.  The  movements  are  slow 
and  fatigue  rapidly  follows  their  repetition,  more  so  in  isolated  than 
synergistic  movements.    The  paresis  is  most  apparent  in  the  legs,  usual 


844  DISEASES  OF   THE  SPINAL  CORD 

in  the  arms  and  frequent  in  the  eyes,  head  and  speech.  It  sometimes 
does  not  develop  until  late,  and  is  associated  with  increased  reflexes 
and  spasticity.  The  gait  is  spastic,  scuffling  and  the  feet  stick  to  the 
ground;  to  this  is  sometimes  added  a  cerebellar,  atactic  or  paretic  ele- 
ment. Muscular  atrophy  is  rare.  The  electrical  reactions  are  practically 
normal,  (b)  Muscular  rigidity,  the  most  frequent  finding,  is  referred  to 
disease  of  the  lateral  columns  and  is  most  developed  in  the  legs.  It 
increases  with  successive  movements,  each  step  becoming  more  stiff  in 
walking.  The  spasticity  may  be  so  extreme  and  the  muscles  so  hard  that 
the  limb  cannot  be  moved.  Contractures  develop,  which  usually  affect 
the  adductors  and  extensors  first  and  the  flexors  later  and  draw  the  heels 
up  to  the  buttocks.  Contractures  often  affect  the  muscles  of  the  neck, 
(c)  Tremor  is  one  of  the  most  striking  phases  of  the  disease,  being  present 
in  75  per  cent,  of  cases.  It  is  caused,  as  is  the  paresis,  by  the  loss  of 
the  medullary  sheaths  which  allows  diffusion  of  nerve  impulses,  by  foci 
in  the  pons  or  thalamus  or  by  lack  of  coordination  between  antagonistic 
muscles.  There  is  no  tremor  during  rest,  but  it  appears  when  voluntary 
efforts  are  attempted  (intention  tremor).  The  hand  carrying  a  glass  of 
water  to  the  mouth  shakes  so  much  that  all  the  water  may  be  spilled  by 
the  rhythmic  tremor,  which  possesses  a  wide  range,  and  occurs  five  or 
six  times  to  the  second.  It  is  apparent  in  the  head  when  the  patient 
sits,  because  the  muscles  of  the  neck  are  in  constant  action  to  support  the 
head;  it  disappears  in  the  recumbent  posture.  Tremor  occurs  in  the 
face,  larynx,  trunk  or  legs  on  changing  posture,  as  rising;  in  the  fingers 
it  produces  handwriting  which  becomes  more  erratic  with  each  word 
written;  and  in  the  thoracic  muscles  it  causes  a  species  of  cog-wheel 
respiration,  {d)  Nystagmus  occurs  in  50  per  cent,  of  cases.  These  short, 
jerking  lateral  movements  of  the  eyes  are  most  common  on  lateral  or 
vertical  movements.  It  is  considered  a  tremor  or  an  incoordination. 
(e)  The  speech  is  scanning  (54  per  cent.),  syllabic  or  staccato;  it  is  slow, 
monotonous,  unmodulated  and  sometimes  explosive,  especially  for  the 
letters  c,  p,  g  and  d.  The  speech  muscles  fatigue  easily  and  the  end 
of  a  sentence  is  often  elided;  the  sounds  are  often  nasal,  interrupted  by 
yawning  inspiration  or  expiration.  The  cause  of  the  peculiar  speech 
may  be  tremor  or  ataxia  from  foci  in  the  pons  or  medulla.  (/)  Paresis 
of  the  eye  muscles  (in  17  per  cent.)  affects  the  third  or  sixth  nerve,  con- 
vergence or  associated  movements.  About  50  per  cent,  are  nuclear. 
Transient  diplopia,  unequal  pupils,  hippus  and  strabismus  are  less 
common,  (g)  Apoplectiform  seizures  (in  1  per  cent.)  are  marked  by 
partial  coma,  increased  pulse,  high  fever,  aphasia  and  hemiplegia,  which 
is  usually  fugitive  and  flaccid.  In  most  cases  negative  pathological 
findings  exist,  but  Leube  and  Leyden  refer  them  to  acute  encephalo- 
myelitis. Though  usually  hemiplegic,  they  may  exceptionally  produce 
paraplegia,  hemianesthesia  or  ataxia,  or  monoplegia. 

2.  Sensory  Symptoms. — Marked  aberrations  are  less  frequent  (30  per 
cent.)  because  the  sensory  fibers  are  more  resistant  to  disease.  Sub- 
jectively, dull  pains,  formication  and  paroxysmal  headache  are  frequent; 
lightning  pains,  crises,  girdle  sensation,  trigeminal  neuralgia,  palpitation 
and  dyspnea  are  very  uncommon.    Objectively,  any  species  of  sensation 


MULTIPLE  SCLEROSIS  845 

may  be  involved.  Ataxia  referable  to  disease  of  the  posterior  columns 
or  higher  sensory  tracts  is  marked  in  50  per  cent,  and  may  produce  a 
t^^pical  tumbling  cerebellar  gait. 

3.  Special  Senses. — The  optic  nerve  is  affected  in  45  per  cent., 
usually  as  a  pallid  'partial  atrophy  involving  its  temporal  side,  and  less 
often  as  neuritis  or  atrophy  with  total  blindness.  The  change  is  more 
conspicuous  pathologically  than  clinically.  It  may  be  the  first  sign 
of  the  disease.  In  60  per  cent,  of  cases  there  is  central  scotoma,  and  at 
times  narrowing  of  the  field  of  vision. 

4.  Psychical  Sy:\iptoms. — Mental  impairment  is  common;  the  patient 
is  complacent  and  the  memory  is  weak.  Compulsory  laughing  and 
weeping,  partly  without  motive  and  partly  emotional,  probably  should 
be  referred  to  lesions  in  the  medulla,  pons  or  crus. 

5.  Bulbar  Syjmptoms. — These  may,  in  rare  cases,  resemble  the  symp- 
toms of  bulbar  palsy,   as   dysphagia,   anarthria  and  tongue  atrophy. 

6.  Reflexes. — The  patellars  are  exaggerated,  there  are  ankle-clonus 
and  Babinski's  sign,  showing  disease  of  the  pyramidal  tracts.  The 
abdominal  reflexes  are  absent  in  70  per  cent,  of  cases. 

7.  Sphincters. — Lasting  or  severe  symptoms  in  the  bladder  or 
rectum  are  uncommon;  the  bladder  is  often  hypertonic  and  irritation 
is  frequent. 

8.  Trophic  Sy^viptoms. — These  are  rare;  they  consist  of  skin  eruptions, 
edema,  sweating,  chronic  arthritis  and  erythromelalgia. 

Course  and  Prognosis. — The  onset  is  usually  gradual;  in  most  cases 
weakness  in  the  legs  appears  first  and  for  a  long  time  is  hard  to  interpret; 
it  occurs  without  pronounced  sensory  symptoms,  bladder  disorder  or 
atrophy.  Sometimes  the  onset  is  acute,  with  loss  of  consciousness,  trans- 
ient hemiplegia,  vertigo,  headache,  eye  symptoms,  vomiting  and  optic 
neuritis.  Leg  paralysis  is  followed  by  scanning  speech,  nystagmus  and 
tremor.  The  symptoms  remit  and  recur.  Bramwell  found  that  death 
occurred  in  less  than  five  years  in  29  per  cent.,  in  less  than  ten  years  in 
66  per  cent.,  and  in  less  than  fifteen  years  in  89  per  cent.  The  terminal 
stage  presents  dementia,  decubitus,  sphincter  paralysis,  cystitis  and 
septicopyemia. 

Diagnosis. — The  typical  case  is  unmistakable,  because  of  the  cardinal 
symptoms:  intention  tremor;  spastic  paresis;  nystagmus;  scanning 
speech;  ataxia;  increased  reflexes;  optic  atrophy:  the  slow,  uneven 
course  with  remissions  and  recurrences;  the  variability  of  the  symp- 
toms; apoplectic  insults;  and  moderate  involvement  of  the  mentality, 
sensation,  bladder  and  rectum. 

Differentiation. — Transient  hemiplegia  may  suggest  hemorrhage, 
syphilitic  thrombosis,  embolism,  paretic  dementia  or  tumor  {q.  v.). 
In  paralysis  agitans  the  fine  tremor  of  the  hands  and  fingers  (not  of  the 
large  joints,  and  much  less  of  the  head)  which  is  not  increased  by  move- 
ment, its  persistence  during  rest,  the  mask-like  facies,  festinating  speech, 
peculiar  attitude,  gait,  propulsion,  retropulsion,  muscular  rigidity  with- 
out increased  reflexes  and  the  advanced  age  are  clear  and  characteristic 
points. 


846  DISEASES  OF   THE  SPINAL  CORh 

Multiple  Sclerosis. vs. Syphilis. 

Occurs  in  the  medullary  substance.  Meningomyelitis  and  root  symptoms. 

A  focal  disease.  Diffuse. 

Nystagmus,  scanning  speech,  tremor.  More'  frequent    insults,    hemiplegia,    etc.; 

speech  may  be  slow  in  pons  lesions  but  is 

not  scanning. 
Partial  optic  atrophy  occurs.  Amaurosis,  choked  disk  or  neuritis  frequent. 

Mydriasis  1  per  cent.,  myosis  4  per  cent.       Mydriasis  is  very   common. 
Argyll- Robertson  pupil  very  rare.  Argyll-Robertson  pupil  frequent. 

Hysteria  more  than  any  other  disease  simulates  early  multiple  sclerosis; 
the  two  affections  often  occur  together  and  in  both  the  symptoms  are 
changeable.  In  hysteria  sensory  symptoms  are  much  more  prominent, 
there  are  often  limitation  of  the  visual  fields,  monocular  diplopia,  con- 
tractures and  convulsions,  but  there  is  no  optic  atrophy,  nystagmus, 
scanning  speech,  or  intention  tremor.  The  movements  in  hysteria  are 
often  accompanied  by  contraction  of  the  antagonist  muscles,  a  most 
valuable  diagnostic  aid.  In  extremely  rare  cases,  described  first  by 
Westphal  as  pseudosclerosis,  the  autopsy  shows  nothing;  the  tremor 
affects  the  arms  chiefly;  there  is  no  ataxia  or  nystagmus;  the  facies  is 
somewhat  rigid  and  outbursts  of  anger  are  frequent;  syphilis  is  a  possible 
cause.  Birth  palsies  accompanied  by  jerky  movements,  incoordination 
and  even  scanning  speech  are  excluded  by  the  history. 

Treatment. — Drugs,  hydro-  and  electrotherapeutic  measures  are  futile. 
The  patient  should  live  in  a  warm  climate  during  the  winter  months. 

SYRINGOMYELIA. 

The  term  refers  to  cavities  in  the  cord,  and  was  first  employed  by 
Ollivier  (1824).  The  affection  was  first  described  by  Morgagni. 
Syringomyelia  must  be  distinguished  from  hydromyelus,  which  is  a 
dilatation  of  the  central  canal  due  to  developmental  anomalies;  it  is 
usually  an  accidental  finding  at  necropsy,  or  if  symptoms  are  present 
they  are  those  of  syringomyelia. 

Etiology. — Sixty-three  per  cent,  of  cases  occur  between  the  tenth  and 
thirtieth  years  and  70  per  cent,  in  males. 

Pathology. — 1.  Gross  Pathology. — The  cord  is  often  lax,  sometimes 
fluctuating  or  flat.  The  cavity  is  usually  localized  but  may  extend  from 
the  medulla  to  the  filum  terminale;  it  is  most  often  found  in  the  lower 
cervical  or  upper  dorsal  region;  in  size  it  ranges  from  a  narrow  slit  to  a 
cavity  as  wide  as  the  cord  itself;  it  may  communicate  with  the  central 
canal,  may  be  multilocular  and  diverticula  may  be  found.  Its  wall 
is  smooth,  sometimes  pigmented  from  rupture  of  the  new-formed  blood- 
vessels. The  cord  usually  suffers  sclerosis  in  the  form  of  tumor-like, 
asymmetrical  neurogliar  proliferations,  which  later  break  down  and  form 
secondary  cavities.  The  posterior  horns  and  columns  are  often  affected, 
the  anterior  horns  and  columns  less  frequently  and  the  lateral  columns 
very  rarely. 

2.  Minute  Pathology. — The  essential  finding  is  the  neurogliar  hyper- 
plasia, probably  due  to  some  congenital  anomaly,  which  also  explains 
its  frequent  association  with  hydromyelus;  the  overgrowth  is  rich  in 


SYRINGOMYELIA  847 

fibers,  whereas  the  ordinary  ghoma  (gUomatosis)  especially  abounds 
in  cells;  syringomyelia  and  gliomatosis  may  coexist.  This  proliferation 
contains  large,  sharply  nucleated  cells,  and  a  few  epithelial  cells,  is  firm  as 
a  whole,  but  somewhat  softer  toward  the  posterior  horns,  is  often  hyaline 
nearest  the  cavity  from  compression  and  abounds  in  bloodvessels.  The 
cavity  is  usually  lined  with  cylindrical  epithelium  like  that  of  the  central 
canal;  its  contents  resemble  cerebrospinal  fluid,  but  is  occasionally 
blood  tinged  or  less  often  gelatinous,  mucoid  or  milky.  The  nerve  fibers 
are  not  much  involved.  Secondary  degeneration  may  occur  in  the 
posterior  and  less  frequently  in  the  lateral  columns. 
Symptoms. — There  are  three  cardinal  symptoms. 

1.  Anesthesia.' — Partial  or  dissociated  anesthesia  occurs  in  the  typical 
case,  in  which  the  sensation  of  touch,  pressure  and  locality  is  preserved 
while  heat,  cold  and  pain  are  not  recognized.  Thermo-anesthesia  usually 
concerns  perception  of  both  heat  and  cold,  sometimes  of  only  one  of  them, 
or  one  in  one  place  and  the  other  in  another;  analgesia  is  frequently 
preceded  by  hyperalgesia;  it  usually  corresponds  with  the  thermo- 
anesthesia. Thermo-anesthesia  and  analgesia  begin  in  the  hands  and 
fingers  and  are  later  found  on  the  upper  trunk;  sometimes  the  entire 
trunk,  legs,  mucous  membranes  and  face  may  be  affected,  depending 
on  the  location  of  the  cavity.  The  patient  may  suffer  burns  or  injuries 
in  these  parts  without  pain.  Dissociated  anesthesia  is  most  probably 
caused  by  disturbed  conduction  in  the  gray  substance  due  to  neurogliar 
proliferation  and  cavity  formation.  Anesthesia  may  involve  all  varieties 
of  sensation.  Subjective  sensory  disturbances  include  paresthesia  and 
burning,  tabes-like  pain  in  the  neck,  arms  or  trunk  and  sometimes  in  the 
joints,  spine  or  legs. 

2.  Muscular  Atrophy. — ^Muscular  atrophy  is  due  to  involvement 
of  the  anterior  horn  and  affects  the  arms  mostly,  because  the  disease 
is  largely  in  the  lower  cervical  and  upper  dorsal  cord.  It  is  slow  in 
onset,  more  marked  than  the  attendant  flaccid  paresis,  degenerative 
and  often  observed  with  fibrillary  muscular  contractions  and  increased 
myotatic  irritability.  It  usually  involves  the  small  muscles  of  the  hand, 
as  the  interossei,  produces  flattening  of  the  thenar  and  hypothenar 
eminences  and  the  claw-like  hand,  as  seen  in  the  Duchenne-Aran  type. 
The  radial  supply  is  first  aftected,  then  the  ulnar  and  median.  Some- 
times the  scapulohumeral  type  is  observed,  especially  with  bulbar  symp- 
toms. The  muscles  of  the  trunk,  and  much  less  often  of  the  legs,  may  be 
affected.  From  cervical  compression  of  the  pyramidal  tracts,  paraplegia 
results,  with  increased  reflexes  and  spasticity,  in  12  per  cent,  of  cases. 
Other  motor  symptoms  occasionally  occur,  as  tremor,  contractures, 
spasms,  opisthotonos  or  choreiform  movements.  The  gait  is  normal, 
spastic  or  paretic. 

3.  Trophic  Symptoms. — (a)  Phlegmons  and  felons  develop,  particularly 
on  the  fingers.  They  are  painless,  chronic,  often  recurrent  and  lead  to 
necrosis  of  the  bone,  ankylosis,  deformity  or  mutilation,  (b)  The  joints 
suffer  in  over  10  per  cent.,  especially  in  males  (75  per  cent.),  probably 
due  to  loss  of  articular  sensation  (whereby  the  joints  are  used  inappro- 
priately) or  to  lack  of  the  nutritional  reflex.    These  arthropathies  are  of 


848  DISEASES  OF   THE  SPINAL  CORD 

the  hypertrophic  form,  with  thickening  and  bony  formation,  like  arthritis 
deformans',  or  of  the  atrophic  form  with  relaxation  of  ligaments  or  flail 
joint.  There  is  little  exudation,  no  fever,  no  pain.  They  are  similar  to 
the  tabetic  joints  but  are  more  chronic  and  more  often  involve  the  upper 
extremities  (shoulder  32  per  cent.,  elbow  28,  hand  16,  hip  8,  ankle  8, 
knee  6  per  cent.),  (c)  Painless  hone  necroses  and  spontaneous  fractures 
may  occur  late  in  the  disease.  Moderate  scoliosis,  usually  confined  to 
the  dorsal  spine,  sometimes  with  kyphosis,  is  due  to  trophic  vertebral 
changes  or  atrophy  of  the  back  muscles;  perforating  ulcer,  thick,  friable 
nails  and  clubbed  fingers  are  less  common.  Morvan  (1883)  described 
a  paresie  analgesique  avec  panaris,  endemic  in  Brittany,  which  is  clearly 
syringomyelia.  "Morvan's  disease"  is  marked  by  trophic  disorders, 
excessive  or  deficient  secretion  of  sweat,  edema  on  the  dorsum  of  the 
hands,  erythema,  urticaria,  local  asphyxia  and  herpes  zoster. 

4.  Othee  Symptoms. — (a)  The  skin  reflexes  are  usually  normal;  the 
abdominal,  cremasteric  and  plantar  reflexes  are  sometimes  increased; 
the  tendon  jerks  are  often  decreased  in  the  upper  and  increased  in  the 
lower  extremities.  (6)  The  sphincters  are  involved  late  in  the  disease. 
Retention  of  urine  and  constipation  are  more  frequent  than  incontinence. 
(c)  Bulbar  or  pontine  symptoms  are  not  infrequent,  are  usually  unilateral 
and  appear  in  the  later  stages.  They  include  facial  hemiatrophy  or 
paresis,  paresis  of  the  tongue  with  atrophy,  dysphagia,  paresis  of  the 
palate  (nasal  speech),  paralysis  of  the  vocal  cords,  spinal  accessory  nerve 
(trapezius  paralysis)  and  trigeminus  (sensory  symptoms),  eye  paralyses 
(abducens),  unequal  pupils,  nystagmus,  tinnitus,  salivation,  apoplecti- 
form attacks,  polyuria,  glycosuria  and  vagus  symptoms  (disturbed  pulse 
or  respiration,  vomiting,  and  singultus). 

Diagnosis. — A  positive  diagnosis  can  be  made  from  the  three  cardinal 
symptoms:  (1)  the  dissociated  anesthesia  (thermo-anesthesia  and  anal- 
gesia with  practically  normal  tactile  sensation)  is  the  earliest  and  most 
constant  sign.  Grasset  collected  cases  of  twenty  or  more  nervous  dis- 
eases (functional,  traumatic,  neoplastic,  specific)  in  which  this  sensory 
dissociation  has  been  found;  but  it  remains  highly  distinctive  in  con- 
junction with  (2)  muscular  atrophy  of  the  upper  extremities  with  paresis 
and  (3)  trophic  disorders,  e.g.,  felons,  arthropathies  and  scoliosis;  to  which 
may  be  added  the  spastic  paresis  of  the  legs  and  bladder  symptoms. 

Differentiation. — Progressive  spinal  muscular  atrophy  and  amyotrophic 
lateral  sclerosis  present  no  anesthesia,  no  trophic  disturbance  and  bulbar 
symptoms  are  bilateral.  Juvenile  muscular  dystrophy  may  be  simulated 
in  the  scapulohumeral  type  of  syringomyelia.  In  peripheral  neuritis  all 
varieties  of  sensation  are  disturbed;  the  paralysis  is  peripheral,  not 
spinal  or  segmental,  and  there  is  the  reaction  of  degeneration;  neuritis 
of  the  upper  brachial  plexus  produces  paralysis  of  the  shoulder,  arm  and 
supinator  longus,  a  combination  not  found  in  syringomyelia.  Focal 
disease  of  the  anterior  and  posterior  gray  substance,  as  multiple  sclerosis, 
hemorrhage  or  myelitis  may  simulate  syringomyelia,  but  their  course 
is  less  chronic  and  there  is  less  trophic  disorder.  The  root  irritation 
of  tumor  of  the  cord  is  lacking.  Located  in  the  dorsolumbar  region, 
syringomyelia  may  closely  simulate  tahes,  from  the  lancinating  pains, 


SYSTEM  DISEASES  '      849 

crises  and  ataxia,  but  the  Argyll-Robertson  pupil  is  lacking  and  the 
sensory  impairment  is  typical.  In  leprosy,  anesthesia  is  peripheral,  not 
spinal,  in  type;  the  Henssen  bacillus  is  often  found. 

Course  and  Prognosis. — ^The  course  is  progressive  for  years  or  decades. 
When  recognized,  the  affection  is  hopelessly  advanced.  Death  occurs 
from  cystitis,  septicemia  and  bulbar  complications. 

Treatment. — Treatment  is  unavailing.  The  danger  of  self-injury,  as  a 
result  of  the  peculiar  anesthesia,  should  be  borne  in  mind. 


SYSTEM  DISEASES. 

This  small  group  of  very  important  diseases  involves  structures  or 
systems  having  a  common  function,  thus  differing  from  haphazard  disease, 
as  myehtis  or  multiple  sclerosis.  A  primary  slow  degeneration  of  the 
nerve  elements  is  followed  by  secondary  proliferation  of  connective  tissue. 
In  the  obscure  pathogenesis  of  these  degenerations  hereditary  weakness 
causing  nutritional  failure  at  a  certain  age  (familial  form)  and  the 
selective  action  of  toxemia  on  certain  nervous  structures  have  been 
thought  causative. 

I.  System  Disease  of  the  Sensory  Tract. 

The  sensory  type  is  locomotor  ataxia  in  which  the  peripheral  sensory 
neurone  is  affected,  in  the  posterior  roots  and  columns,  while  the  motor 
types  are  spastic  paraplegia,  involving  the  upper  motor  neurone  (pyram- 
idal tracts)  and  muscular  atrophy  due  to  lesions  in  the  lower  neurone 
(anterior  horns  and  roots). 

Tabes  Dorsalis,  Locomotor  Ataxia. — Definition. — A  disease  character- 
ized (a)  etiologically  by  syphilis;  (6)  pathologically  by  lesions  in  the 
posterior  spinal  roots,  posterior  columns  and  nerves;  and  (c)  clinically 
by  ataxia,  Argyll-Robertson  pupil,  pains,  defective  sensation,  loss  of  the 
tendon  reflexes  and  trophic  disturbances. 

It  is  the  best  known  and  most  frequent  chronic  disease  of  the  cord. 
Todd,  in  1847,  gave  the  first  accurate  account,  eliminated  paralysis, 
and  found  the  posterior  columns  diseased  at  autopsy.  Stanley  first 
(1840)  referred  the  affection  to  the  posterior  columns  and  peripheral 
sensory  nerves.  Tiirck  first  examined  the  tissues  microscopically  and 
Romberg  (1851),  and  Duchenne  (1858),  popularized  the  disease;  it 
is  still  known  in  France  as  Duchenne's  disease. 

Etiology. — Syphilis  is  the  sole  cause.  The  following  etiological  data 
are  those  of  syphilis;  age:  50  per  cent,  in  the  thirtieth  to  fortieth  year; 
25  per  cent,  in  the  fortieth  to  fiftieth  year;  less  than  25  per  cent,  in 
the  twentieth  to  thirtieth  year  (Gowers);  of  47  juvenile  cases  collected 
by  Hirtz,  the  parents  in  13  instances  had  syphilis,  tabes  or  dementia. 
Sex:  as  in  syphilis  and  paretic  dementia,  10  cases  occur  in  males  to  1 
in  females.  Like  syphilis,  tabes  is  sometimes  familial.  It  prevails  largely 
in  cities  and  among  the  higher  classes  (" syphilization  and  civilization"). 
It  is  uncommon  in  the  negro. 
54 


850  DISEASES  OF  THE  SPINAL  CORD 

Pathology. — The  gross  changes  are  visible  to  the  unaided  eye;  the 
posterior  columns  are  smaller,  outwardly  flattened,  gray  from  loss  of  the 
medullary  sheaths  and  translucent  from  secondary  increase  of  connective 
tissue.  The  pia  may  be  secondarily  opaque  and  thickened.  The  degener- 
ated areas  are  sunken  on  section.  The  posterior  horns  and  roots  are 
atrophied  and  grayish-red.  As  to  minute  changes,  there  is  a  very  slow 
degeneration  of  the  periyheral  sensory  neurone,  its  fibers  and  processes  of 
the  spinal  ganglia  cells.  These  processes  run  in  two  directions:  to  the 
periphery"  and  to  the  posterior  roots,  (a)  The  ijeripheral  spinal  sensory 
nerves  are  often  degenerated,  less  in  large  trunks  (sciatic  or  crural  nerves) 
than  in  the  peripheral  filaments  of  the  skin,  joints  and  muscles  which 
are  important  in  the  sensory,  trophic  and  atactic  symptoms  of  tabes; 
their  white  substance  wastes  and  then  their  axis-cylinders.  The  trophic 
centres  for  these  fibers  are  largely  in  the  root  ganglion,  (b)  The  fibers 
running  from  the  ganglia  to  the  posterior  roots  are  more  early,  regularly 
and  obviously  changed.  The  posterior  root  fibers  run  (i)  to  the  posterior 
columns,  whence  there  occurs,  low  down  in  the  cord,  degeneration  in 
Burdach's  and  then  higher  up  in  Goll's  columns,  into  which  the  root 
fibers  are  pushed  as  higher  root  fibers  enter  the  cord.  The  location  of 
the  degenerated  fibers  therefore  differs  at  successive  levels  {ascending 
degeneration) .  In  the  lumbar  cord  the  posterior  columns  are  most  inten- 
sively and  extensively  diseased,  especially  in  their  middle  and  posterior 
parts,  nearest  the  posterior  roots  and  surface  of  the  cord.  Early  and 
marked  degeneration  is  found  in  Lissauer's  zone  just  back  of  the  posterior 
horn.  The  anterior  part  of  the  post.  ext.  column  and  the  central  part  of 
the  post.  int.  column  are  slightly,  if  at  all,  diseased  as  they  are  not  derived 
from  the  post,  ganglia.  In  the  dorscd  cord  the  post,  columns  are  degener- 
ated save  in  the  post.  ext.  part  and  in  the  ant.  part.  In  the  cervical  cord 
the  post.  int.  columns  are  diseased  (representing  the  root  fibers  of  the 
lumbodorsal  cord)  and  also  some  areas  in  the  post.  ext.  column  where 
degenerated  root  fibers  have  just  entered,  (ii)  From  the  post,  roots  a 
series  of  fibers  to  Clarke's  column  is  degenerated  but  the  cells  of  Clarke's 
column  and  their  ascending  fibers  to  the  cerebellum  usually  remain  intact, 
(iii)  The  post,  horns  degenerate,  because  they  contain  fine  root  fibers, 
(iv)  The  reflex  collaterals  to  the  ant.  horns  also  degenerate. 

Degenerative  changes  may  involve  analogous  neurones,  as  the  auditory, 
optic,  visceral,  sympathetic  or  ocular  nerves,  or  the  peripheral  motor 
nerves,  pyramidal  tracts,  muscles,  medulla  and  brain. 

The  exact  patliogenesis  is  disputed:  (i)  Obersteiner  conceives  the 
initial  changes  are  in  the  pia  through  which  the  dorsal  nerve  roots  pass; 
(ii)  ]\Iarie  contends  there  is  a  lymphangitis  of  the  post,  columns;  (iii) 
Edinger  believes  that  toxins  attach  those  nerwns  structures  most  in  use 
and  therefore  most  easily  fatigued  (the  sensory  tracts  of  the  lumbar  cord, 
pupil,  bladder  and  intestine). 

Symptoms. — Symptoms  vary  chiefly  as  to  their  intensity,  duration 
and  succession.  Three  stages  are  described:  (1)  The  initial,  neuralgic 
or  pre-atactic  stage,  lasting  sometimes  for  years  (usually  6  to  8,  or  even 
10  to  20).  The  earliest  symptoms  are  pains  which  are  lancinating  or 
"rheumatic,"  perhaps  neuralgic  or  like  migraine  or  paresthesia.     The 


TABES  851 

knee-jerk  is  lost,  usually  very  early  and  the  yuiyil  reacts  to  accommodation 
but  not  to  light.  Much  less  often  optic  atrophy,  sexual,  sphincter,  ocular, 
articular  or  visceral  symptoms  first  attract  attention.  (2)  The  atactic 
stage  may  last  many  years;  muscular  movements  become  incoordinate, 
especially  in  the  legs,  sometimes,  though  later,  in  the  arms.  The  tabetic 
gait  develops,  the  patient  sways  when  his  eyes  are  closed,  sensation  is 
obtunded,  especially  the  muscular  sense,  urinary  and  sexual  disorders 
develop  and  in  some  cases  diplopia.  The  gross  muscular  power  is  un- 
impaired. Trophic,  joint,  bone  and  skin  lesions  and  visceral  crises  occur. 
(3)  In  the  terminal  stage  the  patient  is  bed-ridden,  helpless  from  extreme 
ataxia,  and  bed-sores,  lesions  in  the  medulla  and  cystitis  determine  the 
fatal  issue. 

Special  Symptoms  in  Detail.- — 1.  Motor  Symptoms. — (a)  Ataxia 
(incoordination)  is  of  such  importance  that  the  disease  is  named  locomotor 
ataxia.  It  is  present  in  80  per  cent,  of  cases,  but  may  develop  slowly 
or  perhaps  not  at  all;  it  occurred  in  barely  10  per  cent,  of  Babinski's 
cases,  who  explains  this  low  figure  by  his  use  of  mercury.  Ataxia  is  a 
disturbance  of  harmonic  efficient  muscular  contraction  and  is  probably  a 
disease  of  the  afferent  muscular  fibers  (muscular  anesthesia,  Reynolds 
1855),  intensified  by  sensory  impairment,  disturbance  in  the  reflex 
collaterals  and  sometimes  by  optic  atrophy.  Duchenne  first  made  the 
valuable  distinction  between  ataxia  and  loss  of  muscular  power  which  is 
preserved  until  laite  in  the  disease.  Ataxia  is  frequently  first  observed 
by  the  patient  when  he  walks  in  the  dark  or  closes  his  eyes,  as  in  washing 
the  face.  When  he  looks  upward  or  brings  the  heels  and  toes  together 
he  swa^^s  (Romberg's  sign)  and  perhaps  falls,  because  vision  is  a  sensory 
factor  in  equilibration.  Later,  incoordination  occurs  with  the  eyes 
open,  and  the  patient  can  walk  only  with  a  cane.  It  is  often  increased 
by  removing  the  shoes,  which  support  the  feet.  The  ataxia  is  marked 
when  the  patient  attempts  to  "about  face,"  to  walk  backward,  stand  on 
tiptoe  or  stand  with  the  knees  half -flexed.  Ataxia  is  elicited  also  when  the 
patient,  with  the  eyes  closed,  attempts  to  place  his  heel  on  the  opposite 
knee  or  perform  with  one  limb  those  movements  made  by  the  physician 
in  another  limb.  The  gait  is  atactic,  the  feet  are  lifted  too  high,  thrown 
too  far  forward  and  outAvard  (tvide-leggecl  gait)  and  brought  down  sud- 
denly and  f orcibly^ — " stamping"  or  "  rooster  gait."  A  tumbling  cerebellar 
gait  is  less  frequent,  observed  later  in  the  disease  and  referable  to  in- 
volvement of  the  trunk  or  hips.  Movement  in  tabetics  is  characterized 
by  excessive  excursion,  rapidity,  irregularity  and  uncertainty  of  execution. 
The  patient  cannot  execute  finer  movements,  such  as  writing  or  buttoning 
the  clothes.  Ataxia  is  rare  in  the  head,  eyes,  face,  jaw  and  tongue. 
In  women  marked  ataxia  is  less  frequent  than  simple  awkwardness. 
(b)  Miiscvlar  power  may  be  normal  even  with  extreme  ataxia.  The 
muscles  are  hypotonic,  which  allows  hyperextension  and  hyperflexion  of 
the  joints;  it  is  due  to  loss  of  centripetal  sensory  conduction.  There  is 
a  feeling  of  weakness  in  the  legs  in  two-thirds  of  the  cases.  Transient 
muscular  weakness  is  frequent  (75  per  cent.),  as  in  the  eye  muscles. 
Paralysis,  though  usually  transient,  may  be  permanent  from  disease  of 
the  pyramidal  tracts,  ant.  horns  or  peripheral  nerves,    (c)  Atrophy  is  not 


852  DISEASES  OF   THE  SPINAL  CORD 

common,  but  may  affect  the  arm  (type  of  Duchenne-Aran),  the  leg 
(the  tabetic  club-foot,  usually  due  to  neuritis),  or  most  rarely  the  face 
(hemiatrophy),  (d)  The  electrical  reactions  are  usually  normal.  Some- 
times muscular  contractures,  due  to  abnormal  sensation,  associated 
movements,  in  which  one  leg  moves  when  its  fellow  moves,  and  spon- 
taneous movements,  taking  place  without  volition  or  consciousness 
of  them  and  due  to  slight  unnoticed  reflexes,  may  occur. 

2.  Sensory  Symptoms. — In  the  majority  of  cases  the  disease  begins 
with  irritative  sensory  phenomena,  (a)  Spontaneous  pains  occur  in  85  per 
cent.,  are  sudden,  paroxysmal,  lightning-like,  lancinating  and  often  noc- 
turnal. They  are  usually  severe,  but  may  be  agonizing,  dull,  burning  or  like 
those  of  muscular  rheumatism,  increased  by  dampness  and  cold.  They 
last  from  a  few  hours  to  a  day  or  two.  The  legs  are  the  most  common  seat 
of  pain,  then  the  back,  trunk,  arms  especially  in  the  ulnar  distribution 
and  sometimes  the  head  (occipital  nerves)  and  face  (trigeminus,  whose 
ascending  branch  represents  the  sensory  parts  of  most  of  the  other 
cranial  nerves) ;  Collet  found  migraine-like  attacks  in  40  per  cent. ;  their 
bilateral  occurrence  is  very  suggestive.  The  pains  are  more  often  deep 
than  superficial  and  more  often  irregular  than  exactly  conforming  to  a 
nerve's  course.  The  pain  in  the  trunk  may  assume  the  "girdle  form" 
over  a  narrow  or  broad  zone  (31  per  cent.).  Sometimes  the  area  affected 
shows  local  trophic  changes,  as  herpes,  ecchymoses  or  friable  hair,  (h) 
ParestJiesice  are  common,  as  creeping  sensations,  "pins  and  needles" 
sensations,  a  sense  of  heat  or  cold.  They  occur  in  the  legs  in  66  per  cent, 
of  cases.  If  in  the  arms,  the  ulnar  distribution  is  especially  involved 
(17  per  cent.).  The  ulnars  at  the  elbows  are  often  insensitive  to  pressure 
{Biernackts  sign),  pain,  temperature  and  tactile  impressions.  In  the 
face  a  perverted  feeling  may  be  noted  ("Hutcliinson's  mask"),  (c) 
In  the  early  stages  hyperesthesia  may  be  noted  from  nerve  irritation. 
In  86  per  cent,  of  developed  cases  sensation  is  reduced;  it  is  most  often 
of  the  spinal  or  segmental  type,  though  sometimes  peripheral.  Tactile 
sensation  is  often  disturbed,  especially  in  the  legs  and  soles.  Hypesthesia 
may  be  observed  on  the  buttocks,  scrotum,  perineum,  penis  (the  cause  of 
early  decreased  sexual  power)  or  on  the  trunk  as  a  zone  (80  per  cent.), 
especially  to  light  touch.  It  is  not  usually  found  higher  than  the  third 
rib,  although  there  may  be  occasional  occipital  or  trigeminal  anes- 
thesia. If  the  arms  are  affected  it  is  mostly  in  the  hands  and  palms. 
Sometimes  a  touch  to  one  member  is  referred  to  another  (allocheiria) 
or  a  single  contact  feels  like  several  (polyesthesia) .  Perception  of  pain 
is  lessened  in  50  per  cent,  of  cases,  occurring  alone  or  with  hypesthesia; 
a  short  stab  with  a  pin  is  often  felt  merely  as  a  touch.  Pain  con- 
duction is  often  retarded  (60  per  cent.);  the  sharp  stick  of  a  pin  is 
felt  at  once  as  a  touch,  but  the  pain  is  perceived  only  after  7  to  15, 
even  35  seconds;  the  patient  says  "now"  when  stuck  and  "ouch"  as 
he  feels  the  pain.  Analgesia  may  be  the  cause  of  severe  injuries,  as  in 
syringomyelia.  Sometimes  the  testicles  are  insensitive  to  pressure,  and 
inflammations  such  as  pleurisy  may  run  a  painless  course.  The  tempera- 
ture sense  is  rarely  affected  alone  or  completely.  The  muscle  sense  is  dis- 
turbed; a  change  of  angle  of  one  or  two  degrees  in  the  joints  and  tendons 


TABES  85S 

Is  noted  by  normal  individuals,  while  in  tabetics  much  wider  movements 
are  not  perceived,  especially  in  the  small  distal  joints;  the  toes  may  be 
moved  unnoticed  by  the  patient,  perhaps  in  the  later  stages  the  fingers 
also. 

3.  Reflexes. — (a)  The  skin  reflexes  may  be  increased  early  in  the 
disease.  Later  the  plantar  and  gluteal  reflexes  are  somewhat  decreased. 
The  abdominal  and  cremasteric  may  long  remain  normal,  (b)  Of  the 
tendon  reflexes  the  knee-jerk  is  lost  early  (Westphars  sign);  this  most 
constant  finding  in  tabes  (98  to  100  per  cent.)  is  due  to  disease  of  the 
afferent  nerves  and  reflex  paths  in  the  cord.  These  reflexes  should  be 
examined  with  the  patient  sitting  on  the  edge  of  a  table  with  his  eyes 
closed  and  excluding  cerebral  inhibition  of  the  reflexes  by  having  him  pull, 
in  an  outward  direction,  the  locked  fingers  (Jendrassik's  reinforcement). 
The  patellar  reflexes  are  rarely  present  save  in  exceptional  cases  of 
cervical  tabes.  The  knee-jerk  has  been  known  to  return  after  a  cerebral 
hemiplegia.    The  Achilles  reflex  is  lost  equally  frequently. 

4.  The  Eyes  and  Special  Senses. — (a)  The  pupils  contract  to  accom- 
modation hut  not  to  light  in  97  per  cent.  (Argyll-Robertson,  1869).  The 
patient  must  look  to  a  distance  in  the  dark  room  and  one  eye  tested  at  a 
time  lest  accommodation  be  confused  with  contraction  to  light.  The 
Argyll-Robertson  pupil  may  depend  upon  a  degeneration  of  fibers  con- 
necting the  optic  nerve  with  the  oculomotor  muscles  (see  page  805). 
The  tabetic  pupil  rarely  dilates  on  pinching  the  skin  of  the  neck.  In 
about  50  per  cent,  it  is  small  (spinal  myosis) ;  the  pupils  are  often  unequal 
in  size  and  irregular  in  contour,  (b)  The  eye  muscles  are  aftected  in  50 
per  cent.  Mobius  holds  that  ocular  paralyses  are  as  important  as  the 
pupillary  changes,  especially  when  painless,  wherein  they  differ  from 
the  rheumatic  and  syphilitic  forms;  he  holds  that  the  majority  of  all 
eye  paralyses  in  the  adult  are  tabetic.  Diplopia  is  common  and  usually 
unilateral..  The  order  of  frequency  of  involvement  is  the  sixth,  third 
and  fourth  nerves.  "^Vhen  one  muscle  is  paralyzed  the  others  are  usually 
weak.  The  early  form  of  paralysis  is  usually  transitory;  the  late  form  is 
often  permanent  from  nuclear  degeneration,  (c)  Optic  atrophy  (10  per 
cent.)  is  generally  an  early  symptom.  The  disk  is  pale  and  shrunken, 
especially  on  its  temporal  side  and  at  the  edges,  which  are  sharp.  The 
process  is  always  bilateral;  central  scotoma  and  actual  neuritis  are 
rare.  The  process  usually  progresses  to  blindness.  When  optic  atrophy 
occurs  early,  ataxia  may  not  appear,  "tabes  arrested  by  blindness." 
When  it  develops  later  it  has  no  effect  on  the  ataxia,  {d)  Deafness  may 
develop  gradually  or  suddenly,  sometimes  with  vertigo  or  Meniere's 
complex.  It  may  be  permanent  or  transient.  Auditory  defects  are  present 
in  80  per  cent,  of  cases.  Atrophy  of  the  auditory  and  olfactory  nerves 
has  been  found. 

5.  The  Sphincters  and  Genital  Sphere. — (a)  The  bladder  is  frequently 
affected  (60  per  cent.),  possibly  as  the  first  symptom  of  the  disease. 
The  bladder  is  slowly  or  imperfectly  evacuated,  because  its  centripetal 
sensory  fibers  are  diseased.  There  may  be  overflow,  incontinence  and 
in  the  later  stages  cystitis  frequently  results  from  decomposition  of  the 
residual  urine,  followed  in  turn  by  pyelitis,  nephritis  and  septicemia. 


854  •      DISEASES  OF   THE  SPINAL  CORD 

(b)  The  sphincter  ani  is  weak  but  rarely  incontinent,  (c)  The  sexual 
appetite  and  power  are  reduced  (G(3  per  cent.),  often  early.  Labor  is 
sometimes  painless. 

6.  Trophic  Disorders. — Local  trophic  changes  are  more  common  than 
general  malnutrition,  (a)  Trophic  alterations  in  the  bones  and  joints 
were  first  thoroughly  studied  by  Charcot — Charcot's  disease.  They 
usually  appear  late  and  develop  in  2  per  cent,  of  cases.  The  onset  is 
usually  gradual,  sometimes  acute  with  marked  swelling  or  seemingly 
traumatic.  Two  forms  are  observed:  first  the  more  frequent  atrophic 
form,  especially  in  the  hip  and  shoulder,  in  which  the  cartilages  are 
eroded,  the  articular  surfaces  waste  and  crepitate,  foreign  bodies  develop 
and  the  joint  becomes  so  lax  that  dislocation  of  the  hip  or  knee  (genu 
recurvatum)  results;  second,  the  hypertrophic  form  with  bony  formation, 
ossification  of  the  ligaments,  and  rigidity  resembling  arthritis  deformans 
but  painless,  more  acute,  extreme  and  effusive.  The  a'-ray  plates  are 
characteristic.  The  adjacent  muscles  atrophy — the  arthropathic  mus- 
cular atrophy.  The  large  joints  are  usually  involved,  as  the  knee  (45 
per  cent.),  hip  (20  per  cent.),  shoulder  (11  per  cent.),  elbow  (5  per  cent.) 
or  ankle  (4  per  cent.),  but  smaller  articulations  may  be  affected,  as  the 
tarsus,  jaw,  spine,  thumb,  etc.  The  cause  is  the  same  as  in  syringomyelia. 
The  tabetic  foot  is  characterized  by  thickness  and  roundness  of  its  inner 
border  and  arch,  flattening  of  the  sole,  decreased  motility,  and  patho- 
logically by  erosion  and  atrophy  of  its  bones.  It  must  be  distinguished 
from  the  tabetic  club-foot  due  to  muscular  atrophy  of  the  calf  muscles 
with  contractures.  The  bones  may  break  easily  but  painlessly  (Weir 
Mitchell),  due  to  rarefying  osteitis,  which  renders  the  medullary  sub- 
stance more  porous,  the  cortex  thinner  and  the  inorganic  base  less  in 
amount.  If  a  callus  develops  it  is  often  exuberant.  The  tendons  some- 
times rupture,  probably  from  trophic  changes.  (6)  The  perforating  ulcer 
of  the  foot  {mal  perforant  du  pied)  is  more  frequent.  It  is  "punched 
out"  in  appearance,  painless,  secretes  but  little  pus  and  is  due  to  nerve 
degeneration  or  centric  changes.  Similar  ulcerations  resembling  syphilis 
may  occur  in  the  nose,  ear,  buccal  mucosa,  palate  or  uvula,  (c)  In  the 
skin,  local  sweating,  ecchymoses,  herpes,  blebs,  alteration  of  the  hair  or 
nails,  gangrene  and  ichthyosis  may  occur.  Decubitus  is  not  common 
save  in  the  last  stages,  and  it  may  not  develop  even  after  years  in  bed. 
There  may  be  dental  caries  or  painless  falling  out  of  the  sound  teeth 
with  analgesia  of  the  gums, 

7.  Visceral  Symptoms. — The  most  important  are  the  painful  crises 
first  correctly  interpreted  by  Charcot,  (a)  Gastric  crises  occur  in  5  per 
cent,  of  cases.  There  is  severe,  sometimes  excruciating  epigastric  pain, 
which  often  radiates  into  the  back,  vomiting  of  food,  then  fluid,  finally 
bile  or  even  blood;  this  is  often  attended  by  restlessness,  epigastric 
retraction,  hiccough,  fever  and  a  slow,  rapid  or  irregular  pulse;  hyper- 
acidity is  less  frequent  than  hypacidity.  The  alkaline  urine  contains 
indican  and  decreased  chlorides.  The  crisis  lasts  several  hours  to  days 
and  may  greatly  reduce  the  general  nutrition;  it  is  sometimes  the  first 
evidence  of  tabes.  The  cause  is  usually  considered  nervous,  but  Pal 
thinks  it  is  due  to  increased  arterial  tension.    (6)  Laryngeal  crises  are  next 


TABSS  S55 

in  frequency  but  are  shorter  in  duration.  They  are  due  to  spasm  of  the 
laryngeal  muscles,  and  are  often  dangerous.  In  some  instances  only  a 
hoarse  cough  like  pertussis  is  noted;  in  others  there  is  collapse  or  death 
(ictus  laryngis).  Anatomically,  the  ascending  branch  of  the  fifth  nerve 
and  the  glossopharyngovagus  nucleus  or  its  branches  are  degenerated. 
(c)  Other  crises  are  far  less  common,  as  intestinal  crises,  which  are  char- 
acterized by  colic,  diarrhea  and  sometimes  rectal  tenesmus;  the  author 
saw  obstruction  and  abdominal  retraction  lasting  twelve  days,  imme- 
diately relieved  by  morphine  gr,  | ;  renal  crises  with  scant  urine,  transient 
albuminuria  or  even  hematuria,  and  less  often  nasal,  pharyngeal,  hepatic, 
cardiac,  bronchial,  vesical,  urethral  or  vulvovaginal  crises  occur. 

8.  Cerebral  Symptoms. — Cerebral  symptoms  other  than  the  eye  changes 
noted  above,  are  not  frequent;  they  are  unilateral  atrophy  of  the  tongue; 
paralysis  of  the  vocal  cords;  vagus  and  accessorius  symptoms  other 
than  those  already  noted,  such  as  rapid  pulse,  palatal  weakness  or 
rarely  paralysis  affecting  the  trapezius  and  sternomastoid,  which  is 
probably  neuritic;  and  very  rarely  facial  or  bulbar  paralysis.  Lachry- 
mation,  salivation,  polyuria  or  glycosuria  is  sometimes  noted. 

Complications. — These  include  true  cerebrospinal  syphilis;  aneurysm, 
aortic  regurgitation  (5  per  cent.)  and  especially  dementia  paralytica,  a 
closely  correlated  affection;  myelitis;  muscular  atrophy,  particularly  the 
symmetrical  form  due  to  neuritis;  cerebral  thrombosis  due  to  arterial 
disease;  and  apoplectiform  seizures  which  occur  as  in  paretic  dementia. 

Course  and  Prognosis. — Pain  is  the  first  symptom  in  68  per  cent.,  while 
no  other  single  early  symptom  is  the  first  in  more  than  3  per  cent.  (Sarbo). 
Optic  atrophy  or  insanity  may  arrest  tabes.  Leube  instances  a  man 
who  worked  hard  for  forty  years  after  the  onset  of  tabes;  tabetics  may 
live  for  twenty  years  in  the  last  stages  of  the  disease.  Crises,  alcoholism, 
traumatism,  acute  onset,  intercurrent  affections  unnoticed  because  of 
their  painlessness,  and  affections  of  the  bladder  and  kidney  with  sepsis 
are  unfavorable  prognostics.  In  1960  well-observed  cases  (out  of  4000) 
40  per  cent,  followed  a  long  course  with  exacerbations,  30  per  cent,  were 
steadily  progressive,  19  per  cent,  halted  for  three  years  or  more,  6  per 
cent,  ran  a  severe,  rapid  course  and  5  per  cent,  almost  recovered  (Belugou 
and  Faure).    Tabes  is  incurable. 

Diagnosis. — The  diagnosis  is  made  by:  (a)  The  Argyll- Robertson  pupil, 
which  is  indicative  of  tabes,  paretic  dementia  or  rare  lesions  in  the 
Corp.  quadrigemina.  (6)  The  most  common  and  early  symptom,  loss 
of  the  patellar  reflex  (which  most  rarely  fails  in  health,  marasmus,  old 
individuals  or  as  an  hereditary  lesion),  (c)  Lightning  pains,  "tabetic 
neuralgia,"  girdle  sensation,  gastric  and  other  crises,  {d)  Sensory  changes, 
subjective,  objective  and  vesical,  (e)  Optic  atrophy.  (/)  Painless  ocular 
paralysis,  (g)  Ataxia,  with  Romberg's  sign  and  the  tabetic  gait,  is  prac- 
tically pathognomonic  after  exclusion  of  peripheral  neuritis,  (h)  The 
Wassermann  reaction  is  present  in  70  to  96  per  cent,  of  cases  (see  pages 
219  and  229)  in  the  blood  and  spinal  fluid,  with  globulin  reactions  and 
lymphocytosis. 

In  cervical  tabes  (less  than  1  per  cent,  of  cases)  the  sensory  changes, 
pains  and  ataxia  are  most  manifest  in  the  arms  or  even  in  the  face.    The 


856  DISEASES  OF  THE  SPINAL  CORD 

aim  reflexes  are  sometimes  abolished  and  the  patellars  rarely  may  be 
normal  or  increased.  The  characteristic  pupils  are  present  and  gastric 
crises  appear  early  and  frequently. 

DiFFEEEXTiATiox.- — In  the  earliest  stage  confusion  with  neurasthenia, 
hypochondriasis  and  nosophobia  is  possible,  from  common  symptoms, 
as  pains,  paresthesia,  girdle  sensation  and  weakness  of  the  legs,  but  close 
observation  determines  the  diagnosis;  the  tabes  of  Hippocrates  was  prob- 
ably neurasthenia.  One  form  of  multiple  neuritis  {q.  v.),  viz.,  pseudo- 
tabes, may  require  differentiation.  Cerebrosjjinal  .5?/p/n7z>,  especially  of 
the  roots  and  the  membranes,  may  sometimes  cause  confusion. 

For  differentiation  from  Friedreich's  ataxia,  see  page  865.  In  cere- 
bellar tumor,  usually  the  ataxia  ceases  when  the  eyes  are  closed  and  is  not 
characterized  by  the  excessive  excursion  or  rapidity  of  tabes ;  the  patellar 
reflexes  are  increased,  there  is  no  anesthesia  and  signs  of  tumor  are  often 
present.  In  multiple  sclerosis  there  exceptionally  may  be  crises;  pains 
and  sensory  disturbance,  but  the  Argyll-Robertson  pupil,  ataxia,  marked 
sensory  and  bladder  disturbances  are  most  rare.  There  are  increased 
reflexes,  nystagmus,  scanning  speech,  intention  tremor,  central  scotoma 
and  functional  oculomotor  involvement.  Paraplecjias  are  not  difficult 
to  diff'erentiate,  since  true  motor  disturbance  is  rare  or  late  in  tabes; 
the  reflexes  are  increased  and  spastic  rigidity  is  marked,  even  in  atactic 
paraplegia.  Tabetic  pain  is  often  misinterpreted;  pain  as  a  rule  suggests 
disease  of  the  vertebree  and  membranes  rather  than  of  the  cord  itself, 
but  in  vertebral  disease  or  cord  tumor  the  pain  is  fixed,  and  often  increased 
on  pressure  and  movement.  Tabes  may  be  confused  (on  hasty  or  partial 
examinations)  with  rheumatism,  intercostal  or  trigeminal  neuralgia,  and 
gastric,  renal  or  other  visceral  disease.  Bilateral  sciatica  always  suggests 
tabes,  diabetes  or  nephritis.  Striimpell  describes,  among  workers  in 
tobacco,  a  nicotine  tabes,  in  which  pain,  pupillary  alteration,  atactic  gait 
and  absence  of  knee-jerks  are  observed,  but  also  a  characteristic  tremor 
and  increased  cutaneous  reflexes  in  the  legs  obtain. 

Treatment. — 1.  Etiological  Treatment.  —  Antisyphilitic  remedies 
(g.  V.)  are  indicated. 

2.  Hygienic  Treatment. — Overwork,  overexercise,  worry,  trauma, 
exposure  and  excess  in  tobacco,  alcohol  or  sexual  indulgence  should  be 
avoided.  Tabetics  should  not  marry.  The  diet  should  be  regulated, 
since  dyspepsia  promotes  pain.  If  possible,  the  patient  should  live  in  a 
warm  climate  and  at  a  moderate  altitude. 

3.  Drug  Treativient. — Silver,  strychnine  and  nitroglycerin  give 
uncertain  results.     Gowers  considers  arsenic  beneficial. 

4.  Balneotherapy. — "Warm  baths  are  injurious;  lukewarm  baths, 
electrotherapy  and  massage  exert  no  specific  influence  on  the  disease. 

5.  Sy:viptomatic  Therapy. — (a)  If  pain  is  superficial,  sinapisms,  chloro- 
form liniments  or  the  galvanocautery  should  be  tried;  if  moderate, 
acetanilide,  cannabis  indica  or  peripheral  faradization  is  beneficial;  mor- 
phine should  be  avoided  as  long  as  possible,  because  the  habit  is  readily 
acquired.  Gowers  described  cases  in  which  pain  was  a  salient  symptom 
and  existed  without  ataxia  or  loss  of  the  patellar  reflexes;  for  this  "tabetic 
neuralgia,"  differing  from  the  ordinary  pains  of  tabes,  he  recommends 


SPASTIC  SPINAL  PARAPLEGIA  857 

salicylates  and  aluminium  chloride,  gr.  v-x,  t.  i.  d.  (b)  Crises  usually 
necessitate  morphine  hypodermics.  Laryngeal  crises  often  respond 
to  nitroglycerin  hypodermically,  chloroform  by  inhalation  or  cocaine 
locally.  Stretching  the  spine  and  cord  probably  relieves  pain;  the  patient 
sits  on  the  floor  with  the  legs  extended;  without  other  movement,  the 
body  is  carefully  pushed  forward  (flexed)  as  far  as  possible.  Section  of 
the  nerve  roots  (rhizotomy)  and  cocaine  injections  are  recommended,  {c) 
For  vesical  affections,  catheterization  for  residual  urine  is  indicated,  but 
under  most  rigid  antisepsis;  belladonna  and  faradization  are  often  helpful. 
Cystitis  is  treated  by  lavage,  {d)  Secondary  infection  should  be  avoided. 
Corns  should  never  be  cut  but  always  rubbed  off. 

6.  Ataxia. — This  may  be  relieved  by  H.  G.  Frenkel's  systematic 
exercises,  "a  reeducation  of  the  central  nervous  system  by  repeated 
exercises;"  carefully  and  persistently  executed  muscular  movements, 
not  forceful  movements,  are  desirable.  Nerve  stretching  and  suspension 
are  useless. 

II.  System  Diseases  of  the  Motor  Tract. 

The  motor  paths  may  be  diseased  (1)  in  the  upper  neurone,  as  in 
spastic  spinal  paralysis;  (2)  in  both  neurones,  as  amyotrophic  lateral 
sclerosis;  (3)  in  the  peripheral  neurone,  as  spinal  muscular  atrophy 
or  bulbar  paralysis;  (4)  in  the  peripheral  motor  nerve,  as  the  neuritic 
muscular  atrophy  and  (5)  in  the  muscles  themselves,  as  the  dystrophies. 
These  types  may  blend;  separate  descriptions  are  necessary  to  bring 
out  the  classical  symptoms. 

1.  Spastic  Spinal  Paraplegia. — Lateral  sclerosis  described  first  by  Erb, 
in  1875,  concerns  only  the  upper  motor  neurone. 

Etiology  and  Pathology. — The  disease  represents  a  symptom-complex 
rather  than  a  pathological  entity.  The  causal  factors  are  uncertain,  as 
syphilis  or  an  hereditary  tendency.  In  75  per  cent,  it  occurs  between 
the  twentieth  and  fortieth  years.  It  was  thought  that  there  was  a  primary 
sclerosis  of  the  lateral  pyramidal  tracts,  especially  their  lower  parts,  for 
which  confirmation  is  still  lacking;  there  are  some  lesions  in  other 
neurones,  as  in  the  post,  columns. 

Symptoms. — There  are  three  cardinal  findings,  motor  weakness,  mus- 
cular rigidity  and  increased  reflexes,  (a)  Motor  weakness  is  usually  the 
first  sign;  it  begins  slowly  and  is  evidenced  by  weakness  or  stiffness 
in  the  flexors  of  the  hips  especially  but  also  the  knees  and  ankles.  Every 
gradation  from  paresis  to  paralysis  may  be  noted  in  different  cases  or  in 
different  stages.  Striimpell  attributes  the  loss  of  finer  synergistic  move- 
ments to  involvement  of  the  lateral  pyramidal  tracts;  the  coarser  move- 
ments for  groups  of  muscles  are  possible  via  the  anterior  pyramidal 
tracts.  The  muscles  are  large  and  well  nourished,  (b)  Muscular  rigidity 
results  also  from  disease  of  the  lat,  pyram.  tracts,  which  lessens  the 
inhibition  and  is  proportionate  to  the  loss  of  power.  The  muscles  resist 
quick,  passive  efforts  at  flexion,  but  yield  to  slow  flexion  and  remain  in 
the  position  given  them,  "lead-pipe  contraction."  The  knees  are  rigidly 
extended,  even  when  the  patient  sits  on  the  edge  of  the  bed;  the  great 
toe  is  stronglv  flexed  dorsallv;  when  one  leg  is  lifted  the  other  comes 


S58  DISEASES  OF   THE  SPINAL  CORD 

with  it;  the  specially  tense  adductors  prevent  abduction  of  the  thighs. 
The  muscles  are  stiff  in  the  morning;  painful  spasms  may  occur  during 
the  night;  hypertonicity  may  lead  to  active  contractures  and  patients 
complain  of  the  "tendons  getting  too  short."  In  active  movements 
rigidity  is  manifest ;  the  gait  is  paretic  and  spastic,  the  knees  are  extended 
and  closely  apposed,  the  steps  are  short,  the  balls  of  the  feet  cleave  to  the 
ground  and  the  feet  scuffle,  (c)  Increase  of  the  reflexes  is  also  due  to  lateral 
pyramidal  sclerosis.  The  knee-jerks  are  most  excessive;  ankle-clonus 
and  Babinski's  reflex  are  present;  a  strong  clonic  contraction  of  the 
quadriceps  follows  depression  of  the  patella  and  the  gait  may  be 
hopping.  The  arms  are  often  normal;  there  may  be  rigidity  like 
that  of  a  late  hemiplegia;  there  may  be  clonic  spasm  of  the  fingers 
and  increased  tendon  and  periosteal  reflexes.  There  sometimes  are 
weakness  in  the  back  and  painful  contractions  of  the  chest  and  back 
muscles  with  dull  aching.  The  cranial  nerves  are  rarely  diseased, 
although  the  jaw-jerk  may  be  increased.  The  electrical  reactions, 
sensation,  muscular  nutrition  and  eyes  are  usually  normal.  The  sphincters 
are  usually  affected  late. 

Clinical  Forms  and  Diagnosis. — Diagnosis  concerns  the  paresis,  hyper- 
tonicity, increased  reflexes  and  absence  of  sensory,  trophic  and  other 
symptoms.  Six  types  may  be  described:  (1)  There  are  rigidity  and 
spasticity  in  the  legs,  arms  and  perhaps  the  face,  sometimes  with  com- 
pulsory laughing  or  weeping,  as  in  amyotrophic  lateral  sclerosis,  but 
without  muscular  atrophy. 

2.  The  hereditary  or  familial  form  commences  between  twenty  and 
thirty  years  of  age;  the  paresis  develops  late;  this  form  is  characterized 
anatomically  by  sclerosis  of  the  (congenitally  weak)  lateral  pyramidal 
tracts  and  also  by  sclerosis  of  the  cerebellar  and  Goll's  columns  (more 
properly  classified  under  combined  system  disease). 

3.  In  infantile  diplegia,  the  rigidity  is  less,  foot-clonus  less  common 
and  tonic  spasms  rare;  athetoid  movements,  deficient  mentality  and 
epileptiform  convulsions  are  common. 

4.  In  the  syphilitic  form  of  Erb  there  are  paresis  and  slight  spasticity, 
plus  urinary  incontinence,  retention  and  impotence. 

5.  There  are  forms  symptomatic  of  brain  disease  (tumor,  syphilis, 
paresis),  cord  disease  (tumor,  compression,  syringomyelia,  multiple 
sclerosis)  and  hysteria  which  has  not  the  peculiar  extensor  spasm;  loss 
of  power  is  rarely  complete  and  ankle-clonus  is  rare,  although  a  spurious 
half-voluntary  contraction  of  the  calf  muscles  may  be  noted. 

6.  Periodic  familial  paralysis  affects  the  legs  chiefly,  is  flaccid  and 
results  in  decrease  of  the  patellar  and  absence  of  the  plantar  reflexes, 
decreased  faradic  irritability,  sleepiness,  but  without  sensory  symptoms; 
it  lasts  one  to  three  days.    The  prognosis  is  good. 

Prognosis.^ — "It  is  perhaps  the  least  dangerous  to  life  of  any  chronic 
spinal  lesion."    Recovery  or  arrest  is  rare. 

Treatment. — Overexertion,  fatigue,  electrotherapy  and  strychnine  are 
to  be  avoided.     Massage  and  warm  baths  relieve  the  spasticity. 

2.  Amyotrophic  Lateral  Sclerosis. — This  is  often  called  the  maladie 
de  Charcot  (Charcot  and  Joff'roy,  1865). 


AMYOTROPHIC  LATERAL  SCLEROSIS  859 

Etiology. — It  occurs  mostly  between  the  twenty-fifth  and  forty-fifth 
years,  more  frequently  in  males;  its  cause  is  not  known. 

Pathology. — The  name  amyotrophic  lateral  sclerosis  designates  the 
leading  changes,  which  are,  amyotroyhy ,  from  atrophy  of  the  anterior 
horns  and  sclerosis  of  the  lateral  columns .  (a)  The  lateral  'pyramidal  tracts, 
and  to  a  lesser  extent  the  anterior,  show  symmetrical  primary  degen- 
eration, followed  by  interstitial  sclerosis  which  is  most  marked  in  the 
lower  part  of  the  upper  neurone,  but  in  some  cases  extends  upward  to 
the  medulla,  pons,  crus  or  even  the  central  convolutions,  the  ganglionic 
cells  of  which  may  be  atrophied.  In  some  cases  unimportant  changes 
may  be  found  in  the  cerebellar  tracts  or  posterior  columns.  (6)  The 
ganglionic  cells  of  the  anterior  horn  are  degenerated,  so  that  the  anterior 
motor  part  of  the  cord  is  distinctly  smaller  and  flatter.  Likewise  the 
nerve  filaments  from  the  pyramidal  fibers,  anastomosing  with  the  pro- 
cesses of  the  ant.  horn,  are  degenerated.  These  changes  in  the  trophic 
centre  of  the  second  motor  neurone  explain  the  atrophy  of  the  anterior 
roots,  motor  nerves  and  muscles,  (c)  The  bulbar  nuclei,  analogues  of  the 
ant.  horns,  with  their  nerves  and  muscles,  show  identical  changes. 

Symptoms. — The  symptoms,  like  the  lesions,  are  strictly  motor. 

Stage  1. — The  disease  begins  with  weakness  and  atrophy  of  the 
muscles  of  one,  then  the  other  hand,  most  marked  in  the  thenar,  hypo- 
thenar  and  interosseal  muscles,  and  follow^ed  by  wasting  and  weakness 
in  the  forearm  extensors,  deltoid  and  triceps;  other  muscles  of  the  arm 
and  forearm  escape  or  are  involved  later.  Sensory  symptoms  are  absent. 
Weakness  is  often  manifest  before  the  atrophy.  Other  symptoms  of 
disease  in  the  lower  neurone  appear,  as  fibrillary  contractions  and  the 
reaction  of  degeneration;  the  nerve  trunks  respond  normally.  As  evidences 
of  involvement  of  the  upper  neurone,  paralysis  often  precedes  the  wasting 
and  accentuates  the  weakness  from  ant.  horn  involvement;  there  are 
increase  of  the  reflexes  (which  never  occurs  in  muscular  atrophy  due  to 
disease  of  the  ant.  horns  alone)  and  rigidity  and  contracture  in  which 
the  arm  hugs  the  chest,  the  forearm  is  flexed  and  pronated,  and  the 
wrist  and  fingers  are  fiexed.  Sometimes  the  neck  is  rigid  and  trismus 
is  observed. 

Stage  2. — In  less  than  a  year  the  legs  are  involved;  weakness,  especially 
in  the  flexors  of  the  hip,  knee  and  dorsal  flexors  of  the  foot  and  spasticity 
prevail.  The  gait  is. spastic  and  paretic  as  in  spastic  spinal  paralysis 
and  walking  becomes  impossible  because  of  the  rigidity  and  the  tivitching 
tetanic  movements  of  the  extensors.  The  patellar  reflexes  are  exaggerated; 
ankle-clonus  is  frequent;  when  the  patient  attempts  to  flex  the  thigh 
while  the  examiner  holds  the  ankle,  there  is  a  visible  contraction  of  the 
tibialis  anticus  (the  tibialis  phenomenon) ;  Babinslns  reflex  is  present — 
evidences,  in  short,  of  pyramidal  disease,  because  symptoms  referable  to 
the  lower  neurone,  as  atrophy,  are  much  less  frequent,  less  marked  and 
less  early  in  the  legs  than  in  the  arms. 

Stage  3. — This  stage  occurs  in  one  or  two  years  with  dysphagia, 
atrophy  of  the  lips  and  tongue  with  fibrillation,  as  in  primary  bulbar 
paralysis  (q.  v.).  A  marked  jaw-jerk  is  elicited,  tonic  tension  of  the  facial 
muscles  may  occur  and  spasmodic  laughing  or  weeping  from  loss  of  in- 


860  DISEASES  OF   THE  SPINAL  CORD 

hibition.     The  mind  is  clear.     Death  results  from  respiratory  failure, 
aspiration  pneumonia,  etc. 

Course  and  Prognosis. — In  some  cases  the  pyramidal  or  paretic,  in  others 
the  atrophic,  symptoms  are  dominant.  The  course  covers  one  to  four 
years  and  is  fatal. 

Diagnosis. — The  involvement  of  both  motor  neurones,  muscle  atrophy 
with  increased  reflexes,  rigidity  and  the  final  bulbar  symptoms  establish 
the  diagnosis. 

3.  Progressive  Spinal  Muscular  Atrophy. — Duchenne  and  Aran  (1849- 
50)  gave  the  first  full  clinical  description  of  this  disease. 

Etiology. — The  ultimate  causes  are  not  known.  Seventy-five  per  cent, 
of  cases  occur  in  males,  mostly  between  the  twenty-fifth  and  forty- 
fifth  years.  Hereditary  factors,  often  observed  in  the  muscular  dys- 
trophies {v.  i.)  are  infrequent,  although  28  familial  infantile  cases  are 
reported.  Hard  work,  mental  distress,  syphilis,  trauma,  infections  and 
poliomyelitis  are  possible  factors. 

Pathology. — In  the  cord,  especially  in  the  cervical  region,  (a)  the 
anterior  horns  are  small  and  flattened;  their  ganglion  cells  are  deformed, 
w^asted,  their  processes  lost;  interstitial  changes  are  secondary,  ih)  The 
anterior  roots,  especially  the  cervical,  are  degenerated  and  often  also  the 
peripheral  nerves,  although  changes  in  them  are  most  difficult  to  dis- 
tinguish, (c)  The  muscles  are  small,  stringy  and  pale  and  their  individual 
fibers  are  small;  their  transverse  striation  persists  remarkably,  and 
waxy,  fatty  or  granular  degeneration  and  longitudinal  splitting  are  not 
common;  the  muscle  nuclei  multiply,  round  cells  may  wander  in,  and 
there  is  usually  increase  of  connective  tissue.  Amyotrophic  lateral 
sclerosis,  spinal  muscular  atrophy  and  bulbar  paralysis  are  one  affection. 

Symptoms. — (a)  The  essential  symptoms  are  motor.  The  earliest  is 
muscular  atrophy  with  weakness  in  the  upper  extremity  (90  per  cent.), 
especially  the  (right)  thenar  and  hypothenar  eminences.  The  abductor 
indicis  and  opponens  pollicis  are  first  involved,  then  the  flexor  brevis  and 
adductor,  the  wasting  of  which  brings  closer  together  the  metacarpi  of 
the  thumb  and  index-finger  (the  "ape-hand").  It  is  finally  impossible  to 
appose  the  thumb  to  the  fingers.  The  interossei  on  the  dorsum  waste 
and  leave  marked  furrows,  producing  the  "claw-hand,"  main  en  griffe, 
from  contraction  of  the  antagonist  ext.  digitorum  communis,  the  tendons 
of  which  stand  out  prominently.  The  wasting  lumbricales  hollow  the 
palm.  In  this  Duchenne-Aran  type,  individual  muscles  are  selectively 
involved.  The  muscles  become  lax,  thin  and  flat.  The  atrophy  long 
exceeds  the  paresis.  The  forearin  may  be  next  involved,  first  the  extensors. 
below  the  int.  condyle,  later  the  supinators  and  flexors.  A  deep  depression 
between  the  ulna  and  radius  eventually  occurs.  After  years,  the  shoulder 
muscles,  the  posterior  and  middle  thirds  of  the  deltoid,  the  biceps  and 
brachialis  waste  and  much  later  the  triceps.  Sometimes  the  wasting  of  the 
muscles  of  the  shoulder  and  arm  immediately  follows  the  involvement  of 
the  hand,  or  perhaps  the  disease  begins  in  the  shoulder.  The  bones  of  the 
shoulder  stand  out  clearly,  covered  only  by  the  skin,  "the  living  skeletons" 
seen  in  museums.  The  trunk  muscles  are  involved  in  this  order:  trapezius 
in  its  middle  and  lower  parts  (rarely  in  its  upper  third,  which  is  the 


PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY  861 

idtimum  moriens  of  Duclienne);  pectoralis,  latissimus  dorsi,  rhomboidei 
(causing  the  shoulder  to  droop)  and  extensors  of  the  head  (allowing 
the  head  to  fall  forward).  Lordosis  is  common  and  the  spine  stands 
out  distinctly.  The  platysma  and  face  escape.  The  respiratory  muscles, 
intercostals  or  diaphragm  are  involved,  which  latter  imperils  life.  In  the 
leg  the  muscles  are  affected  late  and  to  a  lesser  degree,  as  the  glutei, 
quadriceps  and  the  peronei.  Very  exceptionally  the  disease  first  develops 
in  them.  In  the  fully  developed  cases  there  is  extreme  helplessness;  an 
added  misery  in  the  form  of  the  sister-process,  bulbar  paralysis,  may  develop. 

(6)  In  the  wasted  muscles  there  are  usually  fibrillary  contractions; 
they  are  involuntary  twitchings,  tremor-  or  even  wave-like  in  character. 
They  may  appear  in  muscles  not  yet  wasted,  (c)  The  electrical  reaction 
in  the  nerves  is  normal.  In  the  muscles  there  is  usually  only  quantitative 
reduction  and  the  voltaic  excitability  remains  long  after  the  faradic  is 
lost;  in  the  last  stages  there  is  a  partial  reaction  of  degeneration,  {d) 
The  reflexes  are  weakened,  or  abolished  in  proportion  to  the  atrophy 
and  due  to  disease  in  the  motor  side  of  the  reflex  arc.  (e)  Sensation  shows 
no  objective  change;  in  some  instances  there  are  dull,  aching  pains  in  the 
muscles.  (/)  Vasomotor,  secretory,  sphincter  and  trophic  symptoms 
are  lacking. 

Diagnosis. — The  diagnosis  is  based  on  the  slow  course;  the  involve- 
ment of  the  hand  and  its  slow  "individualization";  fibrillation;  partial 
reaction  of  degeneration;   and  decreased  reflexes. 

Differentiation  is  necessary  (1)  from  disease  in  which  muscular  atrophy 
is  but  one  among  several  symptoms,  (a)  Syringomyelia  is  marked  by 
its  trophic  characteristics,  its  analgesia,  thermo-anesthesia  and  less 
symmetrical  wasting.  (6)  Meningitis,  spondylitis  and  tumors  are  mani- 
fested by  anesthesia,  pain,  tenderness  and  rigidity,  (c)  In  mnltiple 
neuritis  there  is  a  clearer  reaction  of  degeneration,  more  sensory  signs 
and  tenderness  in  the  nerve  trunks,  (d)  The  occupation  cdropkies  are 
distinguished  by  the  history. 

2.  Other  muscular  atrophies,  (a)  Chronic  poliomyelitis  causes  paralysis 
first  and  atrophy  afterward;  it  affects  groups  of  muscles  at  once,  its 
course  is  rapid  and  fibrillary  contractions  are  infrequent,  (b)  The 
myopcdhic  cdropkies  (see  p.  864).  (c)  Amyotrophic  latercd  sclerosis  is  an 
allied,  perhaps  identical  affection;  the  atrophy  is  not  "individualized," 
but  occurs  en  masse;  the  distinguishing  features  are  the  increase  of  the 
reflexes,  spasticity  and  a  much  more  rapid  course,  (d)  Arthritic  muscidar 
atrophy,  probably  due  to  reflex  influences,  or  direct  extension  of  inflam- 
mation to  the  muscles  or  nerves,  involves  chiefly  the  extensors  in  a 
moderate  wasting;  diffuse  wasting  suggests  a  nervous  cause.  There  is 
usually  increased  myotatic  irritability  and  reflex  action. 

Course  and  Prognosis. — The  onset  between  the  twenty-fifth  and  forty- 
fifth  years  is  gradual,  the  course  is  slowly  progressive,  remissions  in- 
frequent, and  death  usually  results  from  intercurrent  disease,  respiratory 
affections  (tuberculosis)  or  bulbar  palsy.  Arrest  is  rare  and  chiefly  in 
cases  marked  by  symmetry  and  synchronous  involvement  of  both  hands. 

Treatment. — Gowers  gives  strychnine  hypodermically;  he  has  seen 
7  consecutive  cases  of  arrest  of  which  6  were  permanent;  it  has  little 


862 


DISEASES  OF   THE  SPINAL  CORD 


effect  by  mouth.      Massage,  active  and  passive  gymnastics  and  elec- 
tricity do  not  stay  the  disease. 

4.  Neural  Muscular  Atrophy. — Charcot-^NIarie  type.    Peroneal  family 
type  (Tooth j.     Xeiirotic  type  (Hoffmann). 

Etiology. — It  is  often  hereditary,  even 
through  five  generations;  it  is  usuahy 
famihaL  It  occurs  in  the  second  hah  of 
childhood  and  rarely  after  the  twentieth 
year.  Sixty-six  per  cent,  of  cases  are  in 
males. 

Pathology  and  Symptoms. — The  patho- 
logical characteristic  is  neuritis;  secondary 
sclerosis  has  been  seen  in  the  posterior  and 
lateral  pyramidal  columns.  Early  atrophy 
occurs  in  the  small  muscles  of  the  feet,  with 
bilateral,  symmetrical  peroneal  paralysis  and 
club-feet  (pes  equinus  or  varo-equinus).  The 
calf  muscles  suffer  next  and  the  thigh  still 
later.  After  years,  paralysis  and  atrophy 
of  the  hands,  as  in  progressive  spinal  atro- 
phy, develop,  with  the  "claw-hand";  in 
the  forearm,  the  extensors  suffer  more  than 
the  flexors.  The  shoulder,  neck,  trunk  and 
face  are  seldom  diseased.  Fibrillation  is 
infrequent;  the  reaction  of  degeneration  is 
generally  present,  paresthesia  and  anes- 
thesia (especially  plantar)  are  common; 
the  patellar  reflexes  may  long  persist. 

5.  Muscular  Dystrophy. — The  dystro- 
phies or  myopathies  are  often  classed 
with  diseases  of  the  muscles,  which  indeed 
show  the  sole  constant  pathological  lesions. 
They  are  so  closely  related  clinically  to 
the  less  frequent  spinal  atrophies  that  they 
are  here  considered.  Changes  in  the  cord, 
nerve  trunks  and  nerve  filaments  have 
been  found  in  some  cases  of  each  type. 
(a)  Heredity  is  an  obvious  cause  in  5(3  per 
cent,  or  a  familial  incidence  is  often  ob- 
served ;  the  muscular  system  seems  deficient 
in  development  or  vitality,  (h)  It  occurs  in 
childhood  or  pubescence,  (c)  The  muscles 
waste,  with  or  without  h\'pertrophy  or 
with  increase  of  fat  or  interstitial  growth. 
Pseudohypertrophic  Muscular  Paralysis. — Lipomatous  muscular  atrophy 
is  the  least  frequent,  but  is  the  oldest  and  best  known  type  (Bell,  1830; 
Partridge,  1837;  IMeyron,  1852;  Duchenne,  1861).  It  occurs  in  males 
(80  per  cent.)  and  is  less  marked,  less  early  in  life  and  less  fatal  in  women. 
It  is  often  transmitted  by  healthy  mothers,  the  males  being  impotent, 


Fig.  74.  —  Typical 
pertrophic  muscular 
(Dercum.) 


pseudohy- 
paralysis. 


MUSCULAR  DYSTROPHY  863 

and  may  be  seen  in  five  generations.    It  begins  early  (75  per  cent,  under 
ten  years). 

1.  Impaired  motility  is  the  earliest  symptom.  The  weakest  muscles 
are  the  invisible  hip  flexors  and  the  knee  extensors  which  make  climbing 
of  stairs  difficult,  cause  the  waddling  gait  (paresis  of  glutei)  and  interfere 
with  rising  from  the  floor,  so  that  the  child  must  rise  by  resting  on  all 
fours  and  by  "  climbing  his  own  legs  with  his  hands."  Paresis  of  the  back 
muscles  and  hip  extensors  causes  lumbar  lordosis  and  abdominal  pro- 
trusion. The  ankle  extensors  also  weaken.  The  child  stands  with  legs 
far  apart.  The  depressors  of  the  shoulders  are  weakened  early  in  the 
disease,  later  the  shoulder  muscles,  biceps  and  triceps,  but  the  hand 
remains  normal  for  a  long  time,  or  escapes.  The  weak  muscles  show 
nuclear  increase,  atrophy  and  division  of  their  fibers,  which  are  usually 
undersized,  pale  and  narrow;  fatty  degeneration  and  loss  of  striation  are 
rare.  Increase  of  connective  tissue  is  a  later  but  most  characteristic 
change. 

2.  Certain  muscles  show  apparent  increase  in  size  {yseudohypertroyhy), 
due  largely  to  early  adipose  deposit  or  rarely  to  actual  muscular  hyper- 
trophy. The  calf  muscles  are  especially  enlarged,  then  the  glutei,  knee 
extensors,  or  infraspinatus  which  contrasts  strongly  with  the  wasted 
latissimus  and  deltoid. 

3.  The  electrical  irritability  is  lowered,  but  there  is  no  reaction  of 
degeneration.  The  deep  reflexes  disappear,  from  the  muscular  lesion. 
Mentality,  sensation  and  the  sphincters  are  normal.  Cardiac  hyper- 
trophy was  observed  in  60  per  cent,  of  Glotz's  cases.  The  patient  becomes 
bed-ridden,  arrest  is  rare  and  death  occurs  after  years  from  intercurrent 
disease  or  respiratory  inflammation. 

Infantile  Atrophic  Form  with  or  without  Facial  Involvement. — Wasting 
occurs  from  the  beginning.  It  may  be  combined  with  the  first  form,  and 
the  legs  then -show  pseudohypertrophy  and  the  arms  simple  atrophy. 
The  pathology  is  that  of  the  first  form,  but  there  is  no  hypertrophy, 
true  or  false;  increased  connective  tissue  characterizes  this  type  of 
atrophy  and  also  that  of  the  juvenile  form  {v.  i.). 

The /ace  may  be  involved.  The  lids  droop  and  cannot  be  wholly  closed, 
the  forehead  is  smooth,  the  cheeks  are  flaccid  and  droop,  the  lips  part 
and  functionate  poorly,  the  lower  lip  protrudes,  the  nasolabial  fold  disap- 
pears, the  face  becomes  expressionless  {fades  inyoyathica) .  The  masseters, 
tongue,  palate,  larynx,  pharynx  and  eye-balls  are  implicated  rarely. 
Simultaneously  or  more  often  later,  the  shoulder  girdle  wastes  as  in  the 
first  type — the  jacioscapidoliumeral  form  of  Landouzy  and  Dejerine;  the 
latissimus  and  lower  part  of  the  pectoralis  are  usually  first  affected,  but 
in  the  biceps,  triceps  and  often  in  the  supinator  longus,  the  symmetrical 
wasting  and  paresis  are  more  conspicuous.  The  forearm,  save  for  the 
supinator  longus,  and  the  hand  usually  escape.  The  neck  is  seemingly 
lengthened  (Brissaud),  because  of  the  drooping  of  the  shoulders  and 
clavicles.  The  leg  muscles  then  waste,  especially  the  hip  flexors,  knee 
extensors  and  less  often  the  glutei;  lordosis,  the  waddling  gait  and 
symptoms  observed  in  the  next  type  {v.  i.)  may  develop.  The  facial 
wasting  may  follow  that  of  the  arms.    The  course  is  progressive,  very 


864  DISEASES   OF    THE  SPIXAL   CORD 

chronic  (ten  to  fifty  years)  and  death  results  from  intercurrent  infections, 
respiratory  catarrh,  tuberculosis,  etc.  In  the  second  and  third  types  the 
prognosis  is  more  favorable  than  in  the  first  form  and  the  outlook  is 
better  when  the  face  is  unaft'ected. 

The  Juvenile  Form  of  Erb. — This  type  begins  after  puberty,  possibly 
later  (twentieth  to  fortieth  year)  and  is  more  frequent  in  girls  than  the 
above  forms.  It  begins  more  often  in  the  shotdders  and  arms  than  in 
the  legs.  The  pectoralis,  latissimus,  trapezius,  serratus  mag.,  rhomboidei, 
sacroltunbalis,  longiss.  dorsi,  supinator  longus  and  later  the  triceps 
are  wasted,  while  the  sternomastoid,  supra-  and  infraspinatus,  lev, 
anguli  scapulee,  coracobrachialis,  teretes,  deltoid  and  the  hand  and 
forearm  ''except  the  supin.  long. )  are  almost  always  exempt.  If  we  lift 
the  patient  with  our  hands  beneath  his  shoulders  he  tends  to  ''slip 
through":  this  is  due  to  ''loose  shoulders"  f'Erb).  The  scapulee  stand 
out  prominently  from  weakness  of  the  serrati.  The  glutei,  quadriceps 
and  less  often  tibialis  ant.  and  peronei  become  atrophied.  The  lordosis 
and  gait  are  as  above  described. 

Diagnosis  of  Myopathic  Atrophies. —  (a)  Atrophy  from  cerebral  lesions  is 
less  marked  and  follows  the  marked  loss  of  power.  (6)  Spinal  muscular 
atrophy: 

Spixal  Atrophy. vs. Mtopathic  Dystrophy. 

Begins  in  small  hand  muscles.  In  trunk,  shoulder  or  pehic  girdle,  leg  and 

upper  arm. 

Extends  upward  (face  free).  Downward  liace  sometimes  affected). 

Muscular  atrophy.  Frequentlj-  with  hj-pertrophj-. 

Fibrillation  the  rule.  Verj-  exceptional. 

Tendon  reflexes  increased  in   amyotrophic  Xever  increased;    decreased. 

lat.  sclerosis. 

Partial  reaction  of  degeneration.  PracticaUj"  never  present. 

Age;   usually  begins  after  thirtieth  year.  In  childhood,  rarelj'  after  twentieth  year. 

Heredity — rare.  Frequent. 

Bulbar  sjinptoms  not  uncommon.  Never  present. 

(c)  In  congenital  spa^sfic  paraplegia,  increased  reflexes  and  a  regressive 
rather  than  a  progressive  tendency  are  characteristic,  (d)  Peripheral 
neuritis  (q.  v.)  is  toxic,  acute  and  shows  sensory  symptoms  and  local 
tenderness  over  the  nerves  and  muscles,  (e)  In  congenital  defects  in  the 
pectoral  muscles  and  trapezius,  progression  is  absent. 

Treatment. — Electricity  causes  too  much  pain.  Reasonable  exercise 
is  advisable,  because  the  patients  begin  to  fail  when  they  cannot  walk. 
The  respiratory  tract  must  be  watched,  since  catarrh  predisposes  to 
tuberculosis. 

Under  diseases  of  the  motor  neurones,  ophthalmoplegia,  Landry's 
paralysis,  bulbar  palsy,  myasthenia,  poliomyelitis,  etc.,  might  also  be 
described,  but  are  treated  elsewhere  for  diti'erential  reasons. 

ni.  Combined  System  Diseases. 

Kahler  and  Peck,  in  1S77.  directed  attention  to  cases  with  simultaneous 
disease  in  several  systems  of  neurones.  Von  Leyden,  Goldscheider  and 
Xonne  consider  them  diffuse,  vascular  or  even  myelitic  afiections  rather 


HEREDITARY  ATAXIA  865 

than  true  system  diseases,  of  which,  in  their  opinion,  there  are  but  two 
examples,  tabes  and  progressive  muscular  atrophy. 

1.  Hereditary  Ataxia,  Friedreich's  Ataxia  (Friedreich,  1861). — Etiology. 
— This  affection  is  hereditary  in  33  per  cent.,  and  in  80  per  cent, 
familial.  Most  cases  occur  in  boys.  It  is  generally  considered  a  con- 
genital abiotrophy  of  the  pyramidal  and  other  tracts  (Freidreich, 
Schultze,  Striimpell) . 

Pathology. — The  cord,  medulla  and  pons  are  small.  The  earliest  and 
dominant  change  is  atrophy  with  secondary  sclerosis  of  the  post,  roots 
and  post,  colnmns,  and  in  Goll's  more  than  in  Burdach's  columns.  Lis- 
sauer's  "root  zone"  is  less  affected  than  in  tabes,  but  more  than  in 
ataxic  paraplegia.  The  direct  cerebellar  tract,  lat.  ascending  tract  of 
Gowers  and  Clarke's  gray  columns  share  in  the  atrophy.  The  lat.  pyram- 
idal tract  suffers  in  most  cases,  its  inner  portion  being  usually  normal. 
Chronic  leptomeningitis,  with  annular  sclerosis  of  the  cord,  is  occa- 
sional. 

Symptoms. — (a)  The  cardinal  sign  is  ataxia,  which  is  less  rapid,  ex- 
cessive and  stamping  than  tabetic  ataxia,  and  more  closely  resembles 
cerebellar  ataxia  in  its  tumbling  character  and  involvement  of  the  trunk. 
Static  ataxia  appears  later,  the  head  oscillates  or  the  arms  show  jerky 
movements  (51  per  cent.).  Romberg'' s  sign  is  usually  present  and  the 
subject  leans  over  to  watch  his  feet;  this  leads  to  some  kyphosis.  Testing 
the  sense  of  location  elicits  ataxia,  as  in  the  knee-ankle  test.  The  arms 
become  atactic  after  a  few  years.  Nystagmus  develops  as  a  late  symptom; 
it  is  elicited  chiefly  on  lateral  (or  upward)  movements  and  is  atactic, 
as  is  also  the  disturbance  of  speech,  which  is  monotonous,  irregular, 
unclear,  slightly  scanning,  slow  and  strained;  syllables  are  often 
elided. 

(6)  The  knee-jerks  are  early  decreased  or  abolished  and  Babinski's 
sign  obtains.  The  skin,  pupillary  and  sphincter  reflexes  are  usually 
normal.  In  some  (possibly  syphilitic)  cases  the  pupil  reflex  may  disappear. 
(c)  Club-foot  (pes  equinovarus)  is  common;  the  foot  is  shortened  and 
widened,  the  arch  is  exaggerated  (pes  cavus),  the  great  toe  is  strongly 
extended  dorsally.  Scoliosis  and  kyphosis  are  common.  Muscular 
paralysis  or  wasting  is  rare.  Paresthesise,  crises,  lancinating  pains  and 
trophic,  vasomotor  and  sensory  disturbances  are  lacking.  General  or 
sexual  development  may  be  retarded. 

Course  and  Prognosis. — About  33  per  cent,  develop  before  the  sixth 
year,  33  between  the  sixth  and  tenth  and  33  after  the  tenth  year.  The 
atactic  gait  is  the  first  sign,  then  speech  is  involved,  possibly  then  the 
kyphosis  and  club-foot  develop,  and  later  the  arms  are  affected;  the 
course  is  progressive,  possibly  with  remissions,  and  the  patient  becomes 
bed-ridden  in  twenty  to  thirty  years.  Death  follows  from  acute  infection^ 
cystitis  and  sepsis. 

Diagnosis. — The  diagnosis  is  based  on  the  hereditary  or  familial 
etiology,  age,  ataxia,  absent  knee-jerks  and  disturbance  of  speech. 

Differentiation.  —  1 .    In   tabes  there   are  the   syphilitic   stigmata, 
immobile  pupil,  optic  atrophy,  pains,  crises  and  vesical,  trophic  and 
marked  sensory  disturbances. 
55 


866  DISEASES  OF  THE  SPINAL  CORD 

2.  MuUiijle  sclerosis  is  differentiated  by  the  spasticity,  increased  reflexes, 
optic  atrophy,  compulsory  laughing,  apoplectiform  insults,  intentional 
tremor  and  scanning  speech. 

3.  In  cerebellar  tumors  there  are  optic  neuritis,  headache  and  vomiting. 
Marie,  Londe  and  Nonne  described  an  hereditary  cerebellar  ataxia,  which 
is  possibly  due  to  congenital  atrophy  of  the  cerebellum  (middle  lobe), 
degeneration  in  Clarke's  columns,  cerebellar  tracts  and  posterior  columns, 
is  also  hereditary  or  familial,  but  develops  later,  between  the  twentieth 
and  thirtieth  years.  The  ataxia  is  cerebellar.  The  reflexes  are  increased 
(which  Patrick  thinks  is  the  sole  differentiating  point),  often  with  spas- 
ticity; quite  frequently  there  are  o^ptic  atrophy,  limitation  of  the  visual 
field,  eye  paralysis  and  sometimes  an  immobile  pupil,  nystagmus,  chorei- 
form movements  and  moderate  sensory  and  speech  disturbances.  Club- 
foot, scoliosis  and  Romberg's  sign  are  absent.  Sanger  Brown  reported 
25  and  Neff  13  cases. 

4.  Cerebral  diplegia  of  children  and  ataxic  paraplegia  are  distinguished 
by  reflex  increase  and  spasticity. 

5.  ''  Amaurotic  family  idiocy''  (Warren  Tay,  1881,  and  B.  Sachs,  1887) 
is  characterized  by  paralysis,  idiocy,  optic  atrophy,  marasmus  and  death 
before  the  third  year  of  life.  Most  cases  are  Jews.  At  autopsy  hypoplasia, 
microgyria,  decreased  pyramidal  cells,  tangential  and  other  fibers  are 
noted.    Bing  (1909)  collected  106  cases. 

Treatment." — Treatment  is  symptomatic. 

2.  Ataxic  Paraplegia. — Most  cases  occur  in  males  between  thirty  and 
forty;  syphilis  is  a  rare  cause.  Pathologically,  there  is  a  lateroposterior 
sclerosis;  in  the  lat.  column  the  degeneration  is  not  wholly  symmetrical 
or  pyramidal;  it  may  invade  the  mixed  zone;  in  the  post,  column  the 
process  is  not  more  intense  in  the  lumbar  cord  and  is  less  intense  in  the 
root  zone  than  in  tabes.  Sometimes  the  process  is  so  diffuse  that  it 
suggests  myelitis  or  arterial  obstruction. 

Symptoms. — ^The  early  symptoms  are  those  of  a  gradual  spastic  para- 
plegia (weakness,  exaggerated  reflexes,  rigidity),  followed  by  ataxia' 
(mostly  in  the  legs,  with  Romberg's  sign).  The  arms  are  involved  later 
and  to  a  less  degree.  In  the  last  stages  the  ataxia  is  obscured  by  the 
spastic  paraplegia;  vesical  or  rectal  tenesmus  and  muscle  cramps  are 
common.  Cranial  nerve  involvement  is  sometimes  suggested  by  slightly 
disturbed  articulation,  nystagmus,  tremulous  facial  movements  and 
increased  jaw-jerk.  The  mind  is  usually  clear.  Dull  sacral  pain  is 
sometimes  observed. 

Differentiation.— (a)  Certain  tabetic  symptoms  are  absent,  as  the  high- 
stepping,  stamping  gait,  immobile  pupils,  pains,  crises,  and  absent  knee- 
jerks.  (6)  Friedreich's  ataxia  is  distinguished  by  the  age,  heredity, 
speech  and  absence  of  patellar  reflexes. 

Prognosis  and  Treatment. — See  Spastic  Spinal  Paraplegia. 

3.  Other  Combined  System  Diseases. — Combined  sclerosis  may  also 
occur  in  pellagra,  ergotism,  lathyrism  (q.  v.),  multiple  neuritis,  diabetes, 
pernicious  anemia,  icterus,  leukemia,  brain  tumor,  plumbism  or  diphtheria. 
It  was  found  by  Putnam  in  enfeebled,  middle-aged  persons,  especially 
in  women, 


MONONEURITIS  8G7 

Pathologically,  there  is  posterolateral  sclerosis  with  diffuse  or  discrete 
degenerative  foci.  The  most  diffuse  changes  are  in  the  cervical  and  the 
least  in  the  lumbar  cord  and  sometimes  changes  exist  in  the  ant.  horns 
and  Clarke's  columns.  There  are  sensory  symptoms  (lancinating  pains, 
paresthesia,  anesthesia,  ataxia),  motor  symptoms  (paresis,  paraplegia, 
chloreiform  movements)  or  reflex  symptoms  (the  patellars  being  exag- 
gerated or  lost). 


DISEASES  OF  THE  PERIPHERAL  NERVES. 

MONONEURITIS. 

Definition. — Inflammation  of  a  single  nerve  trunk. 

Etiology. — (a)  Wounds,  fractures,  dislocations,  delivery,  violent  mus- 
cular contractions ;  disturbed  metabolism ;  anesthesia  paralyses,  the  arms 
being  held  over  the  head,  the  legs  bound  in  holders  or  when  Esmarch's 
bandage  is  applied  too  tightly;  ether  hypodermically,  malpositions  of 
the  arm  during  sleep  and  the  use  of  crutches  are  causes.  (6)  Contiguous 
disease  (pleurisy,  pelvic  inflammation,  tumors  or  aneurysm)  may  produce 
neuritis,  (c)  Cold  (rheumatic  paralysis). causes  inflammation  in  the  sheath 
with  extension  to  the  nerve,  (d)  Toxic  causes  and  infections  are  factors 
{v.  i.  Multiple  Neuritis). 

Pathology. — In  acute  cases  the  nerve  is  red,  swollen  and  sometimes  the 
seat  of  punctate  hemorrhages  or  extravasation  of  white  cells  in  the  sheath 
or  between  it  and  the  nerve  fibrils.  In  some  cases  inflammation  involves 
chiefly  the  sheath  (perineuritis)  and  in  others  the  interstitial  tissue  (inter- 
stitial neuritis),  in  which  the  enclosed  nerve  fibrils  are  compressed.  The 
process  is  disseminated  or  focal  (where  the  nerve  divides  or  enters  the 
fascia  or  bone).  It  is  often  difficult  to  distinguish  between  inflammation 
and  degeneration  (parenchymatous  neuritis);  in  both  processes  there  are 
nuclear  multiplication  and  protoplasmic  swelling  in  the  neurilemma; 
this  compresses  the  myelin  sheath,  which  becomes  varicose,  granular, 
fragmented  and  finally  emulsified.  The  axis-cylinder,  composed  of  thirty 
to  fifty  primitive  fibrils,  becomes  granular,  divided  and  may  largely 
or  wholly  disappear.  Regeneration  is  accomplished  from  the  spinal  or 
cerebral  centres  and  probably  also  from  the  periphery. 

Symptoms. — Constitutional  and  local  symptoms  vary  with  the  intensity, 
extent  and  seat  of  the  neuritis. 

1.  Sensory  Symptoms. — The  chief  local  symptom  is  2^awi,  experienced 
locally  or  eccentrically  over  the  area  of  distribution  of  the  sensory  nerves, 
increased  by  tension  or  movement  and  usually  intense.  Tenderness 
indicates  involvement  of  the  nervi  nervorum.  Hyperesthesia,  hypesthesia 
and  paresthesia  may  be  noted,  but  complete  anesthesia  is  rare  except  for 
relatively  small  areas.  Sometimes  the  swollen  or  nodular  nerve  may 
be  felt. 

2.  Motor  Symptoms. — The  muscles  supplied  are  tender  to  touch,  pain- 
ful on  movement,  paretic  and  atrophied  (separation  from  their  trophic 


868 


DISEASES  OF   THE  PERIPHERAL  NERVES 


centres).  They  are  less  clearly  striated,  granular  and  finally  indurated. 
Muscular  contractures  may  result  reflexly,  especially  in  traumatic  and 
occupation  neuritides.  The  reaction  of  degeneration  is  present.  The 
normal  nerve  is  stimulated  by  the  faradic  current  which  produces  a 
continuous  muscular  contraction  and  by  the  voltaic  which  produces 
a  contraction  when  the  circuit  is  made  or  broken— the  cathode  closing 
contraction,  which  is  first  to  appear  and  stronger  than  the  anode  closing 
contraction.  In  disease  the  following  changes  occur:  (a)  The  muscle 
responds  weakly  and  sluggishly  to  faradism,  and  tends  to  maintain 
contraction  after  the  current  is  withdrawn.  This  modal  change  is  the 
essential  element  in  the  reaction,  (b)  The  nerve  trunk  loses  progressively 
its  responsiveness  to  both  galvanism  and  faradism— a  quantitative  change. 
(c)  The  muscle  becomes  more  excitable  by  galvanism  and  less  excitable 


y  [galvanic 

2  (  FARADIC 

^  I" GALVANIC 
£<       AND 
z  (^ FARADIC 


ATROPKY  AND  NUCLEAR 
PROLIFERATION  OF  MUSCLE 


REGENERATION 
9 


"1^    WEEK 


DEGENERATION 


10         20         30         10         00         00         70        SO         DO       lUO   WEEK 


Fig.  75. — 1,  Paralysis  with  early  return  of  motion;    2,  incurable  paralysis  with  com- 
plete degeneration. 


by  faradism;  the  latter  reaction  and  the  responses  in  the  nerve  trunk 
are  completely  lost  after  two  or  three  weeks— a  qualitative  change,  (d) 
A  polar  change  appears  in  the  muscle  about  the  second  week  when  directly 
stimulated  by  galvanism ;  the  muscle  is  more  readily  caused  to  contract 
by  the  constant  current,  but  the  normal  mastering  strength  of  the  nega- 
tive closing  contraction  over  the  positive  disappears  and  the  positive 
closing  contraction  equals  or  exceeds  the  negative. 

3.  Trophic  Symptoms.— The  skin  is  sometimes  red,  "glossy,"  edema- 
tous or  more  rarely  thickened.  Increased  secretion  of  sweat,  eruptions 
as  herpes,  erythema  or  pemphigus,  inflammation  or  adhesions  in  the 
joints  and  perforating  ulcers  are  less  common. 

Neuritis  may  sometimes  ascend  to  the  cord,  as  in  traumatic  cases  or 
in  bladder  disease.    In  the  rare  progressive  hypertrophic  interstitial  neuritis 


MULTIPLE  NEURITIS  869 

of  childhood  (Dejerine  and  Sottas,  1893),  sclerosis  and  hypertrophy  of  the 
nerves,  ant.  and  post,  nerve  roots,  and  sclerosis  of  the  post,  columns 
cause  muscular  atrophy,  pains,  anesthesia,  nystagmus,  immobile  pupils 
and  kyphoscoliosis. 

Diagnosis. — Diagnosis  depends  on  localization  of  symptoms  to  a 
nerve  trunk  and  its  distribution;  pain,  tenderness  and  objective  sensory 
alteration;  muscular  atrophy  or  paralysis;  and  trophic  changes.  The 
early  diffuse  pain  may  simulate  disease  of  the  bones  or  joints.  Chronic 
sensory  forms  may  resemble  neuralgia,  in  which  the  pain  is  paroxysmal, 
the  tender  points  more  localized  and  objective  sensory  alteration  absent. 
Disease  of  the  cord  or  nerve  roots  usually  paralyzes  several  muscles  and 
affects  sensation  segmentally. 

Prognosis.- — ^The  prognosis  depends  on  the  cause  and  intensity  of  the 
process.  Acute  cases  last  for  weeks;  chronic  cases,  for  months.  The 
outlook  is  usually  good  in  traumatic  cases. 

Treatment. — The  treatment  is  (a)  that  of  the  cause,  (b)  Absolute  rest 
is  indicated.  Exertion  increases  as  it  may  initiate  neuritis,  (c)  Pain. 
The  salicylates  and  iodides  are  of  uncertain  value.  Local  heat  may 
cause  burns  and  ulcerations  in  the  anesthetic  skin.  Coal-tar  products 
should  be  given  in  preference  to  morphine  or  cocaine  because  habits 
may  be  contracted;  opiates  are  necessary  in  severe  cases.  The  positive 
pole  of  the  voltaic  current,  just  strong  enough  to  be  felt,  may  relieve 
pain,  (d)  Paralysis  should  be  treated  only  after  the  acute  stage,  by  the 
weak  interrupted  voltaic  current  (not  the  faradic),  massage  and  later 
passive  motion  (the  veins  froni  the  nerves  empty  into  the  muscle  veins). 


MULTIPLE  NEURITIS. 

Polyneuritis,  peripheral  neuritis,  described  by  James  Jackson  (1822) 
and  Ladd  (1854),  was  first  accurately  described  pathologically  by  Dumeil 
(1864)  and  Leyden  (1880). 

Definition. — Neuritis,  due  to  the  selective  action  of  toxic  substances 
on  the  less  resistant  peripheral  nerves,  causing  (a)  multiple,  symmetrical, 
flaccid  or  atrophic  paralysis  with  (b)  the  reaction  of  degeneration,  (c) 
sensory  and  (d)  trophic  disturbances. 

Etiology.— The  causes  are  (a)  poisons;  alcohol  is  the  most  important; 
lead,  arsenic  (in  beer),  mercury,  phosphorus,  carbon  monoxide,  silver, 
aniline  and  ergot  may  also  produce  the  disease,  (b)  The  infections,  acute, 
as  diphtheria,  typhoid,  sepsis  and,  occasionally,  almost  every  acute 
infection,  and  chronic,  as  beri-beri,  leprosy,  tuberculosis  or  syphilis, 
are  etiological  factors,  (c)  Intoxications,  as  diabetes,  nephritis,  digestive 
disorders,  cachexias  and  pregnancy,  may  be  causal,  (d)  Other  causes 
include  the  seemingly  primary  cases.  Our  present  knowledge  cannot 
explain  the  action  of  cold  and  rheumatism;  probably  these  cases  should 
be  classified  as  infectious.  It  may  occur  with  tabes  or  arteriosclerosis 
of  the  nerve  vessels.  It  is  a  disease  of  adults  (twentieth  to  fiftieth  year) ; 
Thomas  and  Greenbaum,  1907,  collected  138  non-diphtheritic  cases  in 
children. 


870  DISEASES  OF   THE  PERIPHERAL  NERVES 

Pathology. — In  acute  cases  the  nerve  may  be  red,  swollen  and  the 
seat  of  punctate  hemorrhage,  exudation  of  leukocytes  or  albuminous 
exudation  in  the  connective  tissue,  but  usually  parenchymatous  de- 
generation predominates.  It  appears  first  and  most  markedly  in  the 
smaller  nerves.  As  in  mononeuritis,  the  axis-cylinders  waste  and  the 
medullary  sheaths  disintegrate.  The  symmetry  and  multiplicity  of 
degeneration  in  the  nerve  endings  are  caused  by  the  blood  condition 
or  toxins.  Acute  polymyositis  of  similar  origin  may  accompany  neuritis 
multiplex.  In  cases  which  are  chronic  from  the  beginning  there  is  slow 
degeneration  of  the  nerves.  The  connective  tissue  is  increased  in  certain 
forms,  as  gouty  or  leprous  neuritis.  The  toxic  cause  may  also  produce 
degeneration  of  the  cord  or  brain  and  changes  in  the  liver  (alcoholic 
cirrhosis),  kidneys  (alcohol  and  lead),  etc. 

Symptoms. — Acute  cases  may  begin  with  chills,  fever,  delirium,  head- 
ache, diarrhea,  icterus,  splenic  tumor,  albuminuria  or  other  toxemic 
symptoms;  chronic  cases  develop  slowly. 

1 .  Sensory  symptoms  are  usually  first  to  ay-pear,  the  last  to  disappear 
and  throughout  are  the  most  vexing  manifestations.  Paresthesia  precedes 
pain  and  pain  precedes  paralysis.  The  muscles,  nerve  trunks  and  skin 
are  the  seat  of  spontaneous  pain,  tenderness  to  pressure  and  pain  on  move- 
ment. The  palms  and  soles  are  especially  hyperesthetic  in  the  tabetic, 
diabetic  and  diphtheritic  forms.  Sensation  is  often  blunted,  perverted 
or  less  often  completely  suspended,  most  markedly  helow  the  elbows  and 
knees,  although  higher  extension,  even  to  the  face,  is  possible.  Some 
sensory  disturbance  is  rarely  absent.  Delayed  conduction  may  occur. 
The  joints  may  be  painful,  swollen  and  thickened. 

2.  Motor  Syiviptoms  occur  chiefly  in  the  -peripheral  distribution  of  the 
spinal  nerves;  they  develop  first  and  are  most  marked  in  the  extensors 
of  the  leg  and  foot,  forearm  and  hand,  and  produce  the  ankle-  and  wrist- 
drop (ext.  popliteal  and  musculospiral  nerves).  The  foot  is  also  inverte'd. 
The  paralysis  is  flaccid.  If  it  is  only  moderately  severe  in  the  legs,  the 
"steppage'  gait  is  noted  and  the  patient  lifts  the  legs  high  to  clear  the 
pendant  toes  {"  turkey-gobbler  walk' ') .  Paralysis  later  involves  the  flexors 
and  the  muscles  of  the  arm  and  thigh.  The  reaction  of  degeneration 
sometimes  appears  before  paralysis.  The  muscles  rarely  fail  to  respond 
to  the  galvanic  current,  even  in  the  extreme  cases.  Then  the  muscles 
atroyhy,  chiefly  in  distal  parts,  i.  e.,  where  the  sensory  and  motor  changes 
predominate.  Other  motor  manifestations  are  cramps,  tremor,  fibrilla- 
tion, ataxia  and  contractures.  The  patient  lies  on  the  back  with  the 
members  extended  or  on  the  side  with  flexor  contractures,  which  draw 
the  heels  to  the  buttocks  and  the  thighs  to  the  abdomen.  The  trunk 
muscles  may  be  affected  as  well  as  those  of  the  neck,  eyes,  face,  tongue  or 
indeed  those  supplied  by  any  cranial  nerve  as  in  the  neuritic  form  of 
Landry's  paralysis;  rapid  pulse,  palpitation,  dyspnea  and  vocal  disturb- 
ance indicate  involvement  of  the  vagus;  optic  neuritis  and  amblyopia 
may  occur.  The  tendon  and  skin  reflexes  decrease  or  disappear.  The 
organic  reflexes  are  almost  always  preserved.  Involvement  of  the 
sphincters  is  very  rare  and  referable  to  the  mental  state  or  neuritis  of 
the  pudendal  plexus. 


MULTIPLE  NEURITIS  871 

3.  Trophic  Symptoms.— The  skin  is  cold,  turgid,  harsh,  sometimes 
glossy;  herpes,  erythema,  ulceration,  bed-sores  and  trophic  changes 
in  the  nails  or  hair  are  uncommon;  edema  over  the  wrists  and  ankles, 
especially  in  alcoholics,  is  trophic  or  vascular  in  origin. 

4.  General  Symptoms. — Mental  symptoms  and  malnutrition  may 
result  from  the  antecedent  toxemia  or  pain;  Korsakow's  "neuritic 
psychosis"  is  marked  by  amnesia  for  the  recent  past,  confabulation, 
delirium  and  hallucinations;  recovery  is  the  rule. 

Course  and  Prognosis. — The  common  order  of  symptoms  is  paresthesia, 
pain,  paralysis,  amyotrophy,  trophic  and  mental  symptoms.  The  distal 
parts  are  involved  more  early  and  intensely  than  the  proximal.  The 
prognosis  depends  in  part  on  the  cause.  It  is  good  in  sensory  types  and 
in  forms  of  slow  evolution,  when  the  sensorium,  arms  and  trunk,  cranial 
nerves  (vagus)  and  sphincters  escape  involvement,  and  when  visceral 
disease,  as  liver  cirrhosis,  cord  or  brain  complications,  and  edema,  are 
absent.  The  prognosis  must  cover  the  possibility  of  recurrence  and  the 
progress  of  the  disease,  inevitably  slow,  requiring  a  year,  despite  treat- 
ment. 

Diagnosis. — The  cardinal  signs  are  (a)  the  motor  and  sensory  symptoms, 
which  correspond  in  function,  peripheral  distribution  and  symmetry; 
(6)  the  reaction  of  degeneration;  (c)  tenderness  of  the  nerves  and  muscles; 
(d)  loss  of  reflexes  and  (e)  the  etiology. 

Diagnosis  of  Type. — (a)  The  alcoholic  form  is  the  most  frequent; 
70  per  cent,  of  cases  occur  in  women;  the  legs  are  often  involved;  there 
is  the  ''steppage"  gait;  atactic,  sensory  and  mental  symptoms  are 
marked.  .  (b)  In  lead  poisoning  the  occupation,  lead  line,  colic  and 
constipation  are  characteristic;  the  arms  alone  are  involved  as  a  rule; 
there  is  little  sensory  participation;  the  involvement  rarely  extends; 
the  wasting  is  conspicuous,  (c)  Diphtheritic  form  (q.  v.).  (d)  In  the 
toxeviic  form  with  fever  and  constitutional  reaction,  it  begins  in  the 
legs  or  all  members  simultaneously,  involves  equally  the  flexors  and  is 
attended  by  slight  sensory  symptoms,  (e)  Beri-beri,  leprous  neuritis, 
erythromelalgia  and  Dercum's  disease  are  considered  elsewhere. 

Differentiation. — Atactic  polyneuritis  (pseudotabes,  Dejerine)  with 
little  motor  disturbance,  may  resemble  locomotor  ataxia: 

Locomotor  Ataxia. vs. Multiple  Neuritis. 

tlistory  or  stigmata  of  syphilis.  Rare;    infection  or  intoxication. 

Argyll-Robertson  pupil  Loss  of  accommodation  in  diphtheria. 

Optic  atrophy,  10  per  cent.  Rare,  but  toxic  amaurosis  is  frequent. 

Eye  paralysis  frequent.  Much  more  rare. 

Girdle  sensation  and  lightning  pains.  Very  rare. 

Gait  ataxic,  stamping,  striking  heel  first.  Disturbance  motor.     Striking  toe  first. 

Sensory  symptoms  predominate.  Motor  predominate. 

Paralysis,    reaction    of    degeneration    and       In  nearly  all  cases;    rapid  in  development 

amyotrophy  rare.  and  symmetrical. 

Nerve  trunks  often  insensitive.  Tender,  as  are  muscles. 

Arthropathies,  osteopathies.  Unknown;    glossy  skin  more  common. 

Crises.  Almost  unknown;    toxemic  vomiting,  etc. 

Sphincters  frequently  involved.  Very  rarely,  and  from  delirium. 

Clinical  evolution  very  slow.  Rapid. 

Disease  incurable.  Recovery  usual,  if  not  early  death. 


872  DISEASES  OF   THE  PERIPHERAL  NERVES 

Poliomyelitis. vs. Multiple  Neuritis. 

Usually  in  children.  In  adults. 

More  sudden  onset.  Gradual. 

Embraces  whole  limb,  at  random.  Strictly  peripheral  and  symmetrical. 

Muscles  functionating  together.     Reaction  Dissimilar  muscles  involved, 
of  degeneration  in  both,  but  strong  gal- 
vanic   current    not   required    to    produce  Muscles  respond    only    to    strong    galvanic 
muscular  contraction.  current. 

Pain  and  tenderness  rare.  Common  in  nerves  and  muscles. 

Sensory  disturbance  rare.  Usually  (but  not  invariably)  present. 

Immediate  tendency  to  regress,  but  usually  Tendency  to  progress, 

some  deformity.  Total  recovery  the  rule. 

In  acute  myelitis  the  onset  is  acute,  there  are  girdle  pains,  paraplegia, 
with  corresponding  anesthesia,  bed-sores,  disturbance  of  the  bladder 
and  rectum;  there  is  no  tenderness  of  the  nerves  or  muscles,  little  or  no 
ataxia  and  recovery  is  unusual.  Landry's  paralysis  often  cannot  be 
distinguished  (one  form  of  Landry's  disease  is  neuritic). 

Treatment.— Alcohol  must  always  be  considered  and  deception  guarded 
against;  it  should  be  withdrawn  at  once.  For  pain  see  Neuritis.  Ab- 
solute rest  should  be  enforced.  A  full  diet,  rich  in  fats,  should  be  given 
if  the  stomach  is  tolerant;  tonics,  as  iron,  maintain  nutrition,  but  arsenic 
should  be  avoided.  When  the  lower  cranial  nerves  are  affected,  feeding  by 
the  nasal  tube  or  by  rectum,  measures  to  avoid  hypostasis,  as  in  typhoid, 
and  cardiac  stimulants  are  indicated.  To  overcome  contractures  from 
ankle-  or  wrist-drop,  splints  or  sand-bags  are  employed  when  they  do  not 
cause  excessive  pain,  and  frames  to  lift  the  bedclothes  from  the  feet. 
Gentle  massage  and  voltaism  may  be  tolerated  after  the  acute  stage,  may 
prevent  contractures  and  aid  the  return  venous  flow.  Bromides  and 
chloral  are  the  most  certain  somnifacients,  but  chloral  requires  care  in 
chronic  alcoholism. 

NEUROMA. 

Two  varieties  exist,  the  true  and  the  false.  The  true  neuroma  may  be 
medullated  or  non-medullated,  though  ganglion  cells  are  exceptional; 
they  are  usually  multiple,  sometimes  very  numerous  (3020  in  one  case) 
and  have  been  found  on  every  cranial,  spinal  and  sympathetic  nerve 
(von  Recklinghausen's  disease,  of  which  Adrian  assembled  447  cases). 
They  may  undergo  sarcomatous  degeneration.  The  titberciila  dolorosa 
(Virchow)  are  small,  painful,  subcutaneous  nodes  on  the  trunk  or  ex- 
tremities, the  anatomy  of  which  is  obscure.  The  congenital  neuroma 
plexiforme  consists  of  twisted  cords  with  nodes  and  occurs  largely  in  the 
distribution  of  the  fifth  nerve.  The  false  neuroma  is  usually  fibrous; 
glioma  is  rare;  sarcoma  or  carcinoma  may  by  contiguity  invade  adjacent 
trunks;  neuromata  have  been  found  in  the  cerebral  nerves  in  syphilis  and 
in  the  peripheral  nerves  in  leprosy.  The  nerve  trunks  suffermore  in  the  false 
than  in  the  true  form.     Neuromata  in  amjmtation  stumps  are  frequent. 

Symptoms  and  Treatment.- — There  may  be  no  symjjtoms;  local  tender- 
ness and  local  or  projected  pain  are  frequent.  Reflex  muscular  spasm 
is  common  from  nerve  irritation.  Mentality,  sensation  or  motility  may 
be  affected.  Pigmentation  is  usual.  Treatment  is  symptomatic  for  the 
exhausting  pain  or  radical  in  localized  growths. 


OPTIC  NERVE  873 

DISEASES  OF  THE  CRANIAL  NERVES. 

OLFACTORY  NERVE. 

The  end  nerves  located  on  the  two  upper  turbinate  bodies  and  the 
upper  septum,  run  to  the  olfactory  bulbs,  which  are  part  of  the  brain, 
thence  to  the  centre  in  the  uncinate  gyrus  and  hippocampus,  with  re- 
lations to  the  optic  thalamus,  opposite  internal  capsule  and  cerebral 
cortex.     The  anterior  nares  perceive  odors,  the  posterior  flavors. 

Atiosmia  is  loss  of  smell.  Tests  are  made  not  with  pungent  sub- 
stances, as  ammonia,  which  irritate  the  fifth  nerve,  but  with  musk, 
asafetida,  cologne-water  and  the  essential  oils,  (a)  Disease  in  the  nasal 
mucosa  is  the  most  frequent  cause — from  paralysis  of  the  fifth  nerve, 
arrest  of  secretion  or  atrophy.  (6)  Disease  may  result  from  congenital 
absence  of  the  bulb,  basal  fracture  or  meningitis,  tabes,  foci  in  the  opposite 
internal  capsule,  etc.  (c)  Central  disease,  as  softening,  may  develop 
in  the  hippocampus  and  uncinate  convolution.  The  prognosis  is  unfavor- 
able and  treatment  ineft'ectual.  Hyperosmia,  oversensitiveness  of  smell, 
occurs  in  insane  and  neurotic  subjects;  it  may  be  cultivated,  so  that 
mdividuals  are  recognized  bj'  their  odor.  Parosmia,  perverted  sensation, 
is  rare  and  arises  from  irritation  of  the  nerves  or  centres.  Hallucinations 
of  smell  ma\'  occur,  as  of  burning  flesh  in  the  epileptic  aura. 

OPTIC  NERVE. 

1.  The  Retina. — Retinitis  occurs  in  general  diseases,  as  nephritis, 
especially  late  in  interstitial  forms.  The  degenerative  form  is  most 
common,  next  the  hemorrhagic  form,  with  "flame-like"  hemorrhages 
along  the  vessels,  and  finally  the  inflammatory^  type,  with  marked 
swelling  of  the  retina,  serum  exudation,  cloudiness  and  disk  blurring; 
the  white  foci  are  due  to  exudation,  fatty  change  or  sclerosis.  Similar 
findings  may  occur  in  syphilis,  anemia,  malaria,  leukemia,  plumbism,  dia- 
betes, etc.  (see  Plates  IV  and  VI).     There  are  apparently  primary  cases. 

2.  Optic  Nerve. — Optic  neuritis  (papillitis,  choked  disk)  has  been 
described  (see  Brain  Tumor  and  Plates  IV  and  VI).  Tumors  or  in- 
flammation in  or  back  of  the  orbit  or  errors  in  refraction  may  be  causal. 
In  the  primary  form  there  is  no  initial  inflammation.  The  edges  of  the 
disk  are  distinct,  its  arteries  nearly  normal  and  its  color  grayish;  it  may 
develop  hereditarily  in  males  at  puberty;  it  occurs  in  tabes,  paretic 
dementia,  multiple  sclerosis,  syphilis  and  less  often  from  diabetes, 
alcoholism,  plumbism,  specific  fevers,  amaurotic  family  idiocy  and 
familial  cerebellar  ataxia.  The /orm  secondary  to  inflammation  commonly 
follows  choked  disk  and  has  the  same  significance;  the  disk  has  an 
irregular  contour,  small  arteries  and  is  translucent.  The  s\Tnptoms 
are  diminution  in  acuity  of  vision,  field  of  vision,  color  perception  and 
the  pupillary-  reaction. 

3.  Chiasm. — Each  half  of  the  retina  contains  fibers  from  the  corre- 
sponding occipital  lobe  (see  Plates  XXIII),  that  is,  each  right  half  receives 
fibers  from  the  right  and  each  left  half  from  the  left  occipital  lobe.    The 


874  DISEASES  OF   THE  CRANIAL  NERVES 

outer  temporal  portion  of  the  field  of  vision  is  more  limited  than  the  inner 
nasal  portion,  because  the  nose  cuts  off  light  and  it  receives  fewer  nerve 
fibers.  The  larger  number  of  fibers  from  each  eye,  i.  e.,  those  from  the 
nasal  retinal  half,  decussate  at  the  chiasm  and  lie  in  its  centre.  Those 
from  the  temporal  half  are  direct  and  lie  at  the  side  of  the  chiasm.  While 
disease  of  one  optic  nerve  causes  blindness  in  the  corresponding  eye, 
lesions  affecting  the  centre  of  the  chiasm  (decussating  fibers  to  the 
nasal  half  of  each  retina)  cause  half-blindness  in  the  opposite  (tem- 
poral) visual  fields,  bitemjjoral  hemianopsia,  since  oblique  rays  passing 
the  pupil  fall  on  the  opposite  half  of  the  retina.  The  macula,  the  point 
of  sharpest  vision,  receives  fibers  from  both  sides  of  the  brain  and  escapes 
involvement.  Temporal  hemianopsia  may  result  from  tumors  of  the 
pituitary  gland,  pressure  from  the  third  ventricle,  gummata  and  hemor- 
rhage. The  "oscillating"  or  varying  bitemporal  hemianopsia  often 
indicates  syphilis.  The  diagram  illustrates  effects  of  lesions  of  the  lateral 
part  of  the  chiasm  (3),  lesions  affecting  both  sides  of  the  chiasm  (3  and 
3 A),  as  calcareous  or  aneurysmatic  carotids;  binasal  hemianopsia  is 
most  exceptional;  a  large  lesion  might  produce  temporal  hemianopsia 
in  one  eye  and  total  blindness  in  the  other;  still  more  extensive  disease 
might  produce  total  blindness. 

4.  Optic  Tract. — Just  back  of  the  chiasm  the  temporal  fibers  of  the 
right  and  the  nasal  fibers  of  the  left  side  form  the  right  optic  tract; 
i.  e.,  the  right  tract  contains  all  fibers  from  the  right  half  of  each  retina. 
The  tract  runs  over  the  crus  cerebri,  where  a  lesion  very  often  causes 
hemiplegia  on  the  same  side  as  the  blind  field.  The  fibers  enter  the 
geniculate  bodies  (in  which  80  per  cent,  of  the  optic  fibers  end),  opt. 
thalamus  and  ant.  quadrigeminate  body,  from  which  gray  ganglia  the 
fibers  pass  by  way  of  the  posterior  limb  of  the  internal  capsule  and, 
by  the  optic  radiation,  to  the  visual  centre  in  the  occipital  lobe,  the 
cuneus.  A  lesion  in  the  optic  tract  an;^^'here  between  the  chiasm  and' 
cuneus  produces  homonymous  hemianopsia  (at  5,  in  diagram);  for  in- 
stance, if  it  occurs  in  the  right  optic  tract  it  produces  loss  of  function  in  the 
temporal  half  of  the  right  and  nasal  half  of  the  left  retina,  so  that  the 
left  half  of  each  field  of  vision  is  lacking.  Hemianopsia  may  be  partial, 
or  only  a  quadrant  may  remain  after  partial  recovery.  Heteronymoiis 
hemianopsia  designates  blindness  of  the  right  half  of  one  field  and  the 
left  half  of  the  other  or  the  converse.  Disease  in  the  gray  ganglia  or 
internal  capsule  may  produce  contralateral  hemiplegia;  in  50  per  cent, 
of  cases  of  hemianopsia  this  association  is  observed,  and  less  frequently 
hemianesthesia.  The  optic  tract  is  injured  in  tumors,  multiple  sclerosis, 
trauma,  hemorrhage  or  softening. 

5.  Optic  Centre  (See  page  753). — A  lesion  in  the  cuneus  produces  (a) 
homonymous  hemianopsia.  Sometimes  only  an  upper  or  low^er  quadrant 
is  blind.  Purely  cortical  hemianopsia  is  impossible,  Monakow^  holding 
that  the  optic  radiation  must  be  involved;  (6)  hemichromaiopsia,  or 
homonymous  color-blindness  or  confusion,  in  which  all  colors  seem  gray, 
is  probably  due  to  lesion  of  the  anterior  superficial  cuneal  cortex.  Other 
results  are  (c)  mind-blindness;  (d)  alexia;  (e)  optic  aijhasia;  and  (/) 
crossed  amblyopia,  concentric  blurring  or  limitation  of  the  visual  fields 


PLATE    XXIII 


'^''^^^^ffu^^^^''^ 


Visual   Paths.       (After  Vialet.) 

OP.N.,  optic  nerve.  OP.C,  optic  chiasm;  OP.T.,  optic  tract;  OP.R.,  optic  radiation; 
V.S.,  visual  speech  centre.  A  lesion  at  (1)  causes  total  blindness  in  that  eye;  lesion 
at  (2),  bitemporal  hemianopsia;  at  (3),  unilateral  nasal,  and  lesions  at  (3)  and  (3A), 
bUateral  nasal  hemianopsia;  at  (4),  hemianopsia  of  both  eyes  and  the  hemianopsic  pupillary 
reaction;  at  (5)  or  (6),  hemianopsia  of  both  eyes  (pupillary  reflexes  being  normal;  at  (7), 
amblyopia,  especially  of  the  opposite  eye;  at  (8),  word-blindness. 


OCULAR  PARALYSIS;  THIRD,  FOURTH  AND  SIXTH  NERVES    875 

for  form  and  color;  this  is  usually  referred,  however,  to  flisease  of  the 
gyrus  augularis,  iu  which  there  is  thought  to  be  a  higher  centre  in  which 
the  half-fields  are  combined  and  the  whole  opposite  field  and  part  of  the 
field  of  the  same  side  are  represented. 

Diagnosis. — The  eyes  should  be  tested  separately.  Disease  of  an 
optic  nerve  causes  loss  of  sight  and  pupillary  reaction  in  the  corresponding 
eye.  Central  scotoma  (blindness  in  the  centre  of  the  visual  field)  indicates 
inflammation  or  hemorrhage  in  the  central  (axial)  fibers  of  the  nerve, 
usually  back  of  the  orbit;  it  is  common  in  poisoning  from  tobacco  and 
alcohol.  Peripheral  limitation  of  the  visual  fields  indicates  damage  to 
fibers  coursing  in  the  periphery  of  the  optic  nerve  and  some  damage 
to  all  the  nerve  fibers.  Sectorial  blindness  indicates  a  pronounced  but 
circumscribed  affection  of  the  nerve.  Bitemporal  hemianopsia  always 
results  from  chiasm  disease;  unilateral  temporal  hemianopsia  in  one  eye 
with  complete  blindness  in  the  other  has  the  same  significance,  but  also 
implies  that  the  process  has  extended  laterally,  possibly  even  to  the  optic 
tract.  Homonymous  hemianopsia  indicates  disease  of  the  optic  tract 
betw^een  the  chiasm  and-  cuneus.  If  the  geniculate  (or  quadrigeminate) 
bodies  are  the  seat  of  the  lesion,  Wernicke's  hemianopsic  pupillary  re- 
action is  obtained;  a  small  beam  of  light  in  a  dark  room  should  be  thrown 
on  the  hemianopsic  half  of  the  retina  and  the  patient  should  look  at  a 
distance  to  eliminate  accommodation;  if  the  pupil  does  not  react  to  light 
on  the  blind  half  (Wernicke's  reaction)  the  disease  focus  lies  at  or  to 
one  side  of  the  geniculate  or  quadrigeminate  bodies.  If  the  lesion  lies 
between  these  ganglia  and  the  cortex,  the  reaction  of  Wernicke  is  absent. 
Transient  hemianopsia  is  common  in  vascular  lesions;  if  it  lasts  for 
weeks  it  will  probably  remain.  In  Sequin's  case  it  was  present  for  twenty- 
three  years.  It  may  occur  in  migraine  and  very  rarely  in  hysteria.  Its 
association  with  the  crus,  internal  capsule  or  cortex  symptoms  already 
considered  is  of  localizing  importance.  Amblyopia  and  concentric  limita- 
tion in  the  fields,  marked  in  one  eye  and  less  in  the  other,  may  result 
from  (a)  optic  atrophy,  with  the  absent  pupillary  reaction,  and  seen 
with  the  ophthalmoscope;  or  (6)  disease  of  one  hemisphere,  the  ophthal- 
moscopic finding  and  pupillary  reflex  being  normal. 

Functional  and  Toxic  Blindness. — (a)  Hysterical  blindness  is  transi- 
tory and  rarely  complete;  the  eye  functionates  normally,  though  the 
visual  centre  neglects  the  impression;  it  is  often  associated  with  loss 
or  inversion  of  the  color  perception  and  with  hemianesthesia.  (6)  In 
andAyopia  from  tobacco,  vision  is  gradually  impaired  in  both  eyes, 
largely  as  central  scotoma  with  invariable  loss  of  perception  for  red 
and  green  colors;  the  fundus  is  usually  normal,  sometimes  congested; 
recovery  is  usual,  but  atrophy  may  result,  (c)  Toxic  amaurosis,  usually 
transitory,  may  occur  from  uremia,  poisoning  by  lead,  alcohol  or  quinine, 
syphilis,  acute  anemia,  etc. 

OCULAR  PARALYSIS;  THIRD,  FOURTH  AND  SIXTH  NERVES. 

General  Etiology. — (a)  Trauma  to  the  eye,  orbit  or  base  may  cause 
ocular  paralysis,  characterized  by  a  slow  course  and  often  imperfect 


876  DISEASES  OF  THE  CRANIAL  NERVES 

recovery,  (b)  Compression  by  tumors  in  the  orbit  which  often  produce 
exophthahnos ;  tumors  at  the  base,  aneurysm  and  rarely  hemorrhage  into 
the  nerve  sheath  may  produce  it.  (c)  Neuritis  produced  by  the  above 
factors,  orbital  cellulitis,  meningitis,  syphilis,  cavernous  thrombosis, 
alcoholism  and  acute  infections,  as  diphtheria  may  be  etiological  factors; 
exophthalmic  goitre,  plumbism,  and  diabetes  are  rarer  causes,  (d) 
Nuclear  disease  is  usually  due  to  chronic  wasting  disease,  as  in  tabes, 
multiple  sclerosis  or  bulbar  palsy,  but  sometimes  to  acute  lesions,  polio- 
encephalitic  or  vascular,  (e)  Supranuclear  disease  (v.  i.)  or  (/)  in  rare 
cases  muscular  dystrophy  may  be  a  cause. 

Anatomy  and  Physiology. — The  nerve  supply  is  by  the  sympathetic 
(which  through  the  ciliary  ganglion  dilates  the  pupil)  and  by  the  third, 
fourth  and  sixth  cranial  pairs,  which  arise  from  the  middle  ventricle, 
Sylvian  aqueduct  and  fourth  ventricle  and  are  arranged  as  follows  from 
before  backward :  (a)  the  third  nerve  nucleus  with  the  ciliary  and  behind 
it  the  pupillary  centre,  then  its  muscles  in  this  order :  the  internal  rectus, 
levator  palpeb.  superior,  inferior  rectus  and  inferior  oblique;  ih)  fourth 
nerve  nucleus  for  the  superior  oblique  and  (c)  nucleus  of  the  sixth  nerve 
for  the  ext.  rectus.  Their  connection  with  the  motor  cortex  is  through 
the  internal  capsule  and  corona  radiata.  The  third  nucleus  is  connected 
with  the  seventh;  winking  and  movements  of  the  eyelid  are  thus  asso- 
ciated with  the  pupil  reaction  and  accommodation.  The  action  of  the 
muscles  is  indicated  by  their  names  but  convergence  is  supplemented  by 
the  sup.  and  inf.  recti  and  the  two  oblique  muscles.  The  inf.  oblique 
turns  the  eye  upward,  the  sup.  oblique  downward.  The  upper  lid  is 
raised  by  the  levator  palp.  sup.  (acting  usually  with  the  sup.  rectus) 
and  by  Miiller's  muscle. 

Paralysis  of  the  Third  Nerve. — This  nerve  emerging  from  the  crus 
follows  the  cavernous  sinus,  and  therefore  may  be  involved  in  disease 
of  these  structures.  A  complete  paralysis  results  in  drooping  of  the  lid 
(ptosis),  which  the  patient  attempts  to  overcome  by  overaction  of  the 
frontalis;  the  eye  can  be  moved  only  outward  and  a  little  down  and 
inward  (ext.  rectus  and  sup.  oblique).  Accommodation  is  lost,  the  pupil 
is  wide  from  the  unopposed  action  of  the  sympathetic  nerve  and  does  not 
react  to  light.  There  is  double  vision  from  divergent  strabismus,  due  to 
action  of  the  unrestrained  ext.  rectus  muscle.  Paralysis  is  often  partial; 
the  levator  palp.  sup.  may  escape  involvement  or  be  affected  alone  or 
with  its  associate  (the  sup.  rectus),  especially  in  bilateral  nuclear  disease. 
Ptosis  may  be  (a)  part  of  an  ordinary  oculomotor  palsy;  (6)  part  of  a 
chronic  ophthalmoplegia  (v.  i.);  (c)  reflex  in  rare  cases  of  trigeminal 
irritation,  as  from  disease  of  the  teeth;  (d)  myopathic,  as  in  muscular 
dystrophy;  (e)  a  result  of  sympathetic  paralysis,  false  or  pseudoptosis 
(with  a  red,  edematous  skin,  slight  recession  of  the  eye-ball  and  con- 
tracted pupil);  (/)  an  incurable  congenital  form,  usually  partial  and 
bilateral;  (g)  a  transient  form,  observed  in  the  morning  in  women, 
usually  with  a  good  prognosis;  (h)  an  hysterical  form,  usually  bilateral, 
in  various  associations  with  the  sup.  rectus,  inf.  or  int.  rectus,  the  eye- 
brow being  frequently  lower. 


OCULAR  PARALYSIS;  THIRD,  FOURTH  AND  SIXTH  NERVES    877 

Internal  Oculomotor  Palsy.  —  Internal  oculomotor  palsy  includes 
cycloplegia  and  iridoplegia.  (a)  Cycloplegia  (paralysis  of  the  ciliary 
muscle)  results  in  loss  of  accommodation.  Near  vision  is  poor,  distant 
vision  is  good;  extreme  myopia  or  presbyopia  make  its  detection  difficult. 
Isolated  cycloplegia  in  one  eye  may  indicate  disease  of  the  lenticular 
ganglion;  in  both  eyes  it  is  nuclear,  as  in  diphtheria  or  tabes.  (6)  Irido- 
plegia may  assume  three  forms:  The  first  is  loss  of  associated  action, 
accommodation  iridoplegia,  in  which  there  is  no  pupillary  narrowing  in 
the  act  of  accommodation.  It  is  due  to  the  same  causes  as  cycloplegia 
and  is  usually  associated  with  it.  The  second  is  loss  of  the  light  reflex, 
reflex  iridoplegia,  the  Argyll-Robertson  pupil,  seen  especially  in  tabes 
and  paretic  dementia  (very  seldom  in  softening,  tumors,  senile  atrophy, 
hydrocephalus  or  congenitally) .  The  reflex  occurs  through  the  optic 
nerve,  optic  tracts,  corp.  quadrigemina  or  corp.  geniculata,  anterior 
part  of  the  oculomotor  nucleus,  probably  the  second  branch  of  origin  of 
the  third  nerve,  its  trunk,  the  ciliary  ganglion  and  its  nerves.  The  pupils 
are  often  equally  afi^ected  and  small  (spinal  myosis)  but  may  be  unequal 
(anisocoria,  also  observed  in  some  normal  persons).  If  the  pupils  are 
not  too  small,  cutaneous  iridoplegia  is  not  present.  The  third  form  is 
loss  of  the  skin  reflex,  cutaneous  iridoplegia,  in  which  the  normal  dilatation 
of  the  pupil  upon  pinching,  sticking  or  faradizing  the  skin  of  the  neck 
is  lost.  It  indicates,  in  general  terms,  disease  in  the  cervical  sympathetic 
nerve,  in  the  fibers  between  it  and  the  cervical  cord,  diseases  of  the  cord 
affecting  sensation,  or  of  the  centre  (probably  in  the  corp.  quadrigemina 
outside  the  light  reflex  centre  in  the  trunks  of  the  first  and  third  nerves). 
The  seat  of  lesion  is  probably  nuclear,  unless  special  localizing  symptoms 
indicate  otherwise.  Specifically  it  is  characteristic  of  tabes,  paretic 
dementia  or  syphilis. 

Recurrent  Palsy. — Periodic  palsy,  to  which  Gubler  (1860)  and  Mobius 
drew  attention,  is  a  rare  form,  involving  most  of  the  third,  and  rarely  the 
sixth  nerve.  It  occurs  chiefly  in  women.  At  intervals  of  months  to  years, 
possibly  throughout  life,  a  recurrent  paralysis  develops  for  a  few  days 
or  weeks  and  disappears.  Forms  which  begin  with  headache,  pain  and 
vomiting  were  called  ophthalmoplegic  migraine  by  Charcot.  Its  nature 
is  unknown  (peripheral  or  nuclear) ;  von  Monakow  holds  that  its  cause 
is  tumor,  meningitis  or  tubercle;  the  lesion  affects  the  eye  nerves  (or 
centres)  and  the  descending  branch  of  the  fifth ;  few  cases  are  seemingly 
hysterical. 

Paralysis  of  the  Fourth  (Trochlear)  Nerve. — Paralysis  of  the  superior 
oblique  is  of  little  importance.  In  attempts  to  converge  downward  the 
normal  inward  rotation  of  the  eye-ball  is  lacking. 

Paralysis  of  the  Sixth  Nerve. — The  eye  cannot  be  moved  outward, 
and  is  rotated  inward  by  the  unopposed  internal  rectus,  marked  diplopia 
resulting.  This  nerve  is  frequently  involved,  because  of  its  long  and 
exposed  course.  The  muscles  of  the  eye  are  involved  in  the  following 
order  of  frequency:  1,  ext.  rectus;  2,  sup.  oblique;  3,  inf.  rectus;  4, 
sup.  rectus;  5,  int.  rectus;  6,  inf.  oblique  (von  Grafe). 

Combined  Eye  Paralysis. — Convergence  and  accommodation  are  asso- 
ciated functionally  and  their  centres  lie  adjacent,  whence  they  are  often 


8/8  DISEASES  OF   THE  CRANIAL  NERVES 

lost  together.  The  internal  recti  ma}'  fail  to  contract  together  but  may 
move  separately  in  lateral  eye  movements.  Conjugate  deviation  may  occur 
(see  pages  761,  769);  if  a  lesion  occur  above  the  sixth  nucleus,  the  eyes 
cannot  be  directed  toward  the  side  of  lesion  and  are  directed  toward 
the  paralyzed  side;  if  the  lesion  is  at  the  sixth  nucleus  the  sixth  nerve 
on  that  side  is  paralyzed,  often  also  the  seventh,  and  the  opposite  third 
nerve  is  paralyzed,  not  from  lesion  in  the  third  nucleus  but  from  the  fact 
that  each  third  nucleus  receives  afferent  impulses  from  the  contralateral 
sixth  nucleus  for  associated  eye  movements. 

Symptoms. — The  symptoms  of  "paralysis  are  five: 

1.  Limitation  of  movement  in  the  paralyzed  muscle,  followed  by 
secondary  contraction  of  the  unresisted  opponent.  The  habitual  position 
of  the  head  corresponds  in  every  way  to  the  physiological  action  of  the 
paralyzed  muscle  (Landholt). 

2.  Strahismiis  (squint),  causing  lack  of  parallelism  in  the  visual  axes, 
which  are  divergent  when  the  int.  rectus  and  convergent  when  the  ext. 
rectus  is  affected;  this  constitutes  the  primary  deviation. 

3.  Secondary  deviation  is  the  extra  movement  of  the  sound  eye  in 
its  efforts  to  see,  due  to  its  increased  innervation,  detected  by  testing 
with  the  diseased  eye  closed  or  by  testing  with  ground-glass  over  the 
sound  one. 

4.  Erroneous  projection  in  the  paralyzed  eye.  Distance  is  normally 
judged  by  the  position  of  the  eye-balls  and  muscles  and  therefore  when 
secondary  deviation  from  excessive  innervation  of  the  sound  muscles 
occurs,  it  increases  the  impression  of  distance. 

5.  Diplopia  (double  vision)  results  from  failure  of  the  visual  axes 
to  correspond.  The  sound  eye  sees  the  true  image,  while  the  paralyzed 
eye  sees  the  false  one,  which  is  less  clear,  since  the  image  falls  on  a  less 
sensitive  retinal  area.  AATien  the  images  are  either  near  together  or 
else  widely  separated  the  false  one  may  be  "neglected."  Erroneous 
projection  and  diplopia  always  produce  vertigo  at  first.  If  the  false 
image  is  on  the  same  side  of  the  true  image  as  the  eye  by  which  it  is  seen, 
the  diplopia  is  simple  or  homonymous;  if  on  the  other  side,  it  is  crossed 
or  heteronymous.  The  eyes  are  tested  by  holding  red  glass  before  one 
eye  and  testing  vision  with  a  strip  of  white  paper.  If  the  red  image  and 
covered  eye  are  on  the  same  side  the  diplopia  is  simple;  if  on  opposite 
sides  it  is  crossed.  When  the  eyes  converge  it  is  simple,  when  they  diverge 
it  is  crossed;  i.  e.,  '/when  the  prolonged  visual  axes  cross,  the  diplopia 
is  not  crossed."  Holding  the  test  object  stationary  and  the  head  being 
turned  in  one  way  or  another,  in  some  directions  the  images  converge 
or  perhaps  blend,  while  in  the  opposite  direction  they  separate.  "The 
affected  eye  is  that  one  in  the  direction  of  whose  image  the  diplopia 
increases;  the  paralyzed  muscle  is  the  one  which  would  give  to  the  eye 
the  direction  of  the  false  image"  (Landholt).  ^Monocular  diplopia  is 
hysterical  (unless  there  is  disease  of  the  eye  media  or  error  in  curvature). 

Treatment. — Treatment  is  often  unsatisfactory  from  the  etiological 
standpoint.  Surgical  interference  or  specific  treatment  is  sometimes 
indicated,  but  syphilitic  forms  (q.  v.)  often  recur  or  become  permanent. 
In  acute  forms  counter-irritation  back  of  the  ear  bv  blisters,  leeches  or 


OCULAR  PARALYSIS;   THIRD,  FOURTH  AND  SIXTH  NERVES     879 

hot  fomentations  is  indicated.  Some  find  mercury  useful  in  peripheral 
forms.  Galvanism  is  the  best  form  of  electrotherapy,  but  is  seldom 
beneficial.     Prisms  and  tenotomy  are  sometimes  helpful. 

Progressive  Nuclear  Ophthalmoplegia. — Nuclear  palsy  was  first  de- 
scribed clinically  by  von  Grafe  (1856)  and  pathologically  by  Hutchinson 
and  Gowers.  The  etiology  is  not  clear;  syphilis  (in  17  per  cent.),  lead, 
alcohol  and  toxemia,  as  from  diabetes,  grippe  or  diphtheria,  are  possible 
causes.  A  few  cases  are  hereditary  or  congenital.  Most  cases  develop 
in  males  under  thirty  years  of  age.  The  pathology  usually  consists  of 
degenerative  nuclear  atrophy  resembling  bulbar  paralysis;  sometimes 
compression  or  meningitis  is  found  or  rarely  no  anatomical  alteration  is 
detected,  the  functional  form. 

Sjrmptoms. — The  symptoms  are  those  of  a  slowly  progressive  paralysis 
of  the  eye  muscles;  ophthalmoplegia  is  called  external  when  it  involves 
the  extrinsic  muscles,  internal  when  it  involves  the  pupil,  or  total  when 
both  are  concerned.  The  eye  muscles  are  successively  affected,  but  in  no 
given  order.  The  fades  of  Hutchinson  is  peculiar,  staring,  from  immobility 
of  the  eye-balls,  or  sleepy  from  partial  bilateral  ptosis.  Diplopia  is  un- 
common, or  only  an  early  symptom,  because  of  the  chronicity  of  the 
process.  Associated  muscles  are  often  affected  by  groups,  because  of  their 
successive  nuclear  involvement,  as  the  pupil  and  convergence,  one  internal 
and  the  opposite  external  rectus,  the  two  internal  recti  and  the  sup. 
rectus  and  levator.  Clironic  ophthalmoplegia  may  be  associated  with  the 
analogous  bulbar  paralysis  or  progressive  spinal  muscular  atrophy;  with 
optic  atrophy  or  with  double  facial  ptaralysis  (the  rare  and  obscure  infantile 
or  congenital  oculofacial  paralysis,  without  pupillary  involvement,  of 
which  ]\Iobius  collected  44  cases) ;  it  may  be  a  part  or  a  precursor  of  tabes, 
paralytic  dementia  or  multiple  sclerosis. 

Diagnosis. — Xuclear  iuA-olvement  is  probable  when  there  is  partial 
and  bilateral  ptosis,  escape  of  the  pupil,  or  involvement  of  one  or  more 
conjugate  groups.  The  lesion  may  be  supranuclear,  when  the  head  and 
limbs  are  involved,  exceptionally  when  there  is  isolated  convergence 
paralysis  or  paralysis  of  up-and-down  movements  with  ptosis.  Apoplecti- 
form nuclear  palsy  from  basilar  thrombosis  is  usually  asymmetrical, 
acute  and  associated  with  hemiplegia.  Wernicke's  superior  poliencephal- 
itis  is  distinguished  by  its  acuity  and  toxemia.  Ophthalmoplegia  from 
syphilitic  meningitis,  polyneuritis,  tumors  (corp.  quadrigem.)  and  orbital 
disease,  is  generally  distinguished  by  the  relatively  acute  course  and 
concomitant  symptoms. 

Prognosis. — The  disease  is  very  chronic,  possibly  lasting  twenty  to 
forty  years  and  is  progressive.  Arrest  is  possible,  but  can  never  be 
predicted.  The  disease  itself  causes  little  risk  to  life,  but  its  associates 
are  dangerous,  as  tabes  or  psychoses,  which  develop  in  18  per  cent. 

Treatment. — ^Treatment  is  generally  ineffectual.  Iodides  and  mercury' 
are  useless  in  nuclear  disease,  but  may  be  given  if  the  localization  is  not 
definitely  known. 

Sympathetic  Paralysis. — This  disease  was  first  described  by  Horner;  it 
])roduces  myosis,  due  to  paralysis  of  the  dilator  iridis,  and  slight  ptosis, 
due  to  paresis  of  ^Miiller's  muscle.     The  ocular  tension  is  decreased, 


880  DISEASES  OF   THE  CRANIAL  NERVES 

the  cheek  wasted  and  the  skin  reddened  and  warmer  than  normal.  Irri- 
tation of  the  sympathetic  is  characterized  by  wide  pupils,  widening  of  the 
interpalpebral  space  and  exophthalmos. 

Ocular  Muscular  Spasms. — Spasms  occur  in  conjugate  deviation,  irri- 
tation of  the  nerve  trunks  when  compressed  by  tumor,  and  rarely  in 
chorea,  facial  tic  and  spasmodic  torticollis.  In  hysteria  the  eyes  may  be 
rolled  upward  and  to  one  side,  concealing  the  iris,  or  they  are  often  fixed 
in  convergence;  they  never  diverge;  what  appears  to  be  ptosis  is  really 
spasm  of  the  orbicularis.  Convergent  spasm  may  also  occur  in  hyper- 
metropia  and  divergent  spasm  in  myopia.  Isolated  spasm  of  the  levator 
palpebrse  may  occur  in  irritation  of  the  cervical  sympathetic  or  fifth 
nerve,  in  advanced  years  or  Graves's  disease.  Secondary  deviation  (v.  s.) 
is  spasmodic,  as  is  also  nystagmus,  which  latter  consists  of  rapid,  rhythmic, 
clonic,  involuntary  oscillations,  due  to  muscular  spasm  with  alternating 
contraction  of  the  opposing  muscles.  It  is  continuous,  as  distinguished 
from  the  "tremor  of  weakness"  which  occurs  in  paretic  muscles  on  move- 
ment. It  is  usually  horizontal,  less  often  rotatory  and  rarely  vertical. 
Its  mechanism  is  probably  centric.  The  causes  are  (a)  disease  of  the  eye, 
as  opacities  and  choroiditis;  (h)  it  occurs  frequently  in  albinos,  and  (c) 
in  miners,  from  working  with  the  head  down  and  eyes  strained  to  one 
side;  (d)  it  occurs  as  a  cardinal  sign  in  multiple  sclerosis  and  Friedreich's 
ataxia,  as  a  common  sign  in  tumor  of  the  cerebellum,  corp.  quadrigem. 
and  opt.  thalamus,  occasionally  in  meningeal  disease,  sinus  thrombosis, 
hemorrhage  or  softening  and  very  rarely  in  hysteria. 

FIFTH  NERVE  (TRIGEMINUS;  TRIFACIAL  NERVE). 

The  nerve  originates  from  its  motor  nucleus  in  the  pons,  from  motor 
fibers  descending  from  the  corpora  quadrigemina,  and  from  sensory 
fibers  ascending  from  the  medulla.  It  is  connected  with  the  motor 
cortex  and  cerebellum.  The  motor  and  sensory  fibers  leave  the  pons 
separately  and  join  after  the  sensory  trunk  has  passed  through  the  Gas- 
serian  ganglion,  which  has  three  branches;  (1)  which  passes  to  the  orbit 
by  the  sphenoidal  fissure,  supplying  the  skin  of  the  forehead,  anterior 
scalp,  upper  lid,  bridge  and  top  of  the  nose;  it  is  connected  with  the 
cervical  sympathetic  nerve;  (2)  which  passes  by  the  foramen  ovale  to  the 
sphenomaxillary  fossa  to  supply  the  upper  and  lower  lids,  cheek,  fore- 
part of  the  temples,  side  of  the  nose,  upper  teeth,  gums,  pharynx,  tonsils, 
soft  palate,  uvula  and  roof  of  the  mouth;  it  has  connections  with  the 
sympathetic  nerve  and  the  facial  nerve  by  the  Vidian;  (3)  which  passes 
by  the  foramen  rotundum  and  sphenomaxillary  fossa  supplying  the  rest 
of  the  temples,  anterior  and  upper  parts  of  the  ear,  meatus,  lower  cheek, 
lower  lip,  lower  teeth,  gums,  chin,  tongue,  oral  mucosa,  salivary  glands, 
and  as  a  motor  nerve  to  the  muscles  of  the  lower  jaw,  temporals,  masseters, 
pterygoids,  mylohyoids  and  post,  belly  of  the  digastric.  The  lingual 
branch  gives  off  the  chorda  tympani  which  joins  the  facial  nerve.  From 
the  otic  ganglion  arises  the  small  superficial  petrosal  nerve  which  connects 
with  the  facial  nerve  and  ends  in  the  tympanic  branches  of  the  glosso- 
pharyngeal nerve. 


FIFTH  NERVE  881 

Causes  of  Paralysis. — (a)  Lesions  of  the  cortex  in  very  rare  cases. 
(6)  Focal  disease  in  the  pons,  as  hemorrhage,  tumors  and  less  often 
tabes  or  bulbar  paralysis,  (c)  Diseases  of  the  base,  as  syphilis,  meningitis, 
tumors,  caries  or  aneurysms,  (d)  Affections  involving  the  first  branch 
by  cavernous  thrombosis,  pituitary  tumor,  aneurysm  or  orbital  disease, 
or  the  second  and  third  branches  by  lesions  in  the  sphenomaxillary  fossa. 
(e)  Trauma,  puncture  or  bullet  wounds,  but  (/)  rarely  fractures,  or 
neuritis,  unless  it  is  secondary. 

Symptoms. — 1.  Sensory  Portion. — Anesthesia,  generally  unilateral, 
is  found  in  one  or  all  branches,  and  tactile  sensation  is  more  involved 
than  the  sense  of  pain.  It  is  often  preceded  by  tenderness  along  the 
nerves,  irritation  or  neuralgia.  In  complete  cases  the  skin  and  mucosa 
of  the  mouth,  nose  and  conjunctiva  are  anesthetic.  The  tongue  is  furred 
on  its  anesthetic  half,  because  the  food  is  not  chewed  on  that  side.  The 
conjunctival  reflex  is  abolished.  The  secretions  are  increased  by  irrita- 
tion or  decreased  by  paralysis.  Smell  is  blunted  and  taste  is  lost  (v.  i.). 
Sometimes  there  is  redness,  cyanosis  or  swelling  of  the  face  or  the  teeth 
may  be  loosened.  Two  trophic  manifestations  are  important.  The  first 
is  neuroparalytic  ophthalmia,  which  may  lead  to  ulceration  of  the  eye 
or  loss  of  the  bulb;  it  is  due  not  simply  to  conjunctival  anesthesia, 
which  predisposes  to  inflammation  because  of  foreign  particles  remaining 
unnoticed  in  the  eye,  but  is  rather  due  to  irritation  of  the  fifth  nerve  or 
Gasserian  ganglion.  It  has  not  occurred  in  many  cases  in  which  the 
ganglion  has  been  surgically  removed.  The  second  is  herpes  zoster,  which 
is  most  common  in  disease  of  the  first  branch,  results  from  irritation  of  the 
Gasserian  ganglion  or  the  nerves  just  anterior  to  it,  is  often  preceded 
by  pain  and  sometimes  leads  to  iritis  or  ophthalmitis. 

2.  Motor  Portion. — -Placing  the  fingers  on  the  temporal  and  masseter 
muscles,  when  the  patient  attempts  to  close  the  teeth,  reveals  their 
failure  to  contract.  Paralysis  of  the  ext.  pterygoid  is  shown  by  failure 
to  move  the  jaw  toward  the  sound  side  and  by  deviation  toward  the 
paralyzed  side,  when  the  jaw  is  depressed.  The  wasted  muscles  are  too 
deep  to  elicit  distinctly  the  reaction  of  degeneration. 

3.  Gustatory  Portion. — The  sense  of  taste  covers  only  bitter,  sweet, 
sour,  salty  and  metallic  substances,  while  flavors  are  recognized  by 
the  olfactory  nerve.  The  tip  and  edges  of  the  tongue  detect  saltiness 
or  sourness;  its  base,  bitterness  and  sweetness.  It  is  often  stated  that 
the  fifth  nerve  supplies  the  anterior  two-thirds  of  the  tongue  and  the 
glossopharyngeal  nerve  the  posterior  third  and  the  palate;  but  glosso- 
pharyngeal disease  alone  does  not  destroy  the  sense  of  taste.  In  a  study 
of  cases  of  Gasserian  extirpation.  Gushing  decides  that  taste  is  only 
temporarily  lost  and  that  it  does  not  travel  by  the  fifth  nerve.  Disease 
of  the  lingual  nerve  (from  the  fifth),  after  the  chorda  tympani  joins  it, 
produces  loss  of  taste  (ageusia) ;  disease  of  the  lingual  above  the  juncture 
or  disease  of  the  central  part  of  the  fifth  does  not  result  in  loss  of  taste. 
It  is  thought  that  the  gustatory  fibers  of  the  fifth  run  with  the  chorda 
to  the  seventh  nerve  which  they  leave  by  the  petrosal  nerve  to  again 
reach  the  fifth  through  Meckel's  ganglion.  Anesthesia  of  the  tongue 
may  result  from  facial  neuritis  and  middle-ear  disease. 

56 


DISEASES  OF  THE  CRANIAL  NERVES 

Diagnosis. — Organic  irritation  characterized  by  pain  alone  may  be 
difficult  to  differentiate  from  trifacial  neuralgia,  although  there  is  less 
radiation  and  more  hyperesthesia  in  organic  irritation.  When  all  branches 
are  anesthetic  the  disease  probably  lies  at  the  base  of  the  brain  or  in  the 
Gasserian  ganglion.  In  disease  of  the  mid-pons  the  first  division  alone 
may  be  aflfected;  in  disease  at  its  side  all  divisions  are  involved,  often 
with  implication  of  the  third,  sixth  or  less  often  seventh  and  eighth 
nerves. 

Treatment. — Counter-irritation  may  induce  ulceration.  Galvanization 
is  said  to  be  beneficial.  Gelsemium,  cocaine  and  morphine  must  be  used 
at  times  because  of  severe  pain,  but  the  acquisition  of  drug  habits  must 
always  be  borne  in  mind.  Boric  acid  and  castor  oil  should  be  dropped  in 
the  eye  several  times  daily.  Antisyphilitic  remedies  are  tried  in  doubtful 
cases. 

Masticatory  Spasm. — Romberg's  spasm  is  not  common.  In  the  tonic 
tyye  (trismus)  the  spasm  is  usually  bilateral  and  the  tense  muscles  are 
hard  and  may  be  tender.  The  cause  may  be  tetanus,  hysteria,  epilepsy, 
tetany,  tumor  in  the  pons,  cortical  hemorrhage,  or  it  may  be  reflex  from 
trigeminal  irritation,  as  from  temporomaxillary  disease  or  dental  caries. 
The  rare  clonic  type  may  be  serial  or  intermittent ;  chattering  of  the  teeth 
is  an  example.  It  may  occur  in  chorea,  epilepsy  or  hysteria.  Grinding 
of  the  teeth  occurs  in  paretic  dementia,  meningitis  or  typhoidal  states. 
Treatment  consists  of  tonics,  galvanization,  blisters  and  morphine  and 
cocaine  locally. 

Progressive  Facial  Hemiatrophy. — Of  this  affection,  first  described  by 
Parry  (1825),  about  200  cases  are  reported.  Its  pathogenesis  is  obscure, 
but  it  is  described  here  because  the  only  autopsy  on  record  showed 
neuritis  of  the  ascending  root  of  the  fifth  nerve.  Mobius  holds  that  acute 
infections,  as  measles  or  scarlatina,  are  causal,  some  virus  entering  through 
the  skin  or  tonsils  and  resulting  in  atrophy.  The  essential  change  is  a 
facial  hemiatrophy,  which  develops  most  often  in  persons  between  ten 
and  fifteen  years  of  age,  in  girls  (66  per  cent.)  and  in  60  per  cent,  affects 
the  left  half  of  the  face.  In  some  half-dozen  cases  the  atrophy  was 
bilateral.  The  cardinal  sign  is  atrophy  of  the  sHn,  which  is  blanched  and 
shrunken ;  its  fat  disappears  and  later  the  muscles  waste  and  the  rough 
skin  lies  directly  on  the  bone.  The  hair,  eyebrows  and  beard  on  the 
affected  side  lose  pigment  and  may  fall  out,  sweat  secretion  is  lessened 
and  the  mouth  is  drawn  toward  the  side  of  lesion.  The  bones  waste, 
especially  in  young  subjects,  most  notably  the  maxillae,  but  even  the 
smaller  bones  and  nasal  cartilages.  On  the  wasted  side  there  may  be 
no  vasomotor  reaction;  sensation  is  usually  normal,  although  pain  or 
paresthesia  may  be  noted.  The  tongue,  tonsils  and  palate  are  rarely 
involved.  The  course  is  very  chronic  and  practically  always  progressive, 
possibly  with  remissions.  The  outlook  is  hopeless.  There  is  no  treatment 
other  than  thyroid  extract;  the  injection  of  paraffin  to  lessen  the  facial 
deformity  is  dangerous. 

Facial  Hemihypertrophy. — Facial  hemihypertrophy,  of  which  only  13 
cases  are  on  record,  aft'ects  largely  the  cheek;  Werner  collected  9  con- 
genital cases.    Irritative  neuritis  is  its  suspected  cause. 


SEVENTH  OR  FACIAL  NERVE  883 


SEVENTH  OR  FACIAL  NERVE. 


The  face  is  represented  in  the  lower  Rolandic  cortex,  whence  the 
fibers  run  through  the  corona,  internal  capsule,  cms  and  pons  (g.  v.), 
where  they  decussate  and  enter  the  nucleus  of  the  opposite  side.  The 
nucleus  lies  in  the  floor  of  the  fourth  ventricle  inside  of  the  ascending 
branch  of  the  fifth  nerve  and  receives  fibers  from  the  third  nucleus  above 
for  the  orbicularis  of  the  eye  (whereby  ocular  movements,  winking  and 
accommodation  are  coordinated)  and  fibers  from  the  hypoglossus  below 
for  the  orbicularis  oris  (whereby  correlation  of  lingual  and  labial  move- 
ments is  effected).  It  curves  around  the  sixth  nucleus,  emerging  near 
the  juncture  of  the  pons  and  medulla,  and  enters  the  auditory  meatus 
with  the  eighth  nerve,  bends  sharply,  and  presents  a  ganglionic  swelling 
which  receives  the  large  superficial  petrosal  from  the  Vidian  nerve, 
containing  fibers  of  taste  from  the  fifth  nerve.  These  latter  again  leave 
the  facial  nerve  by  the  chorda  tampani.  In  the  Fallopian  canal  the  facial 
nerve  gives  off  branches  as  follows :  (a)  a  motor  branch  to  the  tympanic 
plexus ;  (b)  a  motor  twig  to  the  stapedius  muscle ;  (c)  the  chorda  ty mpani 
nerve  with  secretory  branches  to  the  salivary  glands.  Passing  through 
the  stylomastoid  foramen,  it  supplies  (i)  a  few  sensory  branches  to  the 
external  ear;  (ii)  motor  fibers  to  the  external  auricular  muscles;  (iii) 
motor  fibers  to  the  posterior  part  of  the  occipitofrontalis;  and  (iv)  in 
the  parotid  gland  breaks  up  into  branches  which  supply  all  the  muscles 
of  the  face,  the  platysma,  stylohyoid  and  post,  belly  of  the  digastric. 

Peripheral  Facial  Paralysis. — Prosoplegia,  Bell's  paralysis  (Bell,  1830), 
is  the  most  frequent  peripheral  palsy. 

Etiology. — 1.  Neuritis  is  the  usual  cause.  Exposure  to  cold  ("rheu- 
matism") produces  73  per  cent,  of  cases,  especially  in  men  between  the 
twentieth  and  fortieth  years.  Angina,  gout,  diabetes,  diphtheria,  typhoid, 
erysipelas,  mumps,  sepsis,  etc.,  are  occasional  causes. 

2.  Disease  of  the  petrous  portion  of  the  temporal  hone  (7  per  cent.), 
especially  caries  and  otitis  media  in  childhood,  is  dangerous  in  proportion 
to  the  extent  of  the  bone  disease;  88  per  cent,  of  cases  of  labyrinth 
disease  cause  facial  paralysis. 

•  3.  Trauma  causes  6  per  cent,  of  cases,  as  basal  fracture  by  tearing, 
hemorrhage,  inflammation  or  undue  formation  of  callus;  much  more 
rarely  meningeal. or  cerebellar  hemorrhage  at  birth;  the  use  of  obstetrical 
forceps  and  trauma  to  the  jaw  or  surgical  operations  on  the  parotid 
gland.     Facial  paralysis  may  occur  in  "head  tetanus." 

4.  In  intracranial  lesions  at  the  base,  syphilis  (3  per  cent.)  should 
always  be  considered;  syphilis  rarely  causes  peripheral  facial  paralysis. 
Aneurysm,  tumor,  meningitis  and  hemorrhage  usually  involve  the  closely 
contiguous  eighth  nerve. 

5.  In  the  pons  the  root  fibers  or  nucleus  may  be  affected,  usually 
with  the  sixth  nerve  of  the  same,  or  the  arm  and  leg  of  the  opposite 
side.  Degenerative  affections,  as  tabes,  bulbar  paralysis,  multiple 
sclerosis,  progressive  muscular  atrophy  or  acute  poliencephalitis  rarely 
invade  the  seventh  nucleus. 


884 


DISEASES  OF   THE  CRANIAL  NERVES 


6.  Rarer  factors  are  hemorrhage  into  the  Fallopian  canal,  disease  of 
the  parotid  or  lymphatic  glands  and  leukemic  infiltration. 

Pathology. — Few  autopsies  have  been  made.  The  nerve  has  been  found 
severed,  its  sheath  and  axis-cylinders  destroyed,  the  nuclei  in  Schwann's 
sheath  increased,  the  connective  tissue  increased  and  the  muscles  the 
seat  of  fatty  change.  The  essential  and  usual  change  is  perineuritis, 
exudation  in  the  sheath  compressing  the  nerve  fibers,  which  undergo 
parenchymatous  degeneration.  In  some  cases  degeneration  only  is 
seen;  it  is  probable  that  slight  swelling  interferes  with  conduction. 
Facial  neuritis  differs  from  multiple  neuritis  in  that  alcoholism  is  a  sub- 
ordinate factor  and  the  chief  change  is  not  in  its  peripheral  twigs  but 
in  the  trunk,  usually  within  the  Fallopian  canal. 


SUPER.   MAJOR 


ROOT  FACIALIS 

ROOT  ACOUSTICUS 


LATE  GANGLION 


DIAGASTRIC  NERVE 
STYLOHYOID 


ly'^S  "TO  FACE 
""^O  PLATYSMA. 

Fig.  76. — Relations  of  the  fifth  and  seventh  nerves  and  branches  of  the  seventh. 


Symptoms. — The  affection  sometimes  begins  with  headache,  pain, 
twitchings  in  the  face,  even  fever  or  albuminuria,  or  without  prodromes, 
when  one  half  of  the  face  is  suddenly  paralyzed  and  comiDletely  immobile 
and  toneless  within  two  days.  The  forehead  is  smooth,  the  lids  cannot 
close  (lagophthalmos),  the  tears  run  over  the  cheek  and  when  a  strong 
effort  is  made  to  close  the  eyes  the  eye  on  the  affected  side  is  turned 
upward  by  the  inf.  oblique  muscle  (Bell's  sign).  The  orbicularis  at  times 
escapes  involvement,  since  it  receives  some  fibers  from  the  third  nerve. 
Smell  is  impaired  because  of  absence  of  tears,  the  nasal  aperture  is  smaller 
and  cannot  be  dilated,  sniffing  on  the  affected  side  is  impossible  and  the 
nasolabial  furrow  is  lost.  The  mouth  is  lower  from  paralysis  of  the  levator 
anguli  oris,  it  cannot  be  closed  and  the  saliva  runs  out,  although  its  total 
secretion  is  often  lessened.  Labial  enunciation  is  imperfect,  puckering 
the  lips,  as  for  whistling,  is  impossible  and  expectoration  is  impaired. 
The  loss  of  wrinkles  and  expression  on  the  affected  side  is  less  marked  in 
young  subjects,  especially  about  the  eye,  since  years  lessen  the  elasticity 
of  the  skin  and  the  subcutaneous  fat.    Chewing  is  impaired  by  weak- 


SEVENTH  OR  FACIAL  NERVE  885 

ness  of  the  buccinator  and  food  accumulates  between  the  teeth  and  the 
cheek.  The  unused  half  of  the  tongue  becomes  furred.  The  tongue  does 
not  deviate  on  protrusion  but  may  seem  to,  on  account  of  asymmetry 
of  the  mouth.  The  tongue  is  sometimes  sHghtly  depressed  from  weak- 
ness of  the  stylohyoid  and  digastric  muscles.  The  platysma  paralysis  is 
elicited  by  asking  the  patient  to  depress  the  lower  lip.  The  palate  is 
sometimes  described  as  sagging,  the  speech  as  nasal,  the  uvula  as  deviat- 
ing toward  the  sound  side,  but  the  uvula  and  palate  are  often  asym- 
metrical in  health  and  there  is  a  tendency  to  regard  the  spinal  accessory 
as  the  motor  nerve  for  these  structures. 

7'aste  is  lost  in  disease  of  the  nerve  between  the  geniculate  ganglion 
and  the  offset  of  the  chorda;  it  is  lost  in  half  the  cases  of  "exposure" 
neuritis;  it  is  not  impaired  in  disease  of  the  pons  or  in  disease  outside 
the  skull.  The  chorda  supplies  the  anterior  two-thirds  of  the  tongue 
and  the  glossopharyngeal  the  posterior  third.  Perverted  taste  (para- 
geusia) results  from  irritation  of  Jacobson's  nerve  or  the  tympanic  plexus. 
Deafness  and  tinnitus  result  mostly  from  coincident  disease  of  the  ear. 
When  the  stapedius  is  paralyzed  the  unopposed  tensor  tympani  (fifth 
nerve)  overacts  and  results  in  aural  oversensitiveness,  especially  to  low 
notes  (hyperakusis  or  oxyokoia). 

All  facial  reflexes  are  abolished,  with  wasting  in  thin  subjects  and  the 
reaction  of  degeneration  in  a  week  or  two  in  severe  cases.  In  cases  of 
moderate  severity  the  excitability  may  be  first  increased  and  then  grad- 
ually decreased  in  seven  to  ten  days.  Pain,  even  anesthesia  in  the  ear 
and  tenderness  over  the  nerve  trunk  are  sometimes  observed,  caused  by 
involvement  of  the  fifth  nerve  or  possibly  because  the  facial  carries  some 
sensory  filaments.  Sympathetic  edema  and  sweating  have  been  observed. 
Herpes  indicates  trifacial  involvement.  The  saliva  is  decreased  (the 
fibers  for  its  secretion  run  with  the  chorda)  and  secretion  of  tears  is 
lessened  (the  fibers  from  the  facial  nerve  run  to  the  fifth  by  the  large 
petrosal  nerve). 

Diagnosis. — The  diagnosis  is  made  at  a  glance  in  fresh  cases;  in  older 
cases  secondary  spasm  on  the  paralyzed  side  may  cause  confusion.  The 
etiological  and  topographical  diagnosis  is  important. 

1.  Supranuclear  paralysis,  paralysis  in  the  upper  neurone,  from  the 
cortex  to  the  nucleus,  is  differentiated  as  follows: 

Supranuclear  Palsy. — — — vs. — Peripheral  Palsy. 

Etiology;    vascular  disease,  tumor,  etc.  Neuritis,  ear  disease,  etc. 

Distribution  of  paralysis;  partial,  lower  facial  Complete;     orbicularis  and  occipitofrontalis 

involved  or  only  slight  weakness  of  orbi-  involved.     When  eyes  cannot  be  closed, 

cularis  palpebrarum.  probably  peripheral  or  nuclear. 

Reflexes  persist  and  increased.  Lost.    Paralysis  flaccid. 

Taste,  auditory,  salivary  and  sensory  symp-  Often  present. 

toms  lacking. 

Pilocarpin  increases  salivary  flow.  Does  not  increase  it. 

Voluntary    motion    lost,    while    emotional  Both  lost. 

movement  very  often  persists. 

Degenerative  reaction  and  wasting  absent.  Present. 

Cerebral    symptoms    present,     general     as  Absent. 

headache,   or  focal  as   cortical   epilepsy, 

alternating  paralysis  (see  crus  and  pons 

localization). 


886  DISEASES  OF   THE  CRAXIAL   XERVES 

In  lesions  of  the  pons  all  parts  of  the  facial  nerve  are  affected,  wherein 
it  differs  from  facial  nerve  disease  in  the  internal  capsule.  In  nuclear 
disease  the  orbicularis  oris  is  less  invoh-ed  or  escapes  affection,  its  centre 
being  in  the  h^"poglossus  nucleus. 

2.  Localization  in  the  perijjheral  tyye  (see  Fig.  76)  may  be  (a)  in  the 
jjons  (q.  v.).  General  disease  of  the  posterior  pons  also  affects  the  sixth 
nerve  about  whose  nucleus  the  seventh  nen^e  curves.  (6)  In  locaUzation 
at  the  base,  taste  is  not  involved  and  deafness  results  from  coincident 
disease  of  the  eighth  nerve,  (c)  If  in  the  Fallopian  canal  taste  is  impaired, 
the  salivary  flow  decreased  and  hearing  often  abnormally  acute,  (d) 
If  external  to  the  skull  there  is  no  involvement  of  taste,  salivary  flow  or 
the  stapedius. 

Double  facial  paralysis  is  rare  and  usually  indicates  disease  within 
the  skull,  bulbar  paralysis,  disease  of  both  sides  of  the  pons  or  one  focus 
in  its  centre,  double  otitis,  especiallv  syphihs,  multiple  neuritis,  tetanus 
or  in  a  form  observed  in  childhood  with  ocular  paralysis  {q.  v.).  Organic 
facial  paralvsis  may  exist  on  one  side  and  an  hysterical  paralysis  on 
the  other. 

Prognosis. — Its  duration  varies  from  two  to  three  months  for  moderate, 
and  six  to  eight  months  for  severe  cases.  Even  in  cases  which  seemingly 
recover  and  in  those  lasting  over  a  month,  some  vestige  of  paralysis 
usually  remains.  The  prognosis  depends  (1)  on  the  cause;  it  is  faA'orable 
in  syphilis,  birth  trauma  and  polyneuritis;  in  ear  disease  it  is  better  if 
the  drum  has  not  ruptured;  it  is  unfavorable  in  tmnor  or  nuclear  disease; 
(2)  on  the  electrical  reaction.  If  after  ten  days  the  irritability  is  not 
reduced  recover}'  may  be  expected  in  about  three  weeks;  if  after  fourteen 
days  it  is  lowered  but  not  lost,  recovery  occurs  within  two  months; 
if  after  fourteen  days  the  irritability  is  lost,  the  prognosis  is  doubtful 
and  the  course  is  likely  to  cover  months.  Recurrence  is  infrequent, 
although  five  attacks  are  recorded.  Contracture  (secondary  overaction) 
usually  occurs  in  four  to  six  months  and  progresses  for  eight  to  twelve 
months,  when  it  lessens  and  disappears  in  mild  but  remains  in  severe 
cases.  In  old  subjects  it  balances  up  the  facial  contour;  in  young  subjects 
it  produces  deformity.    It  depends  on  functional  alteration  of  the  nucleus. 

Treatment. — (a)  The  cause  should  be  reached,  if  possible;  antisyphilitic 
remedies  and  ear-drainage  have  cured  cases  even  of  twenty-three  years" 
duration,  (b)  Antirheumatic  drugs  do  not  shorten  the  course.  A  mer- 
curial purge,  hot  fomentations,  which  must  be  carefully  maintained  for 
two  or  three  days,  keeping  the  patient  indoors,  and  a  blister  over  the 
mastoid  and  one  over  the  side  of  the  neck  are  beneficial,  (c)  Correction 
of  deformity:  The  eye  should  be  douched  with  boric  acid,  bandaged 
closed  during  sleep  and  the  lids  massaged,  the  cheek  and  mouth  should 
be  massaged  upward  and  a  hook  in  the  angle  of  the  mouth  (sustained 
by  tape  over  the  ear  or  by  adhesive  plaster)  prevents  deformity  to  some 
extent,  (d)  Electricity  should  not  be  used  for  two  or  three  weeks,  and 
then  the  galvanic  current  should  be  given,  for  fifteen  minutes  each 
day,  in  strength  just  sufficient  to  produce  muscular  contraction;  the 
application  of  the  anode  over  the  muscles  is  the  least  painful  method. 
The  faradic  current  causes  pain,     (e)  For  contracture  little  can  be  done 


THE  EIGHTH  OR  AUDITORY  NERVE  88^ 

excepting  massage  and  steaming  the  face.  (/)  In  irreparable  cases, 
surgical  transplantation  of  the  facial  trunk  into  the  spinal  accessory  or 
h^-poglossus  has  been  successfully  performed. 

Facial  or  Mimetic  Spasm  (Tic  Convulsif).— Etiology. — The  causes 
are  {a)  organic  disease  in  the  cortex,  pons  or  nerve  trunk,  which  irritates 
(perhaps  later  paralyzes)  the  centre,  nucleus  or  paths.  Irritation  of  the 
fifth  nerve  is  considered  causal,  (h)  There  is  an  idiopathic  form,  which 
occurs  in  persons  between  the  fortieth  and  sixtieth  years,  most  often  in 
women  with  neuropathic  or  emotional  tendencies  (see  Habit  Spasm 
under  Chorea)  .  (c)  There  is  also  a  reflex  form  which  results  from  worms 
or  uterine  disease. 

Symptoms. — The  spasm  begins  paroxysmally  on  one  side  and  is  more 
often  clonic  than  tonic.  The  clonic  form  affects  the  orbicularis  palpe- 
brarum (blepharospasm)  and  zygomatici  most  frequently,  although  the 
frontalis,  chin  depressors  or  all  the  facial  muscles  may  be  concerned 
in  severe  cases.  Pain  and  paresis  are  absent  save  in  progressive  organic 
disease.  The  spasm  is  lessened  by  rest  and  increased  by  cold  or  emotion. 
It  may  spread  to  the  opposite  side  or  exceptionally  to  the  muscles  of 
mastication,  tongue,  pharynx,  larynx,  neck  or  arm.  The  tonic  form  is 
seen  in  photophobic  disease  of  the  eye,  paralysis  agitans,  tetanus,  tetany 
or  hysteria. 

Prognosis. — The  prognosis  is  unfavorable  after  the  first  few  months 
and  the  disease  is  then  likely  to  last  for  years  or  for  life. 

Treatment. — Treatment  varies  with  the  cause.  Trigeminal  irritation 
should  be  removed  if  possible.  Arsenic  is  beneficial  in  some  cases,  but 
nervines  and  antispasmodics  are  useless.  Some  cases  are  cured  b\' 
galvanization,  if  tender  points  are  found,  freezing  of  the  cheek  with 
ethyl  chloride,  stretching  of  the  facial  nerve  usually  with  but  temporary 
relief  and  alcohol  injections. 

THE  EIGHTH  OR  AUDITORY  NERVE. 

The  eighth  nerve  in  the  old  nomenclature  was  the  portio  mollis  of  the 
seventh  pair,  the  facial  nerve  being  the  portio  dura;  as  the  names  imply, 
the  auditory  is  softer  than  the  facial  nerve  and  therefore  less  resistant  to 
pressure.  It  is  purely  sensory  and  consists  of  two  distinct  roots,  the 
cochlear  and  vestibular.  At  the  point  where  the  roots  separate  is  found 
a  group  of  cells,  analogous  to  the  spinal  ganglia,  from  which  arises 
Wrisberg's  nerve,  an  accessory  structure  with  vasomotor  and  salivary 
secreting  fibers. 

The  cochlear  nerve  is  the  true  auditory  nerve  and  its  nuclei  are  found 
in  the  floor  of  the  fourth  ventricle.  It  is  connected  through  the  teg- 
mentum of  the  crus  and  internal  capsule  with  the  contralateral  and  to  a 
less  degree  the  homolateral  temporosphenoidal  lobe.  It  is  distributed 
to  the  cochlea  and  ganglionic  cells  of  the  organ  of  Corti.  (a)  Cortical 
disease  (see  Brain  Localization)  may  in  rare  cases  cause  word-deafness, 
as  may  (6)  disease  of  the  auditory  tracts  by  lesions  of  the  lateral  lemniscus, 
the  post.  Corp.  quadrigemina,  internal  capsule  or  pons.  Nuclear  disease 
is  almost  unknown.     Neuromata  are  rare,  but  occur  on  the  auditory 


DISEASES  OF   THE  CRANIAL  NERVES 

trunk  oftener  than  on  any  other  cranial  nerve.  The  nerve  trunk  may 
degenerate  hi  tabes,  (c)  Lesions  at  the  base  may  follow  trauma,  menm- 
gitis,  hemorrhage  or  syphilis,  {d)  Most  auditory  nerve  disease  results 
from  disease  of  the  internal  ear,  either  primary  or  secondary  to  disease 
of  the  middle  ear  (inflammation,  syphilis,  degeneration  or  hemorrhage 
in  the  labyrinth).  There  are  three  prominent  symptoms:  (a)  Nervous 
deafness  may  result.  Deaf-mutism  is  congenital  in  80  per  cent,  and 
acquired  in  early  life  in  20  per  cent,  of  cases.  Deafness  from  occlusion 
of  the  meatus  or  from  disease  of  the  middle  ear  is  excluded  by  Rinne's 
test;  a  vibrating  tuning-fork  or  watch,  if  held  over  the  meatus,  is  not 
heard  in  these  affections,  but  is  heard  when  its  base  is  placed  on  the 
mastoid  which  conducts  vibrations  to  the  internal  ear.  In  disease  of  the 
internal  ear,  bone-conduction  is  lacking.  Differentiation  between  deafness 
due  to  disease  of  the  internal  ear  and  that  due  to  bone  disease  is  only  made 
by  means  of  the  associated  symptoms.  The  treatme?it  of  nervous  deafness 
is  etiological.  Iodides  are  sometimes  beneficial,  as  are  full  doses  of  pilo- 
carpine. Electricity  is  useless.  (6)  Auditory  hyperesthesia  may  result 
from  central  or  peripheral  disease.  In  genuine  hyperesthesia  (hyperacusis) 
sounds  are  heard  by  the  patient  which  other  individuals  may  not  hear, 
as  in  hysteria,  epilepsy,  migraine,  meningitis,  acute  mania  and  at  times 
after  use  of  caffeine,  alcohol  or  opium.  Spurious  hyperacusis  results 
from  paralysis  of  the  stapedius.  In  dysacusis  ordinary  sounds  cause 
disproportionate  sensations  or  discomfort;  this  is  common  in  headache 
and  cerebral  disorders,  (c)  Tinnitus  aurium  designates  subjective  dis- 
tressing and  intractable  sensations,  as  ringing,  roaring  or  whistling  in 
the  ears.  In  80  per  cent,  of  cases  it  is  caused  by  disease  of  the  internal 
ear.  It  may  also  occm*  in  any  disease  of  the  middle  ear,  when  there  is 
cerumen  or  foreign  bodies  in  the  external  meatus,  or  occlusion  of  the 
Eustachian  tube,  when  the  individual  is  subject  to  long  exposure  to  loud 
sounds,  as  in  boiler  factories,  and  in  the  neuroses  (hysteria,  neurasthenia, 
migraine,  epilepsy),  aneurysm,  anemia,  gout  or  cinchonism.  Sounds  of 
centric  origin  are  usually  continuous  and  sometimes  elaborate.  Wax 
or  bilateral  labyrinthine  disease  may  also  cause  continuous  timiitus, 
while  in  anemia  or  aneurysm,  these  sensations  are  intermittent.  Hearing 
may  be  hyperacute,  deranged  or  lost.  Spasm  of  the  palate  or  musculature 
of  the  Eustachian  tube  may  produce  a  most  annoying  snapping  somid, 
at  times  audible  to  bystanders.  Treatment  depends  on  the  cause. 
Bromides  are  most  useful,  combined  with  a  few  drops  of  the  tr.  bella- 
donna or  cannabis  indica.  Quinine  and  salicylates  seldom  give  relief. 
Full  doses  of  nitroglycerin  relieve  certain  cases  and  counter-irritation 
over  the  mastoid  sometimes  mitigates  tinnitus. 

The  vestibular  nerve  arises  from  the  medulla,  supplies  the  vestibule 
and  semicircular  canals,  subserves  sensation  of  space  and  equilibration 
and  has  cerebral  and  cerebellar  comiections. 

Meniere's  Disease,  Auditory  Vertigo  (Vertigo  ab  aure  Isesa). — Paul 
Meniere,  in  1861,  described  a  syndrome  consisting  of  vertigo,  tinnitus, 
vomiting  and  sometimes  deafness,  developing  with  apoplectiform  sudden- 
ness and  due  to  acute  labyrinthine  disease.  The  lesion  is  usually  a  slightly 
irritative  disease  of  the  vestibular  nerve,  which  supplies  the  organs  of 


THE  EIGHTH  OR  AUDITORY  NERVE  ■       889 

equilibration,  the  semicircular  canals.  xA.ccording  to  Gowers,  80  per  cent, 
occur  in  persons  between  the  thirtieth  and  sixtieth  years,  66  per  cent, 
in  males,  and  90  per  cent,  of  all  cases  of  vertigo  not  due  to  epilepsy  or 
organic  brain  disease  are  caused  by  lesions  of  the  labyrinth.  Frankl- 
Hochwart  classifies  Meniere's  complex  as  follows:  (a)  Apoplectiform 
cases,  which  occur  in  healthy  ears,  of  which  few  more  than  30  cases 
are  recorded,  due  to  labyrinthine  hemorrhage  or  to  trauma;  leukemia 
and  arteriosclerosis  are  promoting  factors  and  it  is  thought  that  acute 
angioneurotic  transudation  of  l^-mph  may  occur  in  the  canals,  (b) 
Cases  developing  in  ears  already  acutely  or  chronically  diseased;  the 
internal  ear  is  the  usual  seat  of  disease,  but  the  external  or  middle  ear 
may  be  affected  or  the  branches  of  the  eighth  nerve,  perhaps  by  tumors, 
syphilis,  tabes,  paretic  dementia,  gout,  cold,  facial  paralysis  or  quinine 
and  salicylates,  (c)  External  influences,  are  pressure  on  the  drum  by 
violent  douching  of  the  ear;  {d)  pseudo-Meniere's  disease,  which  occurs 
in  epilepsy,  hysteria,  neurasthenia,  migraine  or  sea-sickness. 

Symptoms. — The  symptoms  begin  gradually  or  suddenly,  with  occa- 
sionally momentary  loss  of  consciousness;  the  paroxysms  may  be  sepa- 
rated by  weeks  or  months  or  perhaps  occur  daily,  {a)  The  vertigo  is 
subjective  or  objective,  perhaps  combined;  the  patient  cannot  stand; 
he  is  likely  to  fall  backward  or  if  standing  is  possible  is  ataxic.  These 
symptoms  indicate  lesion  in  the  vestibular  nerve;  slight  vertigo  may 
persist  between  paroxysms,  (b)  Nausea  and  vomiting  are  usual,  save 
in  the  lighter  forms  and  are  often  attended  by  headache,  sometimes 
collapse,  pallor  and  clammy  skin  and  rarely  by  death,  (c)  The  tinnitus 
of  a  roaring  throbbing  character  and  {d)  nervous  deafness,  which  is  usually 
not  absolute,  indicate  disease  of  the  cochlear  nerve.  Nystagmus,  double 
vision  and  ataxia  are  occasional  symptoms  and  result  from  the  relations 
between  the  labyrinth,  cerebellum  and  cerebrmn.  Acute  or  progressive 
disease  is  unfavorable.  The  vertigo  may  cease  when  complete  destruction 
of  the  nerve  results  in  deafness.    Some  cases  recover. 

Diagnosis.— Aural  vertigo  constitutes  90  per  cent,  of  vertigo.  Differ- 
entiation is  as  follows :  (a)  Gastric  disease  may  cause  vomiting  and  vertigo 
{a  stomacho  loeso)  but  does  not  produce  tinnitus  or  deafness.  Gastric 
vertigo  was  once  thought  to  cause  80  per  cent,  of  cases  of  vertigo;  now, 
but  5  per  cent,  are  attributed  to  it  (Gowers).  Many  of  these  cases  are 
neurotic,  (b)  Epilepsy,  especially  petit  mal,  may  produce  vertigo,  very 
rarely  tinnitus  or  deafness  and  much  oftener  loss  of  consciousness,  (c) 
Cardiac  disease,  as  aortic  regurgitation  or  arteriosclerosis,  may  cause 
vertigo  but  not  the  other  symptoms,  {d)  Organic  brain  affections,  as 
tumor,  have  other  distinctive  signs,  as  headache  or  focal  lesions.  Con- 
fusion is  possible  with  arteriosclerotic  vertigo,  and  especially  with  coinci- 
dent accidental  deafness,  (e)  Ocular  vertigo  ceases  on  closing  the  e^'es. 
Gerlier  (1887)  described  a  form  endemic  in  France,  Switzerland  and 
Japan,  and  characterized  by  vertigo,  great  depression,  paretic  weakness 
of  the  neck  and  limbs,  ptosis,  strabismus,  diplopia  and  retinal  hyperemia, 
hemorrhage  or  edema.     Recovery  occurs  in  one  to  four  months. 

Treatment. — Labyrinthine  disease  is  little  influenced  by  drugs,  except 
when  s;^'philis  and  gout  are  its  causes.     Quinine,  salicylates  and  nitro- 


890  DISEASES  OF   THE  CRANIAL  NERVES 

glycerin  should  be  given  (see  Tinnitus).  Bromides  are  most  useful 
in  daily  doses  of  one  dram.  Galvanization  with  the  anode  over  the  ear 
and  cathode  to  the  neck  seemingly  has  helped  some  cases,  as  have  blis- 
ters over  the  mastoid.  Disease  of  the  pharynx,  Eustachian  tube  and 
accumulation  of  wax  must  be  treated.  Removal  of  the  malleus  and 
incus  with  mobilization  of  the  stapes  relieves  a  few  cases. 

i 

NINTH  OR  GLOSSOPHARYNGEAL  NERVE. 

This  nerve  is  almost  inseparably  connected  in  its  origin,  course  and 
functions  with  the  vagus  and  the  internal  part  of  the  spinal  accessory 
nerve.  Compared  with  disease  of  the  first  eight  cranial  nerves,  affections 
of  these  visceral  nerves  are  infrequent.  Of  all  the  cranial  nerves,  the 
ninth  is  least  understood  and  is  never  alone  diseased.  The  causes  of 
its  disease  are  the  same  as  those  of  the  vagus  (v.  i.). 

It  is  distributed  as  follows:  (a)  its  sensory  fibers  supply  the  back  of 
the  tongue,  pharynx,  soft  palate,  tonsil,  upper  pharynx.  Eustachian 
tube  and  tympanic  cavity.  It  is  probably  the  nerve  of  nausea,  (h) 
Its  motor  fibers  supply  the  upper  pharynx  and  possibly  the  palate. 
(c)  Taste  fibers  are  usually  thought  to  be  distributed  to  the  posterior 
third  of  the  tongue  and  palate,  but  they  are  not  found  in  the  nerve 
root  and  are  considered  to  pass  through  the  fifth  nerve  to  the  brain. 
Increased  flow  of  saliva  and  loss  of  taste  on  the  root  of  the  tongue  may 
result  from  disease  of  the  middle  ear  due  to  relations  between  the  nerve 
of  Jacobson  (ninth)  and  the  branches  of  the  fifth  nerve.  The  nerve  is 
thought  to  regulate  contractions  of  the  pharynx,  which  become  frequent 
(spasms)  in  disease  or  on  section  of  the  nerve. 

TENTH  OR  VAGUS  NERVE. 

Arising  in  the  medulla,  it  has  with  the  internal  part  of  the  spinal 
accessory  nerve  an  enormously  diffuse  and  important  visceral  distribu- 
tion. It  is  a  mixed  nerve,  the  motor  fibers  originating  from  the  nuclei 
and  the  sensory  fibers  from  the  jugular  and  plexiform  ganglia;  the  vagus 
carries  the  sensory  and  the  accessorius,  motor  fibers. 

Etiology. — Affections  of  the  vagus  result  from:  (a)  Nuclear  disease, 
as  degenerative  bulbar  palsy  or  acute  vascular  lesions,  which  usually 
also  involve  other  nuclei;  (6)  involvement  of  the  root  and  trunk  by 
meningitis,  syphilis,  caries,  trauma,  aneurysm  of  the  arch  or  its  branches, 
carcinoma,  esophageal  growths,  tuberculous  or  other  adenopathies, 
pleural  (right-sided)  or  pericardial  effusions  or  adhesions,  mediastinitis, 
goitres,  operations  on  the  neck  or  rarely  neuroma  and  neuritis  from 
diphtheria  or  other  infections,  tabes  or  plumbism.  Cortical,  especially 
functional,  causes  may  occasion  symptoms. 

Pharyngeal  Branches. — The  pharyngeal  plexus  consists  of  branches 
from  the  ninth  and  tenth  nerves.  In  paralysis,  sensation  and  the  pharyn- 
geal reflex  are  lost;  bilateral  disease  causes  dysphagia.  The  stomach- 
tube  can  be  introduced  without  sensation  or  spasm.  Pulpy  foods  are 
better  swallowed  than  dry  foods  or  fluids.     Food  is  likely  to  enter  the 


TENTH  OR   VAGUS  NERVE 


891 


larynx  and  when  the  palate  is  involved  there  is  regurgitation  into  the 
nose  and  nasal  speech  results.  The  palate  is  probably  supplied  by  the 
accessory  nerve.     SiMsm  is  always  functional,  transient  or   recurrent, 


Fig,  77. — The  laryngeal  paralyses:  1,  normal  phonation;  2,  normal  deep  inspiration; 
S,  normal  cadaveric  position;  A,  bilateral  adductor  palsy;  attempted  phonation;  B,  left 
adductor  palsy;  attempted  phonation;  C,  bilateral  abductor  paralysis;  deep  inspiration; 
D,  left  abductor  paralysis;  deep  inspiration;  affected  cord  in  cadaveric  position;  E,  left 
abductor  paralysis;  phonation;  affected  cord  in  cadaveric  positioh;  right  cord  crossing 
median  line;  F,  bilateral  thyro-arytenoid  paralysis;  G,  bilateral  thyro-arytenoid  paralysis 
and  paralysis  of  arytenoideus,  giving  an  hour-glass  opening.  (From  Church's  Nervous 
Diseases.) 


does  not  allow  of  introduction  of  the  stomach-tube  and  includes  the 
globus  hystericus,  esophagismus,  pharyngismus,  false  and  genuine  hydro- 
phobia and  the  pharyngeal  crises  of  tabes.  The  esophagus  is  rarely 
afl'ected  except  in  diseases  of  the  centres  or  trunk. 


892  DISEASES  OF  THE  CRANIAL  NERVES 

Laryngeal  Branches. — The  superior  laryngeal  is  (a)  the  sensory  nerve 
for  the  larynx  above  the  vocal  cords,  (6)  the  motor  nerve  for  but  one 
larynx  muscle,  the  cricothyroid,  which  modulates  the  voice  by  regulating 
tension  in  the  cords,  and  (c)  the  motor  nerve  for  the  depressors  of  the 
epiglottis,  the  thyro-epiglottic  and  aryepiglottic  muscles,  paralysis  of 
which  causes  the  epiglottis  to  stand  upright,  thereby  risking  aspiration 
of  food  and  pneumonia. 

The  recurrent  laryngeal  curves  around  the  aorta  on  the  left  and  the 
subclavian  artery  on  the  right  side;  (a)  it  is  the  sensory  nerve  to  the 
larynx  below  the  cords  and  the  trachea  and  (b)  is  the  motor  nerve  to 
every  intrinsic  larynx  muscle  except  the  cricothyroid. 

Treatment. — Paralysis  is  usually  peripheral  {v.  i.  table).  In  nuclear 
types  there  is  no  therapy.  Suggestion  is  valuable  in  hysterical  forms. 
The  faradic  current  may  be  used  with  the  positive  pole  to  the  forehead 
and  the  negative  to  the  larynx  externally  or  internally.  Other  measures 
include  laryngeal  gymnastics,  in  which  the  patient  repeatedly  attempts  to 
speak,  intralaryngeal  insufflations  of  alum,  the  administration  of  strychnine 
hypodermically  and  Ollivier's  procedure,  in  which  the  thyroid  cartilage 
is  compressed  between  the  index-j&nger  and  thumb  during  inspiration  and 
expiration,  while  the  subject  attempts  to  phonate.  Tracheotomy  and 
nasal  feeding  are  sometimes  indicated. 

Anesthesia  and  Hyperesthesia  of  the  Larynx. — Anesthesia  of  the  larynx 
is  rare,  but  may  occur  uni-  or  bilaterally  in  disease  of  the  sup.  laryngeal 
nerve,  the  vagus  roots,  its  nucleus  or  in  the  hemianesthesia  of  hysteria 
or  organic  brain  disease.  In  nuclear  disease  it  is  partial;  in  affections 
of  the  nucleus,  root  and  trunk  the  reflexes  are  lost,  but  they  are  present 
in  supranuclear  and  functional  affections.  Hyperesthesia  is  rarer,  being 
observed  in  neurotics  as  a  tickling,  tendency  to  cough  or  spasm;  neuralgia 
and  crises  also  occur. 

Laryngeal  Spasm. — ^The  most  common  form  of  laryngeal  spasm  is 
spasm  of  the  adductors,  which  are  concerned  in  reflexes  inimical  to 
entrance  of  foreign  bodies  into  the  larynx;  it  may  result  from  centric, 
local  (laryngitis  with  croup-like  cough  at  night)  or  reflex  irritation 
from  distant  or  neighboring  foci,  as  elongated  uvula,  goitre  or  hyper- 
trophy of  the  pharyngeal  tonsil.  It  includes  laryngismus  stridulus, 
which  occurs  in  children  under  three  years  of  age  and  is  due  to  rickets 
in  66  per  cent,  of  cases,  tetany,  and  reflexly  to  alimentary  disorders; 
it  comes  on  at  night  or  on  awakening  in  the  morning,  with  croup-like 
cough,  and  presents  all  the  symptoms  of  acute  suffocation,  as  stridor, 
pallor,  cyanosis,  wide  pupils,  protruding  eyes,  low  diaphragm,  involuntary 
evacuations,  centric  vasomotor  and  cardiac  disturbances  and  convulsions 
either  generalized  or  of  the  infantile  carpopedal  type.  The  attacks  last 
from  a  few  seconds  to  one-half  or  one  minute  and  are  sometimes  at- 
tributed to  loss  of  temper  when  they  follow  a  reproof.  In  the  adult, 
laryngeal  spasm  occurs  in  tabes,  hysteria,  tetany,  hydrophobia,  epilepsy 
(the  initial  cry),  asthma  or  migraine.  The  attacks  are  recognized  by 
the  negative  larvngoscopic  findings,  paroxysmal  occurrence  and  the  stridor 
being  manifest  in  both  inspiration  and  expiration.  Partial  spasm  occurs 
in  some  types  of  stuttering,  clergymen's  sore  throat  and  explosive, 
unmodulated  speech. 


TENTH  OR   VAGUS  NERVE 


893 


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894  DISEASES  OF   THE  CRANIAL  NERVES 

Nervous  covgh  is  present  in  the  explosive  hysterical  type,  in  the  metallic 
ovarian  form  in  young  girls  and  in  the  barking  variety  in  young  mas- 
turbators. 

Teeatment. — Treatment  of  spasm  includes  removal  of  local  irritation, 
as  affections  of  the  ear  (which  has  branches  from  the  vagus)  or  pharynx, 
hygiene,  tonics,  as  cod-liver  oil  in  children,  and  such  immediate  measures 
as  thrusting  a  finger  into  the  throat,  dashing  water  in  the  face,  hydro- 
therapy and  for  the  attack  chloral  and  bromides  by  enema,  local  applica- 
tion of  cocaine,  inhalation  of  chloroform  and  in  adults  nitrite  of  amyl 
and  morphine. 

Pulmonary  Branches. — The  vagus  and  the  sj^mpathetic  form  the  pul- 
monary plexus.  Afferent  fibers  convey  sensory  impressions  to  the 
respiratory  centre;  these  include  accelerating  fibers  which  predominate, 
and  inhibitory  fibers,  stimulation  of  which  (sup.  laryngeal  nerve)  arrests 
breathing.  Afferent  impulses  are  also  carried  to  the  vasomotor  centre. 
Efferent  motor  impulses  are  conveyed  to  the  bronchi.  Division  of  the 
vagus  causes  rapid  congestion  of  the  lungs  with  hemorrhage  (also  observed 
in  acute  lesion  of  the  pons)  and  slower  but  deeper  breathing ;  stimulation 
of  the  divided  end  of  the  nerve  accelerates  breathing  even  to  its  tetanic 
arrest.  Bronchopneumonic  foci  are  not  trophic  but  aspiration  pneumonia 
from  paralysis  of  the  palate  and  larynx.  The  pulmonary  twigs  are 
probably  concerned  in  Cheyne-Stokes's  breathing,  bronchial  astluna  and 
hiccough. 

Cardiac  Branches. — The  vagus  and  sympathetic  nerves  constitute  the 
cardiac  plexus,  (a)  Motor  fibers  from  the  spinal  accessory  nerve  inhibit 
and  coordinate  cardiac  action,  which  is  sometimes  imder  the  control 
of  the  will;  the  heart  may  at  times  be  slowed  by  pressure  on  the  neck; 
marked  irritation  of  the  vagus  slows  or  even  arrests  the  heart.  Bilateral , 
division  may  cause  sudden  death.  Paralysis  of  these  fibers  allows  the 
sympathetic  accelerator  fibers  to  dominate,  producing  arrhythmia  and 
tachycardia.  Digitalis  is  ineffective  in  vagus  paralysis.  (6)  The  sensory 
fibers  are  concerned  in  the  cardiac  neuroses  (q.  v.).  (c)  These  fibers 
are  probably  trophic,  as  Eichhorst's  experiments  show  fatty  myocardial 
degeneration  on  division  of  the  vagi. 

Gastric  Branches. — (a)  INIotor  branches  supply  part  of  the  stomach; 
they  cause  nausea  and  are  concerned  in  reflex,  direct  or  centric  vomiting, 
as  in  brain  lesions,  wherein  the  vomiting  usually  occurs  without  nausea. 
(6)  Sensory  branches;  the  vagus  is  the  nerve  of  hunger  and  thirst,  and 
its  disease  often  causes  anorexia  and  loss  of  thirst.  Centric  disease 
causes  the  gastric  crises  of  tabes  and  cortical  functional  disease  produces 
the  epigastric  aura  of  epilepsy  and  perhaps  gastralgia  in  the  neuroses. 
Vertigo  probably  causes  vomiting  through  the  vagus.  Intestinal  and 
splenic  symptoms  are  lacking. 


ELEVENTH  OR  SPINAL  ACCESSORY  NERVE   (EXTERNAL  PORTION). 

The  internal,  minor  part  runs  with  the  vagus,  while  the  major,  external 
segment  is  a  spinal  motor  nerve,  arising  from  the  lateral  portion  and 


ELEVENTH  OR  SPINAL  ACCESSORY  NERVE  895 

ant.  horns  of  the  cord  between  the  sixth  cervical  segment  and  the  medulla. 
It  courses  upward  through  the  foramen  magnum  into  the  cranium. 
It  is  the  chief  supply  of  the  sternomastoid  muscle  and  the  upper  part 
of  the  trapezius,  the  lower  two  parts  of  which  are  usually  supplied  by 
the  cervical  and  upper  dorsal  nerves. 

Paralysis. — Paralysis  is  rarely  caused  by  cortical  disease,  because  the 
muscles  have  bilateral  representation.  The  usual  causes  are  bulbar 
paralysis,  lesions  near  the  foramen  magnum,  meningitis  (usually  with 
involvement  of  the  inner  accessory  branches  and  the  twelfth  nerve), 
syphilis,  tramna,  tabes,  syringomyelia,  progressive  muscular  atrophy, 
caries  or  tumor  of  the  spine,  or  neuritis.  The  symptoms  are  paralysis  of 
(fl)  the  sternomastoid,  in  which  there  is  impaired  rotation  of  the  face  to 
the  side  opposite  the  lesion;  in  old  cases  contracture  turns  the  face 
toward  the  paralyzed  side,  (b)  That  part  of  the  trapezius  from  the  occi- 
put to  the  acromion  is  paralyzed,  showing  a  concave  instead  of  a  straight 
line,  best  seen  in  deep  inspiration  or  shrugging  the  shoulders.  (Paralysis 
of  the  second  portion  causes  imperfect  elevation  of  the  arm,  some  droop- 
ing and  winging  out  of  the  scapula,  the  lower  part  of  which  is  drawn 
toward  the  spine  by  the  rhomboids  and  lev.  anguli  scapulae;  paralysis  of 
the  third  portion  results  in  weakness  in  the  adduction  of  the  scapula 
to  the  spine.)  If  it  is  bilateral,  the  head  falls  forward  or  backward  as 
the  sternomastoids  or  trapezii,  respectively,  are  affected.  In  peripheral 
disease  there  are  wasting  and  the  reaction  of  degeneration. 

Accessory  Spasm,  Spasmodic  Torticollis  or  Wryneck. — Etiology. — It 
occurs  in  women  in  66  per  cent,  of  cases  (Gowers) .  A  neurotic  tendency, 
trauma,  overexertion,  infections,  alcoholism,  plumbism,  cervical  caries, 
brain  tumor  and  diseases  of  the  eye  and  ear  (torticollis  ab  oculo  Iseso, 
ab  aure  Isesa)  are  among  its  uncertain  causes. 

Symptoms. — The  symptoms  vary  as  the  affection  is  clonic  or  tonic, 
unilateral  or  bilateral,  and  with  the  number  of  muscles  involved.  One 
sternomastoid  is  generally  involved,  especially  in  tonic  spasm,  in  which 
the  occiput  is  turned  to  the  diseased  side,  the  face  to  the  opposite  side 
and  the  ear  nearer  the  clavicle.  The  upper  part  of  the  trapezius  comes 
next  in  frequency  of  involvement  and  is  affected  equally  by  clonic  and 
tonic  spasm.  The  affected  shoulder  is  raised  and  slightly  rotated,  the 
scapula  drawn  tow^ard  the  spine  and  the  head  backward.  The  spine  is 
often  convex  toward  the  diseased  side.  The  splenius  is  half  as  frequently 
affected,  the  head  being  drawn  backward,  the  face  a  little  to  the  affected 
side  and  upward.  Less  often  the  scalenus,  platysma,  rectus  and  obliquus 
capitis  are  affected.  The  muscles  in  tonic  spasm  are  hard,  prominent 
and  sometimes  hypertrophied.  Clonic  spasm  disappears  during  sleep, 
is  increased  by  fatigue  and  may  also  invade  the  face,  neck,  eye-balls, 
vocal  cords  or  the  arm.  There  may  be  pain,,  fatigue  and  rarely  tender 
spots  from  compression  of  the  brachial  plexus  by  the  scaleni.  Bilateral 
clonic  or  tonic  spasm  of  the  trapezius  draws  the  head  backward  (retro- 
collic  spasm)  and  always  involves  the  frontalis  muscle. 

Course  and  Prognosis. — The  onset  is  gradual,  the  disease  is  usually 
stationar}'  or  progressive  in  its  course,  rarely  recurrent;  recovery  is 
infrequent.    The  outlook  is  generally  grave  in  well-developed  types. 


896  DISEASES  OF   THE  CRANIAL  NERVES 

Diagnosis. — (o)  In  congenital  or  fixed  wryneck  there  is  no  active  spasm. 
One  sternomastoid  (but  rarely  the  trapezius)  shows  atrophy,  induration 
and  cicatrization,  due  to  traction  on  the  neck  during  deUvery  or  perhaps 
from  a  central  lesion;  70  per  cent,  occur  in  left  occipito-anterior  pre- 
sentations. The  disease  escapes  notice  for  years  because  of  the  shortness 
of  the  child's  neck.  Wilks  always  found  facial  asymmetry.  Tenotomy 
cures  it.  (b)  Hysterical  torticollis  occurs  in  subjects  under  thirty  years 
of  age;  other  stigmata  usually  develop.  Bompaire  and  Brissaud  describe 
a  mental  torticollis,  clearh'  a  psychical  phenomenon,  (c)  In  children 
clonic  spasms,  especially  in  the  deep  muscles,  lead  to  nodding,  salaam 
movements,  spasmus  nutans,  nictitatio  spastica.  The  affection  may 
develop  from  reflex  dental  or  digestive  disorders  or  from  organic  cerebral 
disease.    It  is  sometimes  habit  spasm,  hysteria,  epilepsy  or  idiocy. 

Treatment. — Treatment  is  etiological.  Nervines,  sedatives  and  electric- 
ity seldom  produce  permanent  results.  Morphine  is  a  dangerous  agent, 
although  its  local  hypodermic  use  has  led  to  recovery.  Massage  and 
deep  compression  are  occasionally  helpful.  In  chronic  cases  resection 
of  the  accessory  nerve  is  indicated.  If  many  muscles  are  involved  the 
third  and  fourth  cervical  nerves  are  also  resected. 

THE  TWELFTH  NERVE. 

The  hypoglossal  is  .purely  motor.  Paralysis  of  the  tongue  is  (a) 
rarely  cortical;  supranuclear  glossoplegia  from  lesions  between  its  centre 
and  the  frontal  convolutions,  almost  always  occurs  with  hemiplegia  and 
paralysis  of  the  lower  facial  fibers;  there  is  no  wasting  or  reaction  of 
degeneration.  The  root  of  the  tongue  is  higher  (hyoglossus  paralysis) 
and  on  protrusion  the  tongue  deviates  to  the  paralyzed  side,  being  pushed 
over  by  the  sound  genioglossus.  (6)  Nuclear  paralysis  occurs  in  bulbar 
paralysis,  sometimes  in  tabes  or  paretic  dementia,  and  much  less  fre- 
quently in  acute  inflammation  or  softening  in  the  medulla.  Nuclear 
lesions  are  bilateral  since  the  nuclei  are  closely  contiguous,  and  cause 
the  reaction  of  degeneration  and  wasting,  the  mucosa  being  wrinkled 
over  the  atrophic  half.  Fibrillation  is  frequent,  as  in  paretic  dementia, 
from  cortical  and  nuclear  changes.  In  bilateral  glossoplegia  the  tongue 
cannot  be  protruded,  there  is  impairment  of  the  first  act  of  swallowing, 
m  chewing  and  articulation,  all  of  which  are  but  slightly  marked  in 
unilateral  paralysis,  (c)  Infrayiuclear  paralysis  results  from  lesions  near 
the  surface  of  the  medulla,  which  may  produce  unilateral  paral^'sis  of 
the  tongue,  palate  and  vocal  cord.  Contralateral  hemiplegia  may  occur. 
Syphilis,  trauma  or  tumors  are  causal;  there  are  recorded  only  40  cases 
of  peripheral,  isolated  hypoglossal  paralysis  (Panski,  1903).  Wasting, 
the  degenerative  reaction  and  fibrillation  are  present.  Treatment  is  that 
of  other  paralyses. 

Spasm. — The  tonic  or  clonic  form  is  rare.  It  occurs  in  chorea,  facial 
spasm,  certain  types  of  stuttering,  epilepsy  (in  which  the  tongue  is 
bitten),  hysteria  (in  which  the  tongue  is  rarely  bitten),  psychoses, 
meningitis,  neurotic  spasm  in  speakers  (aphthongia)  or  musicians.  The 
prognosis  in  general  is  favorable. 


THE  PHRENIC  NERVE  897 


DISEASES  OF  THE  SPINAL  NERVES. 

The  spinal  nerves  differ  from  the  cerebral  in  that  they  contain  sensory, 
motor  and  vasomotor  fibers.  Disease  or  injury  therefore  suspends 
motihty  and  sensation,  causes  vasomotor  paralysis,  trophic  changes, 
the  reaction  of  degeneration,  atrophy  and  contracture. 

THE  PHRENIC  NERVE. 

Paralysis. — (a)  Disease  or  trauma  of  the  vertebrae,  cord,  membranes 
or  of  the  third,  fourth  and  fifth  cervical  nerves  of  origin  may  cause  it. 
In  disease  of  the  cord  other  paralysis  is  always  present.  (6)  Its  trunk 
may  be  injured  in  its  course  or  damaged  by  aneurysm,  tumors  or  pleurisy. 
Neuritis  sometimes  occurs  in  multiple  neuritis  or  tabes,  etc. 

Symptoms. — ^The  diaphragm  is  paralj^zed,  usually  on  both  sides. 
The  abdomen  retracts  on  inspiration  and  bulges  on  expiration,  the 
converse  of  its  normal  movements.  Litten's  sign  is  absent  and  there  is 
no  inspiratory  descent  of  the  liver  or  spleen.  Blowing,  coughing  and 
pressing  at  stool  are  impossible.  Costal  breathing  is  exaggerated,  the 
accessory  muscles  are  strongly  in  play,  dyspnea  and  cyanosis  are  present, 
especially  on  exertion,  and  coincident  bronchitis  may  cause  most  alarming 
symptoms  from  stagnation  of  mucus.  The  nerve  may  be  tender  in  the 
neck. 

Diagnosis  and  Treatment. — Costal,  hysterical  breathing  may  at  first 
cause  confusion,  as  may  inflammation  from  diaphragmatic  pleurisy.  The 
outlook  is  grave.  It  is  more  favorable  in  syphilis,  lead  or  diphtheritic 
neuritis  than  in  the  alcoholic  form.  Treatment  is  that  of  the  cause  but 
is  usually  futile.  Faradic,  phrenic  stimulation  is  sometimes  beneficial,  as 
in  apparently  asphyxiated  newborn  infants. 

Phrenic  Spasm. — 1.  In  clonic  spasm,  singultus  or  hiccough,  the  dia- 
phragm spasmodically  contracts  with  a  sound  due  to  sudden  closure  of 
the  glottis,  sometimes  50  to  100  times  a  minute.  Probably  the  vagus 
and  respiratory  centres  are  involved,  for  dyspnea,  dysphagia  or  dysarthria 
may  occur.  Clonic  spasm  occurs  (a)  in  inflammation,  either  thoracic 
(pleurisy,  pericarditis)  or  abdominal  (peritonitis,  appendicitis,  obstruc- 
tion); (6)  in  irritation,  esophageal,  mediastinal,  hepatic  or  gastric, 
directly  or  reflexly;  (c)  in  nervous  affections,  as  centric  disease  or  the 
neuroses;  and  {d)  in  toxemia,  uremia,  etc.  Treatment  is  that  of  the  cause. 
Gastric  lavage;  apomorphine;  circular  constriction  of  the  lower  chest 
with  the  head  bent  forward;  attempts  to  sneeze,  cough,  breathe  deeply 
or  press  down  with  the  glottis  -closed;  faradization,  blistering  the  neck 
and  epigastrium;  asafetida,  chloral  or  bromides;  and  narcotics  and 
inhalations  of  chloroform  or  amyl  nitrite  may  be  beneficial. 

2.  Tonic  phrenic  spasm  is  rarer.  The  causes  are  tetany,  epilepsy, 
tetanus  and  hysteria.  The  diagnosis  is  easy.  The  lower  chest  and  upper 
abdomen  are  distended  and  often  sensitive;  the  upper  chest  moves 
rapidly  and  forcibly,  with  the  accessory  respiratory  muscles  in  full  play; 
there  is  no  respiratory  excursion,  the  lungs  are  acutely  distended,  the 
57 


898  DISEASES  OF  THE  SPINAL  NERVES 

abdominal  viscera  are  luxated  downward,  there  is  dyspnea  and  cyanosis, 
and  death  may  result.  Treatment  consists  of  the  application  of  heat, 
blisters  and  the  faradic  current  to  the  lower  chest  and  chloroform 
inhalations  and  morphine  internall}^  Analogous  spasm  may  occur  in 
the  respiratory  muscles,  as  yawning,  sneezing,  coughing,  laughing  and 
weeping  spasms,  possibly  from  vagus  disease  or  from  the  neuroses, 
psychoses,  multiple  sclerosis,  bulbar  paralysis  or  disease  of  the  ear,  nose 
or  stomach. 

THE  POSTERIOR  THORACIC  NERVE. 

This  nerve  is  often  affected  in  its  long  course,  from  trauma,  muscular 
strains  in  overhead  work  (the  nerve  originates  in  the  scalenus  medius) 
and  from  carrying  loads  on  the  shoulder — whence  its  occurrence  in  men 
in  90  per  cent,  of  cases;  it  is  also  involved  in  muscular  atrophies  and 
neuritis.  The  results  are  impaired  fixation  of  the  scapula,  movement  of 
the  arm  and  inspiration.  The  scapula  wings  out  when  the  arm  is  moved 
forward  and  stands  less  obliquely  than  normal,  its  outer  part  moving 
forward,  while  the  lower  angle  is  drawn  in  by  the  rhomboids  and 
trapezius.  The  sole  sensory  change  is  pain  in  the  neck  and  shoulder. 
The  course  is  tedious  and  rest,  especially  of  the  scaleni,  is  the  prime 
indication. 

SUPRASCAPULAR  NERVE. 

It  originates  in  the  fourth,  fifth  and  sixth  cervical  nerves  and  is  affected 
in  disease  of  the  plexus  or  alone  in  trauma,  shoulder  dislocations  or  falls 
on  the  hands.  The  supraspinatus  and  infraspinatus  are  paralyzed, 
giving  some  weakness  in  fixation  of  the  humerus,  as  uncertainty  in  writing, 
turning  up  and  in  of  the  lower  scapular  angle,  some  anesthesia  over  the 
scapula,  frequently  shoulder-girdle  pain  and  often  involving  the  circum- 
flex nerve,  which  arises  from  the  fifth,  sixth  and  seventh  cervical  nerves 
of  the  posterior  cord  of  the  brachial  plexus.  Deltoid  paralysis  (dislocation, 
crutch  paralysis,  plexus  disease)  produces  inability  to  deviate  laterally 
the  arm,  changes  in  the  shoulder,  which  becomes  angular,  sometimes 
adhesions  in  the  joint,  probably  trophic  from  its  articular  branch  and 
anesthesia  over  the  lower  part  of  the  deltoid.  It  may  be  confused  with 
primary  joint  disease,  in  which,  however,  the  scapula  follows  the  arm 
movements. 

THE  MUSCULOSPIRAL  NERVE. 

.  Arising  from  all  the  roots  in  the  plexus  except  the  first  dorsal  and 
curving  around  the  humerus,  it  is  the  most  exposed  and  most  fre- 
quently injured  nerve  in  the  arm  or  body;  injuries  result  from  fract- 
ure, callus,  blows,  muscular  exertion,  carrying  heavy  weights,  tying  the 
arm  to  the  side  or  behind  the  back,  sleeping  with  the  arm  over  the  back 
of  a  chair,  especially  in  alcoholics,  lifting  the  arms  during  surgical  anesthesia 
and  from  a  tight  Esmarch's  constrictor;  less  often  injury  results  from  cold 
or  lead  palsy.  Mtisculospiral  (radial)  paralysis  involves  (a)  the  extensors 
of  the  upper  extremity,  i.  e.,  the  triceps,  so  that  the  elbow  cannot  be 
extended,  and  the  supinators;  the  triceps  sometimes  escapes  affection; 


THE   ULNAR  NERVE  .    899 

the  supinator  longus  is  not  involved  in  lead  palsy  or  traumatism  below 
the  lower  third  of  the  humerus  and  in  centric  disease  it  escapes  because 
its  centre  is  with  the  flexors.  The  extensors  of  the  ivrist  are  involved, 
producing  marked  atrophy  of  the  back  of  the  forearm  and  the  char- 
acteristic wrist-drop ;  the  extensors  of  the  thumb  and  fingers  are  affected ; 
they  become  semiflexed  and  can  only  be  extended  by  the  interossei  (ulnar 
nerve)  after  the  first  phalanges  are  passively  extended.  Changes  in  the 
synovial  sac  or  bones  of  the  dorsal  wrist  produce  the  painless  carpal 
tumor  of  Gubler,  from  involvement  of  branches  to  the  wrist  or  the  mere 
mechanical  action  of  flexion  (see  Lead  Intoxication).  (6)  Sensory 
distnrhcmce,  slight  compared  with  the  palsy,  may  rarely  cause  anesthesia 
over  the  deltoid  and  back  of  the  forearm  or  more  often  over  the  radial 
side  of  the  dorsum  of  the  hand,  thumb,  index  and  half  of  the  middle 
finger.  Most  cases  recover  with  rest  and  immobilization.  Flexor  con- 
tracture can  be  avoided  by  splints. 

THE  MEDIAN  NERVE. 

The  median  nerve  originates  from  the  outer  and  inner  cords  of  the 
plexus  and  contains  fibers  from  all  its  cervical  roots.  Isolated  paralysis 
is  not  common.  It  results  from  trauma,  fractures,  stabs,  carrying  weights 
in  the  bend  of  the  elbow  and  sleeping  on  the  arm.  (a)  Motor  symptoms 
are  conspicuous.  Both  pronators  are  involved,  besides  all  flexors  of  the 
forearm,  wrist  and  fingers  except  the  flexor  carpi  ulnaris  and  the  ulnar 
part  of  the  deep  flexor  of  the  third  and  fourth  fingers.  In  the  hand,  the 
palmaris  longus,  the  abductor,  opponens  and  short  flexor  of  the  thumb 
(resulting  in  flattening  of  the  thenar  prominence  and  the  "ape-hand" 
from  the  index-finger  and  thumb  lying  parallel)  and  the  two  radial 
lumbricales  are  afiFected.  The  second  phalanges  cannot  be  flexed  on  the 
first  (save  in  the  two  ulnar  fingers) ;  flexion  of  the  first  phalanges  by 
the  interossei  is  possible;  metacarpophalangeal  subluxation  may  result 
from  the  unopposed  extensor  action  of  the  interossei  on  the  second  and 
third  phalanges.  The  paralyzed  muscles  may  waste  and  trophic  mani- 
festations are  common,  (b)  Sensory  symptoms  are  often  slight.  Anes- 
thesia, if  present,  is  greatest  in  the  palm,  front  of  the  thumb,  first  two 
fingers  and  half  of  the  third. 

THE  ULNAR  NERVE. 

Its  origin  is  from  the  last  cervical  and  first  dorsal  nerves;  its  superficial 
course  at  the  inner  condyle,  forearm  and  wrist,  exposes  it  to  injury,  as 
by  dislocation  of  the  elbow,  cuts  and  pressure  on  the  elbow  during  sleep 
and  work.  Neuritis  occasionally  causes  paralysis.  It  must  be  dis- 
tinguished from  spinal  disease,  which  ascends  from  the  dorsal  to  the 
cervical  region;  this  form  is  usually  bilateral  and  is  preceded  by  ulnar 
anesthesia  in  tabes  and  paretic  dementia  (Biernacki).  The  flexor  carpi 
ulnaris  is  paralyzed  (the  hand  deviates  to  the  radial  side  in  attempts 
at  flexion),  and  also  the  ulnar  half  of  the  deej)  flexors  of  the  fingers,  the 
muscles  of  the  little  finger,  palmaris  brevis,  the  interossei,  the  third  and 


900  DISEASES  OF  THE  SPINAL  NERVES 

fourth  lumbricals,  the  adductor  and  inner  head  of  the  short  flexor  of  the 
thumb  (the  thumb  being  rotated  toward  the  palm) .  The  first  phalanges 
cannot  be  flexed  nor  the  others  extended,  although  this  is  less  marked 
in  the  first  and  second  fingers,  in  which  the  lumbricals  are  supplied  by 
the  median  nerve.  The  " clatv-hand"  results;  the  hypothenar  eminence, 
palm  and  interosseous  spaces  become  thin.  Sensory  loss  is  limited  to  the 
back  and  front  of  the  ulnar  side  of  the  hand,  the  dorsum  of  two  and  a 
half  fingers  and  the  front  of  one  and  a  half  fingers  on  the  ulnar  side. 

Combined  Paralysis  of  the  Arm  Nerves. — This  common  affection, 
described  by  Erb  (1884),  is  due  to  affections  of  the  vertebrae,  cord  or 
nerve  roots,  to  tumors,  trauma  or  cicatrices  of  the  neck  and  wrenches 
or  forcible  delivery  in  obstetrics.  Several  nerves  are  involved,  as  the 
musculospiral  and  ulnar  in  fracture  of  the  humerus,  or  in  subcoracoid 
luxation.  In  Erb's  case  the  circumflex,  suprascapular  and  musculo- 
cutaneous nerves,  fifth  and  sixth  cervical  roots,  with  some  branches 
from  the  fourth,  were  imbedded  in  a  cicatrix  and  paralyses  of  the  deltoid, 
teres  minor,  spinati,  biceps,  brachialis  and  supinators,  with  few  sensory 
signs  resulted ;  excision  of  the  scar  and  nerve  suture  resulted  in  recovery ; 
in  one  spot  between  the  scaleni  all  these  nerves  could  be  stimulated  and 
therefore  simultaneously  affected.  Obstetrical  paralysis  usually  recovers, 
while  adult  forms  are  often  protracted  or  permanent,  depending  on  their 
etiology.  Flaubert  (1827)  described  a  combined  paralysis,  which  usually 
bears  Klumpke's  (1885)  name,  in  which  paralysis  of  the  first  dorsal 
and  eighth  cervical  roots  (ulnar  and  median  paralysis)  also  causes 
narrowing  of  the  pupil  and  the  interpalpebral  fissure. 

BRACHIAL  NEURITIS. 

Gowers  first  clearly  described  a  perineuritis  of  the  plexus  or  nerve  roots 
(radicular  neuritis),  occurring  largely  in  gouty  or  rhemnatic  subjects  over 
fifty  years  of  age.  Cervical  rib  may  cause  compression  symptoms; 
Reisman  collected  46  cases  of  which  24  were  operated  on  with  good 
results.  But  5  per  cent,  cause  symptoms  and  85  per  cent,  are  bilateral, 
as  shown  by  radioscopy;  (a)  a  tumor  may  be  palpated;  (b)  nerve  pressure 
or  wasting  may  be  manifest;  or  (c)  the  subclavian  artery,  compressed 
by  the  scalenus  anticus,  may  be  abnormally  high  or  pulsate  like  an 
aneurysm;  even  gangrene  may  ensue.  Neuritis  is  marked  by  great  pain, 
the  first,  most  severe  and  most  enduring  symptom.  It  is  constant,  with 
paroxysmal  exacerbations,  is  increased  by  the  least  movement  and  is 
experienced  over  the  plexus,  nerves  or  referred  to  the  wrist  or  scapula. 
Associated  with  it  are  tenderness  over  the  trunks  or  plexus,  hyper- 
esthesia of  the  skin,  some  muscular  wasting,  mostly  in  radicular  forms, 
and  somewhat  less  often  anesthesia,  anesthesia  dolorosa,  edema,  glossy 
skin  and  trophic  alterations  in  the  joints.  Neuralgia,  angina  pectoris 
and  aneurysm  may  cause  diagnostic  difficulties.  Remak  holds  that 
reported  recoveries  of  acute  poliomyelitis  in  children  (Kennedy's  tem- 
porary paralysis)  are  only  plexus  neuritis.  A  long  course  of  from  a  month 
to  more  than  a  year,  relapses  and  even  wasting,  and  joint  adhesions  must 
be  considered  in  framing  the  prognosis,  despite  early  and  careful  treat- 


THE  NERVES  OF  THE   LOWER  EXTREMITIES  901 

ment.  Treatment,  as  in  neuritis,  consists  of  rest  by  immobilization, 
injection  of  cocaine  in  severe  cases  and  treatment  of  the  underlying 
trauma,  gout  or  rheumatism. 

THE  NERVES  OF  THE  TRUNK. 

These  are  rarely  involved  except  in  lesions  of  the  spine  or  cord.  The 
neuritic  'pain  in  Pott's  disease  or  cord  tumor  and  the  girdle  pain  of  tabes 
are  of  great  localizing  value.  Herpes  zoster  is  due  to  inflammation  in  the 
spinal  root  ganglia. 

THE  NERVES  OF  THE  LOWER  EXTREMITIES. 

These  nerves,  except  in  sciatica,  are  less  frequently  affected  than  those 
of  the  arm. 

The  Lumbar  Plexus. — The  first  three  and  a  half  lumbar  roots  may 
suffer  in  abdominal  tumors,  adenopathies,  parturition,  psoas  abscess, 
pelvic  inflammations,  meningitis  or  vertebral  disease.  The  symptoms 
are  paralysis  of  the  flexors  and  adductors  of  the  hip  and  extensors  of  the 
knee;  all  the  hip  flexors  are  involved  in  plexus  disease  only;  in  neuritic 
forms  great  pain  is  noted  in  the  ilio-inguinal,  iliohypogastric  and  genito- 
crural  areas.  Anesthesia  exists  over  the  lower  abdomen,  front  and  sides 
of  thigh  and  inner  side  of  leg  and  foot  and  adjacent  sides  of  first  and 
second  toes. 

Anterior  Crural  Nerve. — Lesions  in  the  abdomen  cause  paralysis  of 
the  iliacus  (not  the  psoas),  the  hip  flexors  and  knee  extensors,  with 
wasting,  loss  of  knee-jerk  and  anesthesia  over  the  front  and  sides  of  the 
thigh  and  the  inner  side  of  the  leg  and  foot.  It  may  result  from  stab 
wounds  of  the  thigh,  in  which  case  the  iliacus  escapes  involvement,  or 
after  delivery.  Neuritis  of  its  external  cutaneous  branch  (multiple  neuritis, 
alcoholism,  nicotinism  or  gout)  may  cause  isolated  anesthesia  over  the 
lower  outer  half  of  the  thigh,  paresthesia  or  marked  hyperesthesia;  the 
last  condition,  known  as  meralgia,  is  usually  neuritis  but  may  be  due  to 
pressure  from  varicose  veins  or  corsets.  It  is  noted,  chiefly,  on  standing 
or  walking.  In  1900  Musser  and  Sailer  collected  99  cases  (74  per  cent, 
in  men). 

Pressure  on  the  cord  at  the  fourth  lumbar  roots  produces  the  same 
result  as  a  partial  lesion  of  the  ant.  crural  nerve,  as  paralysis  of  knee 
extensors,  loss  of  knee-jerk  and  anesthesia  of  anterior  part  of  thigh,  but 
foot-clonus  is  present.  Anterior  horn  disease  may  occur  exceptionally, 
but  its  wider  prevalence  and  sensory  exemption  are  sufficiently  distinctive. 
Caudal  lesions  are  usually  bilateral. 

Obturator  Nerve. — This  nerve  is  rarely  alone  involved  save  during 
parturition.  Its  paralysis  affects  the  thigh  adductors,  so  that  the  knees 
cannot  be  crossed,  and  the  pectineus  and  ext.  obturator,  with  impairment 
of  outward  rotation  of  the  thigh.  The  hip  and  knee-joints  sometimes 
show  trophic  disturbance.  The  pain  of  hip  disease  is  referred  to  the  knee 
by  the  obturator  nerve. 


902  DISEASES  OF   THE  SPINAL  NERVES 

Superior  Gluteal  Nerve. — This  arises  from  the  lumbosacral  cord,  being 
intermediate  between  the  lumbar  and  sacral  plexuses.  Its  rare  isolated 
involvement  results  in  loss  of  thigh  abduction  and  circumduction  (gluteus 
medius  and  minimus). 

The  Sacral  Plexus. — Half  of  the  fourth,  the  fifth  lumbar  and  the  first 
four  sacral  nerves  supply  motion  to  the  extensors  and  rotators  of  the  hip, 
flexors  of  the  knee  and  all  the  foot  muscles,  and  sensation  to  the  gluteal 
region,  the  back  of  the  thigh,  outside  and  back  of  the  leg  and  most  of  the 
foot  by  the  gluteal  nerves  and  the  two  sciatic  nerves.  The  lesser  sciatic 
is  affected  only  in  disease  of  the  plexus;  it  is  often  involved  in  pelvic 
inflammation  and  tumors,  parturition,  traction  in  leg  deliveries  and 
diseases  of  the  hip. 

Great  Sciatic  Nerve. — This  is  the  largest,  the  most  exposed  through- 
out its  course  and  hence  the  most  frequently  diseased  nerve  of  the  lower 
extremity.  Paralysis  of  the  gluteus  maximus  interferes  with  rising  more 
than  with  walking.  A  lesion  near  the  sciatic  notch  paralyzes  the  extensors 
of  the  hip,  the  flexors  of  the  leg  and  all  muscles  below  the  knee.  If  the 
lesion  lies  below  the  upper  third  of  the  thigh  the  flexors  of  the  leg  may 
escape  involvement  and  walking  is  still  possible,  even  though  all  muscles 
below  the  knee  are  paralyzed,  if  the  ant.  crural  nerve  (hip  flexors  and 
knee  extensors)  is  intact.  Sensation  is  lessened  over  the  outer  half  of  the 
leg,  most  of  the  dorsum  of  the  foot  and  all  of  the  sole.  Wasting  is  marked 
over  the  back  of  the  thigh  and  perforating  ulcer  of  the  foot  may  develop. 
It  has  two  branches:  (a)  the  external  yopliteal  or  'peroneal  nerve,  involve- 
ment of  which  causes  paralysis  of  the  tibialis  anticus,  peronei,  long  toe 
extensors,  extensor  brev.  digitorum;  the  ankle  cannot  be  flexed  dorsally, 
the  first  phalanges  of  the  toes  cannot  be  extended,  adduction  and  lifting 
the  inner  edge  of  the  foot  are  difficult  and  abduction  and  lifting  the  outer 
edge  are  impossible.  Foot-drop  results  and  contracture  assumes  the 
equinovarus  type.  This  nerve  is  the  analogue  of  the  musculospiral  in  the 
arm.  Wasting  is  often  observed  and  the  anesthesia  covers  the  anterior 
outer  half  of  the  leg  and  the  dorsum  of  the  foot.  (6)  Internal  popliteal 
nerve,  involvement  of  which  affects  the  popliteus,  tibialis  posticus,  long 
flexors  of  toes  and  all  the  foot  muscles  except  the  extensors;  plantar 
flexion,  abduction  of  the  foot,  inability  to  stand  on  tiptoe,  talipes  cal- 
caneus and  the  claw-foot  from  overextension  of  the  proximal  and  over- 
flexion  of  the  second  and  third  phalanges  result.  Sensory  alterations 
are  variable;  anesthesia  may  be  observed  on  the  outer  lower  posterior 
part  of  the  leg  and  on  the  sole  of  the  foot.  Its  plantar  branches  are 
rarely  affected  alone;  (i)  paralysis  of  the  internal  plantar  nerve,  which  is 
analogous  to  the  median ;  anesthesia  on  the  inner  part  of  the  sole  and  the 
plantar  surface  of  the  three  inner  toes  and  one-half  of  the  fourth;  paralysis 
of  the  short  toe  flexors,  plantar  muscles  of  great  toe  (except  the  ab- 
ductor) and  the  two  inner  lumbricals;  the  big  toe  is  overextended, 
"the  hammer  toe";  (ii)  paralysis  of  the  external  plantar  nerve,  the  ana- 
logue of  the  ulnar,  produces  anesthesia  of  the  outer  half  of  the  sole,  little 
toe  and  one-half  the  fourth,  paralysis  of  the  accessory  flexor,  small  toe 
muscles,  all  the  interossei,  two  outer  lumbricals  and  great  toe  adductor; 
the  results  are  serious,  walking  being  impaired  by  flexion  of  the  second 
and  third  and  extension  of  the  first  phalanges. 


SCIATIC  NEURITIS  903 

Caudal  Lesions. — (See  Spkval  Localization.) 

Sciatic  Neuritis. — Sciatica,  Ischialgia,  ^Nlalum  Cotunnii  (Cotugno, 
1764)  is,  after  facial  neuritis,  the  most  frequent  isolated  neuritis. 

Etiology. — 1.  General  Causes. — (a)  Sex  and  age;  88  per  cent,  of 
cases  occur  in  men;  16  per  cent,  between  twenty  and  thirty,  31  per  cent, 
between  thirty  and  forty,  25  per  cent,  between  forty  and  fifty  and  18 
per  cent,  between  fifty  and  sixty  years  of  age.  It  is  very  rare  in  children. 
(6)  Acute  infections,  as  rheumatism  and  grippe  are  causative,  (c)  In- 
toxications; gout,  fascial  rheumatism  (sometimes  by  extension  from 
limibago)  and  diabetes  are  factors,  (d)  Anemias  and  neuroses  are  less 
significant  than  in  neuralgia. 

2.  Local  causes  include  (a)  spinal  afi^ections,  tumor  and  caudal 
neuritis;  (6)  abdominal  and  pelvic  diseases,  as  aneurysm,  tumors  or 
inflammation;  (c)  cold,  exposure  and  dampness,  favored  by  certain 
occupations;  (d)  trauma  to  the  spine,  pelvis,  hip  or  peripheral  course  of 
the  sciatic  trunk  or  branches,  as  from  the  use  of  forceps  or  pressure  of  the 
head  in  labor,  fractures,  dislocations,  falls,  protracted  sitting  or  riding, 
use  of  the  sewing  machine,  marching,  peripheral  pressure  by  popliteal 
aneurysm,  tiunors,  callus  or  varicosities. 

Pathology.— The  infrequent  autopsies  or  operations  show  perineuritis 
with  edema  and  in  some  cases  increase  of  connective  tissue  or  varicosities 
of  the  sheath  vessels,  especially  in  the  mid-thigh.  Sometimes  interstitial 
neuritis  is  found. 

Ssonptoms. — The  symptoms  are  unilateral  and  chiefly  sensory,  as 
pai?i  and  tenderness  over  the  sciatic  roots,  trunk  and  branches,  (a) 
The  onset  of  pain  is  usually  gradual  but  is  sudden  and  febrile  in  some 
rheumatic  cases.  It  is  usually  constant,  with  exacerbations  which  may 
be  agonizing.  The  pain  descends  more  often  than  it  ascends;  it  sometimes 
radiates  to  the  buttocks,  crural  region,  even  into  the  other  leg.  The 
local  pain  is  perineuritis  and  the  distant  pain  interstitial  neuritis."  Any 
movement  which  increases  sciatic  tension  increases  or  renews  the  pain 
(Lasegue's  phenomenon),  as  flexing  the  hip,  extending  the  knee,  walking, 
stooping  or  defecation.  The  patient  seeks  positions  which  spare  stretch- 
ing of  the  nerve  and  its  compression  by  the  muscles;  he  may  lie  on  the 
opposite  side  with  the  thigh  extended,  knee  flexed  and  foot  extended,  or 
on  his  back  with  hip  and  knee  flexed  and  foot  extended ;  in  standing,  he  rests 
on  the  sound  leg  and  in  protracted  cases  scoliosis  develops  (ischias  scolio- 
tica),  in  which  the  lumbar  convexity  is  toward  the  diseased  side,  heterol- 
ogous scoliosis,  which  usually  disappears  with  the  disease;  a  homologous 
scoliosis  (with  the  lumbar  concavity  toward  the  affected  side)  may  result 
in  case  the  muscles  of  that  side  become  spasmodic,  (b)  Tenderness  may 
be  detected  over  the  entire  course  of  the  nerve  or  in  certain  locations  only: 
(i)  over  the  lumbar  region;  (ii)  near  the  sacrum  and  post.  sup.  iliac  spine; 
(iii)  at  the  lower  gluteal  fold  where  it  leaves  the  sciatic  notch;  (iv)  be- 
tween the  tuber  ischii  and  trochanter;  (v)  especially  over  the  middle  of 
the  posterior  surface  of  the  thigh;  and  (vi)  lower  over  the  popliteal  space, 
head  of  fibula,  calf,  malleoli  and  sole.  The  enlarged  nerve  may  occasion- 
ally be  felt.  Pain  is  often  experienced  in  the  hip  and  sciatic  notch  when 
pressure  is  made  in  the  popliteal  space,  (c)  Other  symptoms  are  less 
frequent,  as  vasomotor  changes,  herpes,  muscular  cramps,  twitchings, 


904  DISEASES  OF   THE  SPINAL  NERVES 

fibrillation  or  myokymia;  there  is  rarely  a  marked  degenerative  reaction; 
muscular  atrophy  from  disuse  or  neuritic  atrophy,  sciatic  paralysis, 
hypesthesia,  paresthesia,  or  in  severe  cases  anesthesia,  may  develop  in 
the  posterior  part  of  the  thigh,  leg  or  foot.  The  patellar  reflex  is 
usually  normal,  the  Achilles  reflex  is  often  decreased  or  absent  and  the 
cremasteric  usually  increased. 

Diagnosis. — (a)  The  etiological  factor  should  be  sought,  (b)  The 
pelvis  must  be  examined  in  women  and  the  rectum  in  both  sexes,  because 
compression  produces  more  distant  than  local  pain;  the  urine  should 
always  be  examined  for  sugar  and  albumin;  and  free  catharsis  and  bowel 
lavage  given,  (c)  Bilateral  sciatic  pain  suggests  diabetes,  or  disease  of 
the  cord,  especially  tabes,  or  a  lesion  of  the  cauda,  in  both  of  which  there 
is  no  sciatic  tenderness,  (d)  Coxitis,  sacro-iliac  and  psoas  disease  present 
appropriate  local  signs,  without  Lasegue's  sign  or  sciatic  tenderness, 
both  of  which  are  also  absent  in  (e)  hysteria.  (/)  Muscular  rheumatism 
is  chiefly  confused  with  pain  over  the  sciatic  branches. 

Prognosis. — The  prognosis,  generally  good,  depends  on  (a)  whether 
the  affection  is  primary,  as  from  cold,  or  secondary,  as  from  disease  of  the 
cord  or  pelvic  neoplasm;  (6)  the  amount  of  rest  which  the  patient  accepts; 
(c)  the  intensity  of  the  neuritis,  which  may  extend  to  the  lumbosacral  plexus ; 
and  (fZ)  the  chance  of  relapse  (33  per  cent.) .  The  average  course  is  from  two 
to  eight  weeks,  but  cases  may  last  a  year,  indeed  three  to  thirty  years. 

Treatment. — (a)  Treatment  is  that  of  the  cause;  the  salicylates,  in 
some,  but  unfortunately  few,  cases  afford  relief;  gouty  or  syphilitic 
taints  may  be  benefited  by  colchicum  or  antisyphilitic  remedies,  which 
are  often  given  as  a  last  resort  in  other  cases.  (6)  Rest  in  bed  is  the  most 
important  indication.  In  this,  extension  or  Weir  Mitchell's  long  splint 
is  often  beneficial,  (c)  Counter-irritation  by  blisters  over  the  nerve's 
course  or  by  touching  the  tender  or  painful  points  with  the  hot  iron, 
may  give  temporary,  though  rarely  lasting,  relief,  (d)  Analgesics  and 
narcotics.  Acetanilide  has  little  effect.  Gelsemium  (flextr.  TTlij)  at 
intervals  of  two  to  four  hours,  not  infrequently  gives  relief,  though  it  is 
necessary  to  watch  for  pulse  weakness  and  cutaneous  tmgling.  Codeine 
and  atropine  should  be  given  before  resorting  to  morphine;  morphine 
is  often  inevitable,  but  chronic  morphinism  may  be  initiated  by  severe 
pain,  the  long  course  and  tendency  to  relapse.  Hypodermics  of  cocaine 
are  very  beneficial,  though  attended  by  the  same  danger.  The  author 
has  seen  good  results  from  deep  hypodermic  use  of  Schleich's  solution 
given  in  quite  large  amounts  over  sensitive  points.^  Injections  of 
chloroform  and  ether  should  be  avoided  because  of  the  possibility  of 

1  Hecht  found  the  sciatic  at  its  point  of  exit  from  the  great  sacrosciatic  foramen 
in  the  following  manner:  A  line  is  drawn  with  tincture  of  iodine  from  the  sacrococ- 
cygeal articulation  to  the  postero-external  border  of  the  great  trochanter;  at  the 
junction  of  the  inner  one- third  with  the  outer  two- thirds  of  this  line  is  the  spine  of 
the  ischium.  Placing  the  needle  a  thumb's  breadth  to  the  outer  side  of  this  point  and 
penetrating  in  a  directly  perpendicular  line  to  a  variable  depth,  one  engages  the  sciatic 
nerve.  The  needle  with  the  stylet  partly  withdrawn  is  put  through  the  skin,  and  when 
well  in  the  subcutaneous  tissue  the  stylet  is  returned  to  cover  the  point  and  the  needle  is 
directed  perpendicularly  to  the  necessary  depth.  The  moment  the  nerve  is  touched  the 
patient  feels  a  sharp,  lancinating  pain  at  the  heel  or  in  the  calf  associated  with  a  quick, 
jerky  movement.  Occasionally  the  pain  is  felt  in  the  buttock,  thigh,  or  at  the  knee.  The 
filled  syringe  is  now  attached  and  the  solution  (60  c.c.)  injected  slowly  with  steady,  firm 
pressure. 


HYSTERIA  905 

sloughing  and  accentuating  the  neuritis,  (e)  Acupunchire,  tlie  old 
Chinese  treatment,  is  recommended;  it  resulted  in  complete  relief  in  56 
per  cent,  of  Gibson's  cases,  improvement  in  32  per  cent.,  slight  benefit 
in  10  per  cent,  and  failure  in  but  2  per  cent.  (/)  Massage.  Negro  obtained 
results  from  frequent  and  severe  local  rubbing  and  rolling,  over  the  nerve 
trunk,  (g)  Electrotherapy  may  aggravate  the  pain  and  is  at  least  of 
uncertain  value,  (h)  Nerve  stretching  may  be  effected  by  extension  by 
weights,  although  it  is  rarely  tolerated  by  the  patient  in  personal  ex- 
perience. The  direct  exposure  of  the  nerve  has  justly  fallen  into  disuse, 
for  the  same  results  attend  simple  stretching,  performed  under  anesthesia. 
The  hip  should  be  strongly  flexed,  the  knee  extended,  the  foot  dorsally 
flexed  and  the  pelvis  firmly  immobilized.  Ordinary  care  prevents  luxation 
of  the  hip.  The  results  were  excellent  in  half  of  20  personal  cases  and 
were  seemingly  curative  in  7. 


THE  NEUROSES. 


HYSTERIA. 


Definition.- — The  neuroses  are  nervous  affections,  provisionally  desig- 
nated "functional,"  since  no  anatomical  basis  has  been  discovered. 
Mobius  considers  hysteria  "a  state  in  which  ideas  control  the  body  and 
produce  morbid  changes  in  its  functions."  The  school  of  Charcot  estab- 
lished its  psychogenic  nature.  It  is  a  cerebral,  cortical  condition,  in 
which  the  sensory  and  motor  centres  are  affected,  the  perception,  asso- 
ciation and  recollection  of  ideas  are  disturbed  and  trophic  and  vasomotor 
disorders  occur.  As  its  name  implies,  hysteria  was  long  thought  to  be  due 
to  the  uterus;  Sydenham  first  called  it  a  nervous  affection. 

Etiology. — (a)  Age:  It  is  most  frequent  at  puberty  and  adolescence  (fif- 
teen to  twenty-five  years) .  It  is  occasionally  seen  in  children  and  rarely 
in  middle  or  advanced  life.  (6)  Sex:  Women  are  ten  times  as  frequently 
affected  as  men,  although  in  the  lower  French  classes  it  is  more  frequent 
in  males,  (c)  Race:  The  Jewish,  Latin  and  Slavic  races  are  most  fre- 
quently affected,  (d)  Heredity:  Charcot  and  the  French  school  hold 
that  this  is  the  sole  cause,  other  factors  being  only  agents  provocateurs. 
Parental  intoxications,  toxemias,  constitutional  diseases,  as  gout,  diabetes, 
arthritis  deformans  and  a  neurotic  taint  are  important  in  the  transmission 
of  a  congenitally  weak  nervous  system,  (e)  Acquired  hysteria  may  be 
due  (i)  to  various  intoxications,  notably  lead,  alcohol  and  drugs;  (ii) 
to  infections,  as  typhoid,  malaria,  diphtheria  and  syphilis;  (iii)  to  con- 
stitutional maladies,  as  gout,  diabetes,  chlorosis,  secondary  anemia 
or  cancer;  (iv)  to  exhaustion  from  mental  or  physical  overwork  or  ex- 
cesses; (v)  to  emotional  disturbance;  (vi)  to  trauma,  especially  psychic 
shock;  (vii)  it  may  occur  as  an  associate  with  epilepsy,  syringomyelia, 
tabes,  brain  tumor  and  multiple  sclerosis;  (viii)  imitation  is  an  important 
factor  in  schools,  hospitals  and  at  religious  revivals ;  endemics  occur  now 
as  they  did  in  the  middle  ageis.  (Refer  to  Zola's  Lourdes.)  Heference 
to  sexual  factors  is  considered  under  Therapy. 


906  THE  NEUROSES 

Symptoms. — The  disease  is  much  more  commonly  polysymptomatic 
than  monosymptomatic.  French  writers  distinguish  two  main  groups 
of  symptoms,  the  stigmata  and  accidents. 

Stigmata. — The  stigmata  are  usually  persistent  symptoms. 

1.  Sensory  Stigmata. — Sensory  symptoms  (in  85  per  cent.)  are  more 
frequent  than  the  motor  and  are  often  combined  with  them,  (a)  Hys- 
terical anesthesia  is  very  seldom  absent.  It  must  often  be  looked  for, 
without  too  obviously  suggesting  it  to  the  patient.  It  may  be  absolute, 
affecting  appreciation  of  touch,  pain,  heat  and  cold.  Analgesia  is  its 
most  common  form  and,  in  decreasing  order  of  frequency,  there  may  be 
complete  anesthesia,  hypesthesia,  loss  of  tactile  sense,  loss  of  all  sensation 
save  to  the  faradic  current  or  loss  of  faradic  response  alone.  The  same 
deficit  frequently  occurs  in  the  mucosae  and  sometimes  in  the  bones, 
ligaments,  joints  and  muscles.  In  rare  cases  there  is  universal  cutaneous 
and  muscular  anesthesia;  the  following  are  more  frequent:  Hysterical 
hemianesthesia,  which  involves  precisely  one-half  of  the  skin,  accessible 
mucosae  and  special  senses;  segmentary  or  geometrical  anesthesia,  which 
affects  one  limb,  variously  described  as  "mitten  or  stocking"  anesthesia 
and  frequently  associated  with  other  disturbance  in  the  part  affected, 
as  paralysis,  aphonia,  amblyopia  and  deafness;  and  insular  anesthesia, 
which  affects  small  areas,  and  is  therefore  frequently  overlooked. 

Characteristics. — The  anesthesia  is  psychical,  is  associated  with  the 
functions  of  the  part  affected  and  does  not  follow  the  area  of  distribution 
of  the  peripheral  nerves  or  spinal  segments;  it  is  not  noted  by  the  patient, 
at  least  until  suggested;  it  may  be  localized  because  of  injury  or  disease 
in  the  part.  Babinski  holds  that  all  anesthesias  are  initiated  by  sugges- 
tions. The  anesthetic  areas  may  last  during  life,  but  they  move  even 
under  examination  or  disappear  from  emotion,  strongly  aroused  attention, 
drugs  or  on  application  of  various  substances,  as  metal  or  wood  (trans- 
ferring it  to  the  opposite  side).  Most  of  the  reflexes  usually  altered  by 
organic  disease  remain  normal,  as  the  pupillary,  lachrymal,  epigastric, 
cremasteric,  patellar  and' organic  reflexes,  while  the  pharyngeal  in  90 
per  cent,  of  cases  is  lost,  as  well  as  the  plantar. 

Hysterical  hyperesthesia  and  hyperalgesia  are  very  common  in  localized 
areas,  but  never  in  universal  or  hemiplegic  distribution.  They  occur 
spontaneously  or  from  attention  directed  to  a  part  or  organ,  as  by  trauma- 
tism, A  joint  may  be  affected  with  or  without  contracture  (Brodie's 
joints)  and  this  often  leads  to  great  and  unfortunate  errors.  There  is 
sometimes  hyperesthesia  in  the  sphere  of  any  of  the  special  senses. 
The  feeling  of  a  nail  in  the  top  of  the  head  (clavus  hystericus),  sensitive 
spots  in  the  mammse,  epigastrium,  groins  or  spine  are  the  most  common 
forms  and  may  occur  in  the  midst  of  anesthetic  areas.  The  so-called 
ovaralgia  is  cutaneous;  it  has  no  relation  to  the  location  or  to  disease 
of  the  ovary;  it  occurs  also  in  men.  Because  hysterical  attacks  have  been 
initiated  and  sometimes  stopped  by  pressure  over  this  and  other  sensitive 
areas  they  have  been  called  hysterogenic  zones,  but  attacks  are  only  so 
produced  in  patients  already  hysterical,  from  some  associated  memory 
of  the  patient,  or  from  suggestion.  Taste  and  smell  may  be  dulled  or 
hypersensitive,  and  hearing  may  be  blunted,  or  more  rarely  complete 
central  deafness  results,  usually  associated  with  anesthesia  in  and  about 


.    HYSTERIA  907 

the  auditory  meatus.  Complete  loss  of  vision  is  both  rare  and  transitory, 
Hemiopia  and  scotomata  are  almost  ahvays  organic.  Partial  stigmata 
are  more  common.  Concentric  contraction  of  the  msual  field  is  usually 
bilateral,  and  generally  greater  on  the  side  of  the  cutaneous  defects. 
Concentric  contraction  of  the  field  for  colors  (dyschromatopsia)  is  more 
characteristic.  In  the  normal  eye,  blue  has  the  largest  field,  then  yellow, 
orange,  red,  green  and  violet ;  in  hysteria  the  red  field  is  often  wider  than 
the  blue  and  is  the  last  color  lost.  Achromatopsia  designates  the  com- 
plete loss  of  color  perception.  Errors  in  accommodation  (alwaj'^s  ex- 
cluding abnormal  corneal  curvatures)  may  cause  double  images  in  one 
eye  (monocular  diplopia),  triple  images  (polyopia)  or  large  or  small 
images  (macropsia,  micropsia).  In  hysterical  amblyopia  impairment  of 
vision  in  the  affected  eye  is  decreased  when  the  other  eye  is  opened. 

2.  Motor  stigmata  are  much  less  conspicuous  but  foreshadow  the 
motor  accidents  {v.  i.).  Voluntary  movements  are  weaker,  slower,  less 
coordinate  and  with  a  tendency  toward  contractures. 

3.  Mental  Stigmata. — Hysteria  is  always  a  psychic  affection.  The  most 
conspicuous  alienation  is  impairment  of  memory  {amnesia),  which  con- 
cerns memory  in  the  ordinarily  accepted  sense,  as  memory  for  persons, 
things,  words,  hysterical  paroxysms  experienced,  etc.,  or  concerns  mem- 
ory and  associations  for  speech,  writing,  walking  or  standing.  The 
amnesia,  like  paralysis  and  anesthesia,  is  functional  and  like  them  returns, 
save  in  rare  cases.  Mental  potver  is  distinctly  decreased,  will-power  is 
lost  (aboulia)  or  lessened  and  the  patient  becomes  the  ready  victim  of 
impulses,  sensationalism,  suggestions,  fixed  ideas  and  misconceptions 
both  on  his  own  part  and  on  that  of  others  who  incorrectly  consider  him 
deceitful,  vain  or  erotic. 

Accidents. — The  accidents  of  hysteria  are  the  incidental  seizures  or 
paroxysms.  They  are  usually  transient  or  intermittent,  but  may  become 
fixed  and  are  then  ranked  as  stigmata. 

1,  Motor  Accidents. — (a)  Convulsions  occur  in  25  per  cent,  of  all  and 
50  per  cent,  of  female  hysteria.  They  are  much  less  frequently  the 
hysteria  major  (grande  attaque  of  Charcot)  than  the  partial,  modified 
type  (hysteria  minor).  The  "grand  attack"  comprises  (i)  a  prodromal 
stage,  with  mental  depression  or  exaltation,  palpitation,  vasomotor 
symptoms,  nausea,  polyuria,  an  aura  beginning  in  the  epigastrium 
and  culminating  in  choking  (globus  hystericus),  vertigo  and  unconscious- 
ness ;  (ii)  a  period  of  epileptiform  convulsions  (so-called  hystero-epilepsy) 
in  which,  in  exceptional  cases,  there  may  be  biting  of  the  tongue  or  even 
the  cry  of  epilepsy;  the  face  is  at  first  pale,  then  red;  the  teeth  are 
ground;  the  convulsion  is  most  pronounced  on  the  anesthetic  side, 
toward  which  the  face  turns;  the  tonic  spasm  lasts  less  than  two  minutes 
and  is  often  characterized  by  stupor,  stertor  and  slow,  wide  movements 
of  supination,  circumduction  and  overextension,  for  the  trunk  and  body 
are  tetanically  rigid;  then  the  clonic  spasm  develops,  with  sobbing 
respiration,  audible  swallowing,  abdominal  rumbling  and  small,  clonic 
movements,  (iii)  The  period  of  "clownism"  is  characterized  by  con- 
tortions, opisthotonos  (arc  de  cercle),  bowing  movements,  violent  strug- 
gling, screams,  strikes  and  bites,  (iv)  There  is  next  a  period  of  "  passional 
attitudes,"  in  which  the  subject  mimics  terror,  rage,  joy  and  love,  fol- 


908 


THE  NEUROSES 


lowed  by  (v)  a  stage  of  delirium  with  hallucinations,  perhaps  of  animals 
(zoopsia).  The  attack  covers  fifteen  to  thirty  minutes  and  frequent 
repetitions  constitute  the  "status  hystericus." 

The  partial  attack  contains  some  of  the  elements  of  the  major  type, 
and  infinite  variations  occur;  the  globus  type  is  extremely  common; 
there  are  also  the  vertiginous,  tetanic,  emotional  and  syncopal  types; 
trance-like  sleep,  with  cataleps}^  in  which  the  limbs  retain  any  attitude 
given  them,  with  sleep,  which  is  apparent  only,  for  the  subject  later  recalls 
everything;  there  may  be  attacks  of  somnambulism,  in  which  patients 
run  miles  or  undertake  distant  travel  without  recollection  of  the  trans- 
pired interval,  (b)  Paralysis  is  an  accentuation  of  the  stigmatic  muscular 
weakness.  In  over  50  per  cent,  it  develops  after  convulsive  paroxysms; 
again  it  follows  emotional  causes,  traumatism  or  organic  brain  disease. 
It  assumes  the  paraplegic  five  times  as  often  as  the  hemiplegic  form; 
the  monoplegic  variety  is  less  frequent;  the  triplegic,  diplegic  (quadri- 
plegic) or  crossed  forms  are  most  common.  They  are  rarely  complete; 
often  gesticulatory  movements  may  be  seen;  the  antagonistic  muscles 
are  involved,  thus,  in  attempted  flexion  of  the  knee  the  knee  ex- 
tensors contract;  the  paralyzed  part  may  be  limp  or  contractured ;  the 
paralyses  may  be  ephemeral  or  life-long  in  duration;  paralysis  may  be 
"ideal,"  i.  e.,  only  for  standing  or  walking.  Vasomotor  changes  and 
edema  are  rare;  the  tendon,  skin  and  electrical  reactions  are  usually 
normal,  although  the  tendon  reflexes  may  be  increased.  Hysterical 
hemiplegia  occurs  three  times  as  frequently  on  the  left  as  on  the  right 
side. 


Organic  Hemiplegia. — vs, 

Coma:  often  complete. 

Reflexes:  tendon  and  bone  reflexes  abolished 
at  first ;   later  increased.    Ankle-clonus. 

Cutaneous  reflexes  (abdominal  and  cre- 
masteric) early  lessened  or  abolished; 
Babinski  toe  sign;  lachrymal  reflex 
abolished. 

Paralysis:  (1)  Unilateral;  (2)  not  system- 
atized ;  face,  arm  and  leg  are  weak  during 
bilateral  synergetic  movements.  (3)  In- 
volves subconscious  as  well  as  conscious 
voluntary  movements,  producing  the 
platysma  sign  (lessening  of  its  contrac- 
tion on  the  hemiplegic  side,  e.  g.,  on  open- 
ing the  mouth  forcibly),  and  the  com- 
bined flexion  of  the  thigh  and  trunk 
(when  the  patient  attempts  to  sit  up). 
(4)  Paralysis  slowly  improves  some,  but  is 
not  variable. 

The  tongue  deviates  slightly  toward  the 
paralyzed  side. 

Lower  muscular  tone,  as  lowering  of  the 
eyebrow  or  exaggerated  flexion  of  the 
forearm,  in  early  cases. 

Contracture  cannot  be  voluntarily  repro- 
duced; at  first  flaccid  paralysis,  then 
contracture. 

Hemianesthesia:  rarely  total;  of  stereog- 
nostic  and  muscle  sense;  rare;  coarser; 
more  lasting  when  present;  often  with 
])il;i((>rMl  hemianopsia. 


-Hysterical  Hemiplegia. 


Rarely  complete  (automatic  movements.) 
Rarely    abolished;     no    clonus    (or   only   a 

spurious  ankle-clonus  due  to  contraction 

of  the  calf  muscles,  Gowers). 
Skin  reflexes  normal;    no  toe  sign. 


Never  abolished. 

(1)  Not  always  unilateral;  if  face  involved, 
usually  on  both  sides.  (2)  Paralysis 
sometimes  systematized;  and  hemiplegic 
side  functionates  perfectly  in  bilateral 
synergetic  movements.  (3)  Subconscious 
voluntary  movements  are  not  involved; 
absence  of  the  platysma  sign  and  that 
of  combined  flexion  of  the  thigh  and 
trunk.  (4)  Variable  paralysis,  improve- 
ment alternating  with  relapses.  Absolute 
aphasia  with  ability  to  write  (Charcot). 

Very  slightly,  very  greatly  or  even  toward 

the  sound  side. 
None.     Asymmetry  of  the  face  is  due   to 

spasm,    and   exaggerated   flexion    of    the 

forearm  is  absent. 
May    be    reproduced;      variable    paralysis, 

now  flaccid,  now  spastic  from  onset,  with 

increased  reflexes. 
Often  total,  involving  special  senses,  pain 

and  pressure  sense;    frequent;    variable 

in  duration;    usually  with  contraction  of 

visual  field. 


HYSTERIA  909 

In  hysterical  paraplegia  there  are  usually  no  trophic  changes,  no 
bed-sores,  no  electrical  alteration,  no  incontinence  of  urine  or  feces 
and  rarely  retention  of  urine;  many  errors  in  diagnosis  are  made.  Hys- 
terical monoplegia  usually  occurs  with  anesthesia  of  even  greater  extent; 
it  is  lawless  and  illogical,  viewed  from  the  standpoint  of  organic  disease. 
In  astasia-ahasia  (Charcot  and  Blocq)  the  patient  is  unable  to  stand  or 
walk,  although  the  muscles  concerned  may  be  efficient  in  other  move- 
ments. Lesser  degrees  are  called  dystasia  or  dyshasia.  The  term  staso- 
basophobia  is  self-descriptive.  Mobius'  akinesia  algera  is  similar,  (c) 
Hysterical  contractures  precede,  succeed  or  alternate  with  paralysis,  or 
occur  alone;  these  "rigid  palsies"  usually  persist  during  sleep  and  yield 
to  ether  anesthesia,  save  in  severe  protracted  cases  with  irremediable 
deformity.  In  the  arms,  contracture  of  the  flexors  predominates;  in 
the  legs,  that  of  the  extensors  (club-foot).  Spinal  deformities  may 
develop,  most  frequently  from  pseudosciatica.  The  muscles  may  so 
contract  as  to  resemble  muscle  tumors.  It  is  stated  that  the  face  escapes 
paralysis,  but  its  lower  portion  may  be  weak;  more  often,  however,  it  is 
contracted  early,  even  when  paralyzed ;  hemispasmus  glossolabialis  and 
trismus  haye  been  observed.  Spastic  or  pseudoptosis  may  resemble 
the  paralytic  form,  but  spasticity,  the  lowered  or  more  level  eyebrow 
and  the  concentric  or  parallel  folds  in  the  lid  are  distinctive  of  contracture. 
The  ocular  muscles  are  seldom  involved;  voluntary  movement  may  be 
impossible,  but  associated  and  reflex  movements  are  normal;  con- 
vergent squint  may  occur,  but  never  the  divergent  type  nor  contracture 
of  a  single  rectus  or  oblique  muscle;  pain  suggests  hysteria.  Karplus 
maintains  that  the  pupil  light  reflex  is  lost  during  convulsive  seizures. 
Organic  disease  of  the  hip  may  be  simulated;  local  hysterical  edema 
may  occur.  Brodie  (1827)  first  drew  attention  to  this  group  of  cases. 
Many  avoidable  diagnostic  errors  are  constantly  made,  {d)  Rhyth- 
mical spasms,  chorea  major,  the  saltatoric  chorea  {v.  i.)  and  local  mani- 
festations, as  barking  cough  or  the  various  tics,  may  occur.  Hysterical 
tremor  occurs  without  voluntary  movement.  It  may  resemble  the 
senile,  Basedow,  paralysis  agitans  or  lead,  but  rarely  the  multiple 
sclerosis  tremor. 

2.  Sensory  Accidents. — These  are  frequent,  severe  and  painful.  Head- 
ache is  often  dull  or  may  resemble  trigeminal  neuralgia,  migraine  or 
organic  disease,  as  tumor.  Meningitis  (hysterical  pseudomeningitis) 
may  be  closely  counterfeited.  Spinal  or  vertebral  pain  is  frequent  and 
sometimes  suggests  tumor  or  caries.  One  and  three-tenths  per  cent,  of 
cases  of  sciatica  are  said  to  be  hysterical.  Joint  disease  and  various 
visceral  lesions  {v.  i.)  may  be  closely  mimicked.  Dieulafoy  collated  59 
cases  of  hysterical  blindness,  in  5  of  which  this  accident  was  the  only 
symptom. 

3.  Visceral  Accidents.— {a)  Cardiac  accidents  include  tachycardia, 
palpitation  and  pseudo-angina  pectoris.  (6)  Respiratory  accidents: 
Aphonia,  usually  attended  by  normal  capacity  to  cough  and  often  also 
to  sing,  has  been  described  under  Paralysis  of  the  Vocal  Cords.  It  is 
usually  due  to  an  "idea,"  as  in  a  motor  aphasia  which  allows  the  patient 
to  write.    Stammering,  cough  and  cries  may  be  provoked  by  local  naso- 


910  THE  NEUROSES 

pharyngeal  disease.  Dyspnea,  resulting  from  paralysis  of  the  diaphragm, 
and  laryngeal  spasm  have  been  considered.  Rapid  breathing  (tachyp- 
nea) also  occurs;  dyspnea,  aphonia  and  paralysis  of  the  diaphragm 
constitute  Briquet's  syndrome.  Hemoptysis  may  occur,  sometimes 
without  phthisis,  possibly  as  a  vasomotor  derangement;  one  fatal  case 
is  on  record,  (c)  Digestive  accidents:  Hysterical  anorexia  results  from 
cortical  conception,  stomach  pain,  dysphagia  from  spasm  or  simple 
sensory  perversion;  it  may  endure  for  weeks  and  cause  extreme  inanition 
or  even  death.  Hysterical  (pseudo-)  hydrophobia  is  an  analogous  aver- 
sion to  water.  Vomiting  is  sometimes  simulated  by  protracted  globus 
or  esophageal  spasm,  in  which  the  food  is  simply  regurgitated.  Vomiting 
itself  may  be  occasional  or  attacks  may  last  weeks  or  months,  often  with 
remarkably  little  malnutrition;  it  is  rarely  fecal  but  substances  injected 
by  rectum  may  be  vomited  in  a  few  hours;  or  again  vomitus  may  be 
blood-tinged,  possibly  from  vasomotor  disturbance  or  more  often  from 
actual  disease;  ulcer  may  be  simulated  by  pain  and  tenderness,  which 
are  surprisingly  well  confined  not  to  one  spot,  but  to  the  exact  outlines 
of  the  stomach.  The  vomitus  contains  vicariously  large  amounts  of  urea 
when  the  urine  is  suppressed.  Eructations  are  frequent  from  swallowed 
air;  this  also  causes  t.-sTopanites,  as  air  reaches  the  gut  through  the 
incompetent  pylorus.  Phantom  tumors  or  spurious  pregnancy  (pseudo- 
cyesis)  are  explained  as  protrusion  of  the  distended  bowel  by  tonic 
contracture  of  the  diaphragm.  Peristaltic  unrest,  diarrhea  on  eating, 
enteritis  membranacea,  spastic  constipation,  simulation  of  peritonitis, 
rectal  stricture  and  intestinal  obstruction  also  occur,  (d)  Genito-iirinary 
accidents:  Anuria  has  existed  for  ten  days  without  uremia.  Renal  pain 
is  not  frequent,  but  hyperesthesia  of  the  bladder  is  common.  The  urine 
is  often  greatly  increased,  with  low  specific  gravity  and  solids.  During 
attacks  of  the  major  type  the  solids  are  reduced,  the  urea  one- third 
and  phosphates  one-half;  the  phosphates,  which  normally  have  a  pro- 
portion of  3  of  the  alkaline  to  1  of  the  earthy  phosphates,  show  nearly 
an  equal  proportion  of  each.  Depression  of  sexual  desire  is  more  common 
than  exaltation;  anesthesia  is  frequent;  vaginismus  may  be  observed. 
Hysterical  ovarian  and  other  pains  are  not  related  to  pelvic  disease. 

Hysterical  fever  is  a  disputed  topic.  Severe  forms  may  suffer  a  rise  to 
105°  or  110°;  this  may  lead  to  a  diagnosis  of  meningitis,  peritonitis,  etc.; 
simulation  by  the  patient  rubbing  the  thermometer,  or  of  confusion  ^^•ith 
tuberculosis  or  typhoidj  must  be  kept  in  mind. 

4.  Vasomotor  and  trojjhic  accidents  are  rare.  Erythema  is  the  most 
common.  Gangrene,  falling  out  of  the  hair  or  nails,  Raynaud's  local 
asphyxia,  cutaneous  hemorrhages  (crucifixion  stigmata,  stigmata  diaboli), 
bloody  sweats,  lachr\Toation,  hemoptysis,  hematemesis,  sudden  tender 
swellings  in  the  mammae  and  angioneurotic  edema,  which  is  sometimes 
blue  in  color,  have  been  recorded. 

Course  and  Prognosis. — The  course  is  always  chronic.  If  we  regard 
the  disease  as  congenital  the  prognosis  is  poor  as  to  total  recovery,  espe- 
cially with  fixed  psychical  alteration  and  major  manifestations.  In 
mild  forms,  relapses  may  occur  on  disproportionately^ slight  provocation. 
The  outlook  is  better  in  infantile  and  adolescent  forms.    The  stigmata 


HYSTERIA  911 

may  be  ephemeral  or  life-long.  Marriage  may  benefit  light  cases,  but, 
with  maternity,  it  is  injurious  in  the  severe  type. 

Diagnosis. — The  stigmata,  mental,  motor  and  sensory,  are  highly 
characteristic.  The  accidents  are  unequivocally  hysterical  or  prove 
hysterical  after  consideration  of  their  associations.  The  danger  lies  in 
overlooking  concomitant  disease  (a)  nervous,  as  multiple  sclerosis,  brain 
tumor,  paretic  dementia;  (b)  postinfectious  hysteria,  as  hysteria  plus 
neuritis;  (c)  lung,  heart  and  other  visceral  diseases,  all  of  which,  as 
Sydenham  remarked,  may  resemble  hysteria.  Stimulation  does  not 
include  mimicry  of  symptoms  by  hysterics;  simulation  of  hysterical 
stigmata  and  accidents  is  practically  impossible. 

Treatment. — 1.  Prophylaxis. — When  the  earliest  manifestations  occur 
in  childhood,  home  treatment  is  impracticable  because  of  the  family 
tendency.  The  etiological  factors  must  be  studied,  especially  the  hygiene 
and  hours  of  sleep.  Useful  occupations,  as  out-of-door  gardening,  are 
preferable  to  more  artificial  plans  of  distraction.  Cultivation  of  courage 
and  self-control,  is  sought.  Servants  who  teach  fear  of  the  dark  and 
tell  fairy  stories  should  be  watched. 

2.  General  Treatment  of  the  Cause. — ^As  the  disease  depends 
on  disturbed  cortical  relations  between  the  psychical  and  material 
processes,  the  principal  treatment  must  be  psychical.  The  "fixed  idea" 
must  be  grasped  and  eradicated,  which  is  best  accomplished  in  ordinary 
circumstances  by  isolation  of  the  patient  from  home  or  psychical  or 
emotional  circumstances  surrounding  the  inception  of  the  disease.  Then 
the  undue  susceptibility  incident  to  the  disease  may  be  turned  to  thera- 
peutic advantage  by  the  self-confidence  of  the  physician  and  by  his  covert 
suggestions.  Babinski  defines  hysteria  as  that  series  of  phenomena 
produced  by  suggestion  and  cured  by  persuasion.  The  Weir  Mitchell 
rest-cure  may  result  in  great  benefit,  and  later  "vague  hints  regarding 
the  curative  power  of  nature,"  and  fresh  air  and  sunlight  may  captivate 
the  patient.  Symptoms  must  not  be  suggested  to  the  subject,  as  anes- 
thesia or  pelvic  disease,  and  examinations,  especially  of  the  pelvis, 
should  be  omitted.  Hysterics  should  not  be  allowed  to  associate  with 
each  other  for  obvious  reasons.  This  general  plan  is  psychotherapy, 
which  might  include  hypnotherapy,  as  advocated  by  the  Nancy  school, 
Bernheim  and  others.  Hypnotism  is  generally  dangerous  in  its  ultimate 
and  often  in  its  immediate  effects ;  the  danger  of  hypnotism  is  shown  by 
the  fact  that  Striimpell  considers  it  an  "artificial  hysteria,"  and  Fere 
defines  it  as  a  "transformation  of  hysteria."  "It  is  easier  to  make  a 
sound  person  hysterical  by  hypnosis  than  to  cure  an  hysterical  one  by  it" 
(Liebermeister) .  Treatment  is  sometimes  frustrated  by  the  patient's 
vanity.  Successful  treatment  requires  unusual  tact,  profound  knowledge 
of  human  nature,  strong  sympathy  (but  dominance  of  the  patient)  and 
enormous  optimism;  certain  single  qualities  in  an  ignorant  quack 
may  effect  cures. 

According  to  Breuer  and  Freud,  certain  sexual  activities,  mostly  of  a 
perverse  nature,  develop  before  puberty;  these  phantasies  are  mostly 
repressed  by  the  hysteric  and  after  puberty  these  repressed  perversions 
come  in  conflict  with  the  normal  sexual  proclivities.    Freud  traces  every 


912  THE  NEUROSES 

hysteria  back  to  sexiial  traiima  in  childhood.  The  analytic  or  cathartic 
method  consists  of  full  narration  or  confession  by  the  patient.  The 
repressed  complexes,  parasitically  attached  to  or  dominating  the  mental 
states,  are  analyzed  and  replaced  by  proper  mental  reactions — a  process 
of  reeducation.  The  subconscious,  repressed  complexes  are  brought  back 
into  higher  consciousness,  lived  over,  given  verbal  expression  and  there- 
fore eliminated,  forgotten. 

3.  Symptomatic  Treatment. — (a)  In  relieving  pain  the  physician 
should  first  acknowledge  its  existence  and  intensity  to  soothe  the  patient 
and  then  apply  blisters,  liniments  or  the  galvanic  current  with  the 
anode  on  the  painful  area.  Ovaralgia  in  most  cases  should  be  ignored; 
in  exceptional  cases  pelvic  surgery  has  given  relief,  (b)  Convidsioiw  are 
treated  by  dashing  cold  water  into  the  face,  by  suggestive  measures  or, 
if  severe,  by  etherization.  Bromides  are  of  little  value,  valerian  is  some- 
times beneficial  and  turpentine  is  recommended  by  Gowers  as  most 
efficient,  10  drops  of  the  oil  being  given  until  slight  vesical  symptoms 
appear.  Pouring  water  into  the  mouth  or  nose,  which  causes  coughing, 
or  holding  a  towel  over  the  nose  and  mouth  for  fifteen  to  twenty  seconds, 
may  also  serve,  (c)  Paralysis  and  contrachire  should  receive  early  treat- 
ment, for  neglected  cases  may  necessitate  surgical  intervention.  Massage, 
faradism,  blisters  and  fixation  in  new  postures  are  indicated  and  especially 
should  their  significance  be  minimized  and  the  patient  be  assured  that 
they  are  not  organic.  In  2  cases  the  author  has  seen  the  paralysis 
disappear  at  once  on  administration  of  asafetida  in  an  effervescing 
mixture,  (d)  Anesthesia  should  be  ignored,  (e)  Aphonia  is  treated  by 
intralaryngeal  faradization.  Lar^Tigeal  and  other  respiratory  spasms 
usually  answer  to  energetic  traction  on  the  tongue.  (/)  For  insomnia, 
the  patient  should  retire  at  an  absolutely  regular  hoiu-;  nervines  should 
be  given  rather  than  bromides,  and  hot  milk  should  be  very  slowly 
sipped,  {g)  Dysphagia,  vomiting  and  anorexia  may  be  treated  by  rectal 
feeding  or  by  forced  feeding  through  the  stomach-tube.  Constipation 
is  often  obstinate  and  its  mixed  spastic  character  is  shown  by  the  sheep- 
like feces.  Olive  oil  by  mouth  and  rectum,  cold  abdominal  compresses 
and  endorectal  galvanization  are  usually  effective. 

NEURASTHENIA. 

Definition. — Neiu-asthenia  is  a  diffuse  neurosis,  which  affects  the 
entire  nervous  system,  but  chiefly  the  brain;  it  is  characterized  (a) 
by  morbid  irritability  of  the  nervous  system  with  a  tendency  to  its 
rapid  exhaustion  ("irritable  weakness")^  and  (b)  particularly  by  psychical, 
motor,  sensory,  vasomotor,  secretory  and  vegetative  disturbances  in  func- 
tion. The  nervous  tissue  responds  unduly  to  stimuli,  its  reaction  time 
is  short  and  ready  exhaustion  results.  It  seems  probable  that  the  slight 
cellular  and  protoplasmic  changes  in  nerve  cells,  noted  by  Hodge  to  follow 
fatigue,  may  have  some  bearing  on  its  pathology.  The  affection  described 
and  named  by  Beard,  in  1S69,  whose  description,  first  received  with 
skepticism  and  ridicule  abroad,  later  gained  universal  recognition.  It 
is  possible  that  the  disease  is  more  frequent  than  formerly  because  of  the 


NEURASTHENIA  913 

more  strenuous  life  and  methods  of  education.  The  difference  between 
"nervousness"  and  neurasthenia  is  only  quantitative. 

Etiology. — Neurasthenia  constitutes  35  per  cent,  of  nervous  diseases 
and  50  per  cent,  of  neuroses,  (a)  A  neiiwpathic  tendency  is  observed  in 
50  per  cent,  of  cases,  especially  among  Hebrews  whose  proneness  to  ner- 
vous diseases  is  referred  by  Erb  to  inbreeding  and  desire  of  gain.  Other 
neuroses,  as  hysteria,  epilepsy  or  migraine,  the  psychoses  and  parental 
infirmities  or  intoxications  may  be  obtained  in  the  family  history.  (6) 
Age  and  Sex:  75  per  cent,  of  cases  occur  in  persons  between  the  twentieth 
and  fiftieth  year.  Women  are  more  disposed  but  men  more  exposed, 
to  the  disease  by  their  excesses  in  work,  sexual  activity  and  alcoholism. 
(c)  Psychical  causes  include  sorrow  and  care;  hard  mental  or  physical 
work  rarely  produces  neurasthenia.  Worry  is  a  prolific  factor;  it  is  the 
irritable  weakness  of  work.  Hard  work  is  injurious  when  combined 
with  excesses  in  tobacco,  alcohol,  coffee,  drugs  or  venery.  Certain 
occupations  entailing  responsibility  or  emotional  factors  predispose  to 
nervous  weakness,  as  in  railway  or  telegraph  employees,  board-of-trade 
men,  teachers,  actors,  artists  and  musicians.  Trauma  operates  chiefly 
through  psychical  causes,  as  in  the  traumatic  neuroses  (q.  v.).  (d)  In- 
toxications, as  from  stimulants,  drug  habits,  lead  or  arsenic  poisoning, 
infections,  especially  typhoid,  grippe,  malaria  and  syphilis,  and  gout, 
anemia  or  diabetes  may  be  indirect  factors,  (e)  Sexual  life:  Excessive 
coitus  and  coitus  interruptus,  sometimes  promote  neurasthenia,  but  their 
importance  is  enormously  overestimated.  Masturbation  produces  less 
direct  physical  than  psychical  injury,  for  it  leads  to  brooding  over  its 
possible  results  (r.  s.  Freud's  theory).  Continence  is  never  injurious, 
as  sexual  indulgence  is  rather  a  habit  than  a  necessity.  In  neurasthenic 
women  gynecological  complaints  are  more  often  subjective,  secondary 
and  neurasthenic  than  objective,  primary  and  organic.  The  same  state- 
ment holds  in  male  neurasthenics  with  chronic  urethritis  or  prostatitis. 
Pregnancy  and  lactation  are  sometimes  apparent  causes.  (/)  Organic 
diseases  may  possibly  be  factors,  but  it  is  questionable  to  what  extent 
enteroptosis,  chronic  gastric  or  other  somatic  lesions  promote  neuras- 
thenia. 

Symptoms. — A  clinical  description  holding  for  all  cases  is  impossible. 
A  patient  presents  himself  for  the  treatment  of  some  single  visceral  com- 
plaint or  describes  symptoms  in  his  head,  heart,  lung,  stomach,  sexual 
or  other  organs.  The  various  types  will  be  considered  in  the  general 
picture,  for  pure  forms  are  rare;  they  are  the  cerebral  (cerebrasthenia) , 
spinal  {myelasthenia) ,  cerebrospinal  {the  general  type),  the  sympathetic 
or  vasomotor  and  the  visceral  (cardiac,  sexual,  gastric)  types,  (a)  The 
acute  form  from  simple  nervous  exhaustion  in  normal  individuals,  or 
in  those  with  neurotic  stigmata;  (6)  the  subacute  or  chronic  acquired 
form  and  (c)  the  chronic  constitutional  neurasthenia,  which  is  usually 
hereditary. 

1.  Cerebral  Symptoms. — These  are  most  important.     Headache  is 

almost  invariable,  is  more  often  dull  than  acute,  produces  a  sense  of 

pressure  ("lead-cap"  headache)  or  intracranial  paresthesia  and  is  most 

often  occipital.     A^ertigo  is  frequent.     Insomnia  is  extremely  common, 

58 


914  THE  NEUROSES 

but  rarely  absolute,  "uhicli  always  suggests  organic  brain  disease;  sleep 
is  slow  in  onsetj  the  patient  being  kept  awake  by  his  fear  of  sleeplessness, 
by  a  rapidly  mo^Tiig  circle  of  uncontrollable  memory  pictures  or  by 
indigestion  or  palpitation;  sleep,  when  once  attained,  is  restless  or  the 
patient  awakes  in  the  night  or  early  mornmg.  It  is  broken  by  dreams, 
startings  or  sometimes  emissions.  In  mild  cases  distinct  alterations  in 
temperament  and  character  develop,  as  loss  of  courage  and  confidence, 
depression,  irritability,  midue  response  to  emotional  stimulation,  as  on 
seeing  sad  plays  or  hearing  hard-luck  stories,  slight  ethical  blunting, 
tendency  toward  extremes  and  dcA'elopment  of  quiet  self -concentration 
or  obtrusive  egotism.  The  brain  tires  readily  on  mental  or  bodily  exertien, 
especially  as  the  irritable  patient  is  often  prodigal  of  time  and  energy. 
It  is  remarkable  how  in  some  cases  the  morning  depression  may  disappear 
before  an  afternoon  or  evening  excitement,  but  this  is  notably  followed 
by  reaction.  Psychical  processes  are  disturbed;  perception  is  blunted 
and  memory  is  weakened  or  often  temporarily  lost  (dys-,  para-,  amnesia), 
as  shoMTi  by  the  copious  notes  of  his  symptoms  which  the  patient  pro- 
duces in  the  physician's  office  {"I'homme  aiix  jjetits  papiers,''  as  Charcot 
called  him) ;  association  and  combination  are  difficult,  as  m  thought, 
composition,  judgment  or  conclusions,  whence  the  speech  is  often  slow 
and  disjointed,  names  are  forgotten  and  the  patient  re-reads  addresses, 
runs  repeatedly  to  see  if  the  door  was  closed,  etc.  Compulsory  conceptions 
may  lead  to  homicide  or  suicide  in  highly  psychopathic  t\'pes.  Fear, 
being  an  attribute  of  the  weak,  is  common  enough,  and  may  in  marked 
t^'pes  assume  the  form  of  various  phobias,  as  the  fear  of  open  places 
Cagarophobia),  of  enclosures  (claustrophobia),  rivers  (potomophobia), 
high  places  (acrophobia),  stars  (asterophobiaj,  railways  (siderdromo- 
phobia;,  dirt  (mysophobia),  of  high  things  faUing  (batophobia),  of  stand- 
mg  (stasophobia),  or  walking  (basophobia),  of  darkness  (nyctophobia), 
of  a  single  thing  Tmonophobia),  of  all  things  Tpantophobia),  of  places 
ftopophobiaj,  of  men  ( antlu-ophobia)  or  of  disease  ^nosophobia).  Fibril- 
lation of  the  Hds  and  wide,  variable,  sensitive  and  unequal  (3  per  cent.) 
pupils  are  frequent;  permanent  irregularity  is  almost  always  organic. 
Asthenopia  is  very  common,  especially  in  hypermetropia  from  weakness 
of  the  ciliary  and  int.  recti  muscles.  The  field  of  vision  may  be  concen- 
trically limited,  but  this  is  rarely  marked  or  permanent,  and  Forrter's 
shifting  t.^.'pe  may  be  found,  in  which  objects  brought  from  ^"ithout  into 
the  field  are  better  seen  than  those  moved  from  within  the  field  outward. 
HA'peresthesia  of  the  retina  and  ear,  ringmg  in  the  ears,  ^Meniere's 
complex  and  disturbance  of  taste  or  smell  are  not  common. 

2.  Spestal  SYiiPTo:MS. — These  include  the  so-called  "spinal  irritation." 
Many  sjTnptoms  ranked  as  spinal  are  essentially  cerebral.  In  "uomen 
they  are  more  common  and  are  localized  chiefly  to  the  upper  dorsal 
and  coccygeal  regions;  in  men  they  are  liunbodorsal  and  most  frequent 
in  the  sexual  type.  Sensory  s^"mptoms  are  constant.  Hyperesthesia 
is  common  m  the  bodies  of  the  muscles;  paresthesia  is  frequent,  as 
tinglings,  girdle  sensation  or  itching.  Paralgesia  in  the  form  of  headache 
(rhachialgiaj  is  as  frequent  as  headache  and  the  pain  may  radiate  into 
the  various  nerve  plexuses;  it  is  very  often  sacral  and  cutaneous;  the 


NEURASTHENIA  915 

spine  may  be  exquisitely  sensitive  to  pressure.  Neuralgia  is  rare.  Anes- 
thesia is  no  part  of  neurasthenia.  Of  the  motor  symptoms,  myasthenia 
is  the  rule,  spinal  and  cortical  in  origin  and  conspicuous  in  the  morning. 
The  muscles  often  show  fibrillary  contractions  and  a  tremor  (85  per  cent.) 
which  is  as  fine  and  frequent  as  that  of  alcoholism  or  Graves's  disease. 
Muscular  fidgets,  starts,  cramps  and  irritability  of  the  nerve  trunks,  as 
in  tetany,  are  also  observed.  Actual  ataxia  is  most  rare,  although  sug- 
gested by  the  writing.  The  akinesia  algera  (Mobius)  or  the  abasia- 
astasia  of  Blocq,  as  in  hysteria  or  the  psychoses,  is  the  result  of  a  phobia 
or  a  fixed  conception.  One  of  Erb's  patients  remained  in  bed  for  fourteen 
years.     The  skin,  tendon  and  periosteal  reflexes  are  increased. 

3.  Vasomotoe  Symptoms. — These  produce  many  central,  visceral 
and  peripheral  manifestations.  During  brainwork  the  cerebral  vessels 
normally  dilate  while  those  of  the  arm  contract;  this  does  not  occur  in 
neurasthenia.  The  manometer  in  normal  cases  reveals  no  essential 
variation  during  work,  while  in  neurasthenia  marked  manometric  varia- 
tions occur.  Neurasthenics  often  suffer  from  cold  and  wear  more  clothes 
than  is  necessary;  the  skin  is  cold,  clammy,  even  cyanotic  or  locally 
asphyxiated.  On  the  other  hand,  the  skin  may  be  flushed  and  hot. 
Salivation  or  a  dry  mouth,  polyuria,  pseudo-angina  pectoris,  the  wide 
temporal  vessels,  epigastric  pulsation,  edema,  urticaria  and  dermograph- 
ism are  but  vasomotor  manifestations. 

4.  Visceral  Manifestations.— (a)  Some  of  the  cardiovascular  signs 
and  symptoms  have  been  treated.  The  arteries  relax  and  throb,  the  pulse 
may  be  slightly  of  the  "water-hammer"  type  and  capillary  pulsation 'is 
often  apparent  in  the  lips  or  nails.  Palpitation,  precordial  anxiety  and 
dyspnea  are  frequent.  The  pulse  is  frequently  faster  and  may  increase 
10  or  20  beats  on  pressure  over  some  sensitive  area  (v.  i.  Traumatic 
Neuroses).  Man}'  neurasthenics  seek  consultation  for  cardiac  disease. 
(6)  Gastric  symptoms  (in  60  per  cent.)  are  functional  in  character,  as  achlor- 
hydria,  hyperchlorhydria,  hyperesthesia.  Anorexia  is  usually  mental, 
as  are  polyphagia,  polydipsia  and  adipsia  (see  Neuroses  of  Stomach). 
(c)  Intestinal  symptoms.  Diarrhea  is  less  common  than  constipation, 
which,  like  previous  sexual  abuses,  often  occupies  the  patients'  thoughts. 
They  "would  be  perfectly  well  if  they  could  have  one  natural  move- 
ment," and  when  they  do  they  complain  of  "exhaustion  during  the 
entire  day  afterward."  A  sense  of  pressure,  peristaltic  unrest,  hyper- 
esthesia, burning  and  flatulency  torment  the  patient.  Enteritis  mem- 
branacea  and  enteroptosis  are  not  infrequent,  {d)  The  amount  of  urine 
is  equally  often  increased  or  decreased.  The  specific  gravity  is  lowered, 
but  the  urates,  uric  acid  and  urea  are  increased.  Phosphaturia  and 
oxaluria  occur,  often  attended  by  flatulent  dyspepsia,  melancholia  and 
nervous  depression.  Vesical  tenesmus  is  an  occasional  complaint,  (e) 
Genital  symptoms.  Fear  of  the  results  of  previous  excesses  or  of  self- 
abuse  may  dominate  the  patient's  mind,  but  the  trouble  is  more  a 
matter  of  conception  than  of  reality,  since  the  sexual  appetite  is  actually 
decreased  as  a  rule.  In  most  cases  there  is  premature  ejaculation  and  in 
some  patients  there  is  psychical  impotence.  Emissions  are  frequent,  but 
their  importance  is  greatly  overestimated. 


916  THE  NEUROSES 

Course  and  Prognosis. — Acute  cases  are  rare  and  fatal  cases  extremely 
exceptional.  The  vsval  chronic  course  is  one  of  slow  onset;  it  is  attended 
by  evidences  of  nervous  fatigue  which  are  at  first  relieved  by  rest,  but 
which  later  persist  in  spite  of  rest  and  incline  the  patient  to  stimulants 
or  drug  habits.  Later  the  signs  of  cerebral  irritability,  disturbed  sleep, 
vasomotor  disorders,  reduced  mental  and  psychical  capacity,  pains, 
spinal  tenderness,  paresthesia  or  paralgesia,  sympathetic  dyspnea  or 
palpitation  deA'elop,  sometimes  with  temporary  remissions.  The  outlook 
is  poor  in  severe  hereditary  forms  or  when  there  are  complicating  psy- 
choses or  drug  habits.  In  other  types  recovery  is  usual,  although  long 
deferred. 

Diagnosis. — The  diagnosis  is  generally  made  with  ease,  but  several 
rules  must  be  borne  in  mind:  (1)  Xo  single  s^Tnptom  is  pathognomonic; 
(2)  neurasthenia  may  precede,  follow  or  complicate  organic  nervous  or 
visceral  disease,  as  arteriosclerosis.  The  subjective  signs,  irritable  weakness, 
emotivity,  muscular  weakness,  headache,  backache,  insomnia,  amnesia, 
impaired  psychical  co5rdination  and  the  phobias,  together  with  objective 
findings,  as  asthenopia,  insufficiency  of  the  internal  recti,  tachycardia, 
epigastric  pulsation,  vasomotor  alteration,  as  disturbed  secretion  of 
urine  or  sweat,  increased  reflexes,  fibrillation  and  tender  muscles  cannot 
be  mistaken.  Psychasthenia  is  made  by  Janet  to  include  all  cases,  with 
doubts,  phobias,  fixed  ideas,  obsessions,  dazed  conditions  or  a  sense  of 
unreality.  The  neurasthenic  prodromes  of  progressive  paralysis  (q.  v.) 
are  usually  distinguished  on  careful  search  for  organic  disease.  Hysteria 
is  typical  in  its  stigmata  and  accidents;  anesthesia,  persistent  contrac- 
tion of  the  fields  of  vision,  dyschromatopsia,  achromatopsia,  monocular 
diplopia,  convulsions,  paralyses,  contractm-es  and  anuria  are  foreign  to 
neurasthenia.  Hypochondriasis  differs  from  neurasthenia  in  that  it  is 
a  pure  psychosis,  its  concepts  are  primary,  ill-based,  illogical  or  absurd 
and  cannot  be  eradicated  even  for  a  time. 

Treatment. — 1.  Prophylaxis. — Prevention  is  difficult,  but  even  with 
hereditary  stigmata  much  may  be  done.  Treatment  starts  with  the 
education  of  both  child  and  adult.  Children  are  mimics  and  the  clearest 
of  all  observers.  The  inculcation  of  self-control,  fearlessness,  self-sacrifice, 
moderation  in  all  things,  truthfulness,  prompt  decision  and  constancy  of 
purpose  must  be  based  on  actual  parental  example,  and  in  this  way 
the  child  should  also  educate  the  parent.  The  child  must  learn  to  give 
up,  to  sleep  alone,  to  stop  at  the  right  time,  to  finish  what  he  has  begun, 
to  obey  and  to  learn  that  he  is  not  the  centre  of  the  family.  He  should 
be  taught  without  being  forced.  Out-door  living  is  more  important  than 
the  school-room.  The  Enghsh  method  of  treating  children  with  reserve 
has  some  advantages  over  American  demonstrativeness.  Simple,  varied 
food,  without  tea,  cofi^ee  or  alcohol,  and  long  sleeps  develop  a  strong 
nervous  system.     The  sexual  instinct  requires  attention. 

2.  Therapy. — When  once  manifested,  the  disease  should  be  treated 
as  above  outlined  and  causal  factors  should  be  investigated.  Work  alone 
is  seldom  injurious  and  while  the  modern  complexity  in  the  struggle 
for  existence  is  increasing  the  number  of  neurasthenics,  work  should  not 
bear  the  stigma  nor  should  disappointment,  for  both  make  character. 


NEURASTHENIA  917 

Work  must  be  systematic,  not  slavish.  Hurry,  failure  to  learn  indi- 
vidual limitations,  uncontrolled  planning  be.-s'ond  the  immediate  day's 
work  and  worry  cause  the  damage,  especiall\'  when  work  produces 
indifference  to  nature,  family  life,  exercise,  rest  and  the  things  higher 
and  above  one's  own  small  life  and  ambition.  The  time  for  exercise  should 
be  taken  from  the  work  hours,  it  should  not  follow  them,  nor  should  it 
be  enforced  in  every  case,  for  some  are  hurt  by  it;  work  under  stimulation 
is  injurious.  The  chief  element  in  treatment  is  psychical  and  the  physician 
accomplishes  more  than  do  drugs.  He  carefully  examines  and  reexamines 
the  patient  and  his  assurrance  that  no  organic  disease  exists  has  its 
weight  for  the  time.  Conversely,  careless  diagnoses,  as  of  fatty  heart, 
work  damage  to  the  patient's  mental  balance.  The  hygiene  should  be 
regulated.  Strict  dietaries  and  stimulants  should  be  avoided,"  moderate 
out-of-door  life  or  exercise  enjoined  and  in  pronounced  cases  absolute 
rest  from  work,  with  sojourn  near  the  sea  or  at  a  moderate  altitude  free 
from  sudden  changes  or  high  winds  is  recommended.  Sexual  matters 
should  be  left  alone  unless  gross  violations  are  found.  The  patients 
need  sympathy — in  moderation  for  their  sake;  but  the  patient  must  be 
taught  that  he  alone  can  cure  his  malady  by  self-control  and  by  avoiding 
extremes  in  everything. 

Pronounced  cases  in  thin  women,  especially  those  with  gastric  symp- 
toms, are  often  helped  by  the  Weir  Mitchell  rest-cure,  which  consists  of 
absolute  rest  in  bed,  isolation,  forced  feeding,  massage  and  faradization. 
The  patient  is  not  allowed  to  lift  a  hand  and  sees  only  the  nurse,  who  is 
selected  for  her  strength,  optimism  and  lack  of  nerves.  The  patient  is 
fed  milk  every  three  hours  and  the  muscles  are  rubbed  and  faradized. 
Thus  weight  and  strength  are  gained  without  muscular  degeneration. 
Few  men  will  tolerate  this  method  and  obese  do  not  fare  as  well  as  lean 
women.  No  greater  mistake  is  made  than  to  give  all  patients  a  rest-cure; 
they  often  want  work  and  occupation,  harmonized  with  rest. 

3.  Diet. — No  one  dietary  is  essential;  some  physicians  favor  a  meat 
diet,  others  give  well-cooked  vegetable  albumins,  cooked  fruit,  fats,  milk 
and  eggs,  especially  in  cardiac  types.  In  mental  anorexia,  feeding  by 
mouth  or  rectum  must  be  forced.  Water  in  abundance  is  indicated. 
Gastric  hyperesthesia  is  relieved  by  small  doses  of  phenol.  Eructations 
must  be  controlled,  since  the  air  admitted  exceeds  the  gas  expelled; 
asafetida  is  excellent  because  it  makes  as  strong  an  impression  when 
swallowed  as  when  eructed.  Electricitv  is  largely  suggestive.  With 
massage  and  vegetable  diet,  endorectal  faradization  relieves  constipation. 
In  cardiac  types  alcohol  and  tobacco  are  interdicted  and  small  doses 
of  belladonna  and  bromide  usually  control  palpitation;  other  vasomotor 
symptoms  are  relieved  by  these  remedies,  ergotin  or  nitroglycerin, 
according  as  they  are  angioparetic  or  angiospastic ;  or  arsenic  in  anemia. 

Insomnia  is  often  difficult  to  relieve;  the  following  measures  are  valu- 
able: avoidance  of  evening  work,  stimulants  or  excitement;  a  cool  bath, 
the  wet  pack  or  an  ice-bag  over  the  heart;  small  doses  of  bromide  with 
valerian  for  the  "expectant  attention"  which  wards  oft'  sleep;  20  grains 
of  sulphonal  in  hot  milk,  which  should  be  slowly  sipped;  codeine  with 
hyoscine;  and  chloral  (the  continued  use  of  which  induces  vasomotor 


918  THE  NEUROSES 

disturbance).  The  habit  of  sleep  must  be  cultivated  and  the  patient 
must  not  get  up  to  read.  Local,  m-ethral  and  uterine  affections  are  best 
ignored. 

THE  "TRAUMATIC  NEUROSES." 

This  is  a  practical  grouping  of  traumatic  neurasthenia,  hysteria, 
chorea  and  hypochondriasis.  Hysterical  forms  were  first  described  by 
\Yalton  and  Putnam;  Erichsen  (1866j  wrote  on  trauma  to  the  spine,  on 
which  the  illogical  name  of  railway  spme  was  later  conferred,  and  Oppen- 
heim  (1877)  termed  the  group  the  "traumatic  neuroses."  All  organic 
affections  must  be  excluded,  whether  trauma  seems  directly  or  indirectly 
causal,  as  vertebral  caries,  tumor,  chronic  ankylosis,  rarefying  osteitis 
which  Kocher  refers  to  fracture;  hematorrhachis,  meningeal  hematoma 
or  pachymeningitis;  and  cord  affections,  as  poliomyelitis,  myelitis  or 
lateral  sclerosis.  Experimental  trauma  may  produce  molecular  nervous 
changes,  and  trauma  may  hasten  arteriosclerosis.  Alcoholism  and 
syphilis  are  predisposing  factors.  Traumatic  neuroses  are  yureJy  func- 
tional affections  caused  by  trauma,  which  operates  psychically  rather 
than  somatically. 

Symptoms. — The  symptoms  are  those  of  hysteria,  neurasthenia  and 
h^'pochondriasis,  singly  or  in  combination.  The  patient  may  feel  well 
for  a  day  or  two  and  then  pain  dcA'elops  at  the  seat  of  injury  or  in  the 
spine;  anxiety,  fear  of  his  financial  future  or  for  his  family,  a  "fixed 
idea"  of  his  incapacity  and  the  development  of  "litigation  symptoms" 
are  typical  of  hypochondriacal  neurasthenia.  Psychical  symjAoms  are 
usually  prominent;  they  are  accentuated  by  repeated,  sometimes  sug- 
gestive, physical  examinations,  visits  of  la\^yers  or  adjusters,  court-room 
suspense,  reversals  of  judgment  or  appeals.  Vertigo,  backache,  headache, 
sleepiness  by  day  and  nocturnal  insomnia  may  cause  great  distress. 
Pain,  which  seems  to  be  nervous,  may  prove  organic  on  examination  by 
the  a'-rays;  it  may  be  simulated,  but  is  often  real,  as  shown  by  persistence 
after  award  of  damages.  Tender  areas  are  difficult  to  pass  upon,  because 
of  exaggeration  or  simulation;  Mann,  Kopf  and  Rumpf  found  that  press- 
ure on  areas  which  are  actually  tender  increases  the  pulse-rate  by  10 
to  30  beats ;  this  sign  is  subject  to  several  conditions :  (a)  it  is  not  always 
present;  (6)  its  absence  is  no  proof  of  simulation;  (c)  in  simulation, 
the  "^Tithing  which  occurs  when  certain  areas  are  touched  may  increase 
the  heart's  action.  Paresthesia  and  hj'peresthesia  of  the  skin  or  special 
senses  are  frequent.  Anesthesia  indicates  traumatic  hysteria.  Hysteric 
or  neurasthenic  contraction  of  the  visual  fields  may  remain  the  same  from 
day  to  day  and  not  vary  with  approach  or  withdrawal  of  the  test  object; 
this  is  not  a  sign  of  simulation;  Forster's  type  cannot  be  assumed.  The 
pupils  may  vary,  especially  by  dull  illumination;  reflex  immobility 
indicates  organic  disease.  Motor  symjAoms  may  embrace  all  those  of 
hysteria  or  neurasthenia,  abasia,  astasia,  paralyses,  contractures  sug- 
gesting vertebral  injury  or  joint  disease  (Brodie's  joints),  pseudospastic 
or  -tabetic  gaits,  tremor  {forme  trepidante)  or  sometimes  muscular  atrophy 
about  the  joints.  Hysterical  convulsions  are  rare;  the  author  twice  saw 
choreiform   aff'ections   in   telephone   girls  who   sustained   slight  shocks 


EPILEPSY  ■  919 

and  once  a  genuine  chorea.  Patients  must  often  be  watched;  one  of  the 
author's  cases,  with  spastic  gait,  shuffled  out  of  the  office  but  walked 
perfectly  well  around  the  corner.  The  reflexes  are  often  increased, 
perhaps  asymmetrically;  ankle-clonus,  which  is  probably  spurious,  is 
sometimes  reported.  When  there  is  albuminuria  and  glycosuria  the 
question  arises  whether  they  were  previously  present. 

Diagnosis. — Several  points  are  often  difficult  to  establish,  because 
objective  findings  are  frequently  few:  (a)  It  is  usually  possible  to  state 
whether  one  of  the  neuroses  is  present  or  whether  organic  disease  obtains. 
(6)  Exaggeration  and  simulation  are  difficult  to  estimate,  as  shown  by  the 
change  of  professional  opinion  from  the  idea  that  most  cases  are  simulated 
to  the  present  statement  of  some  writers  that  it  is  present  in  4  per  cent, 
of  cases  only,  (c)  If  disease  is  present  is  it  directly  due  to  injury?  {d) 
If  so,  the  most  difficult  of  all  questions  is  presented,  namely,  the  degree 
and  duration  of  the  disease  and  the  damages  to  be  awarded. 

Prognosis. — (a)  As  to  life,  the  outlook  is  usually  good,  though  some 
cases  become  insane  or  suicidal.  (6)  As  to  complete  recovery,  it  is  less 
favorable.  In  most  cases  it  is  surprising  how  soon  symptoms  disappear 
after  satisfactory  legal  settlement  is  made;  this  is  said  without  cynicism. 
Many  persons  do  not  then  recover  completely  and  sj^mptoms  may  endure 
in  those  who  reject  litigation.  Hysterical  are  more  favorable  than  neu- 
rasthenic or  hypochondriacal  symptoms. 

Treatment. — Treatment  is  psychical.  The  physician  dreads  the  effect 
of  litigation  on  the  patient,  assures  him  that  there  is  no  organic  lesion 
and  advises  early  settlement  and  return  to  work. 


EPILEPSY. 

Definition. — Epilepsy,  by  derivation,  "being  seized  upon,"  has  been 
called  the  "falling  sickness"  and  morbus  sacer.  It  does  not  include 
Jacksonian  or  s^^mptomatic  epilepsies.  Classified  with  hysteria  and 
neurasthenia  as  one  of  the  "three  great  difi^use  neuroses,"  it  probably 
includes  more  than  one  disease.  It  is  a  disturbance  of  balance  between 
the  central  exciting  and  inhibiting  nervous  processes  attended  by  (a)  a 
typical  chronic,  co7ivuhive  disorder,  affecting  the  entire  central  nervous 
system,  each  attack  being  followed  by  loss  of  consciousness,  (b)  partial 
or  atypical  manifestations  of  these  characteristics,  or  (c)  concomitant 
or  consecutive  psychical  or  other  symptoms.  It  occurs  in  from  one  to 
six  persons  per  thousand. 

Etiology. — Of  the  ultimate  causes,  the  7ieuro-  or  p)sychopathic  tendency 
of  Griesinger  is  found  in  37  per  cent,  of  cases;  only  the  tendenc}^  is  trans- 
mitted by  inheritance,  rarely  the  disease  itself.  Neurotic  or  psychopathic 
antecedents,  parental  alcoholism  (51  per  cent.),  morphinism,  plumbism, 
syphilis,  tuberculosis,  gout,  diabetes,  or  ovarian  and  testicular  diseases 
lessen  the  nervous  resistance  of  the  offspring.  The  disease  rarely'  develops 
after  the  thirtieth  year;  75  per  cent,  of  cases  develop  before  twenty; 
46  per  cent,  between  ten  and  twenty,  mostly  at  puberty;  28  per  cent, 
before  ten.     The  sexes  are  equally  affected. 


920  THE  NEUROSES 

Inciting  causes  include  infections,  as  malaria  or  typhoid;  syphilis  may 
be  hereditary,  induce  the  Jacksonian  type  from  cortical  gumma,  or  it 
may  be  parasyphilitic ;  intoxications,  especially  alcoholism;  exhausting 
affections,  as  diseases  of  the  blood  or  metabolism;  and  trauma  or  fright. 
Inciting  causes  are  found  in  37  per  cent,  of  cases. 

Reflex  epilejjsy  is  said  to  occur  from  painful  scars,  nerve  tumors,  or 
foreign  bodies  in  the  ear,  nose,  nasopharynx  or  larynx;  diseases  of  the 
digestive  tract,  uterus  and  heart;  onset  of  the  menses  or  their  monthly 
appearance;  pregnancy,  phimosis  or  onanism;  from  gall-stones,  colic  or 
abdominal  paracentesis. 

Pathology. — There  is  no  characteristic  macro-  or  microscopic  change. 
The  usual  finding  after  death  is  that  of  any  convulsion,  viz.,  venous  en- 
gorgement and  punctate  ecchymoses.  Induration  of  the  cornu  ammonis, 
induration  in  the  medulla,  neurogliar  increase  in  the  cortex,  thickening, 
asymmetry  or  deformity  of  the  skull  and  persistence  of  the  thymus 
have  not  been  proved  causal. 

Symptoms. — The  symptoms  are  best  studied  from  the  completely  devel- 
oped attack,  in  which  there  are  three  component  parts:  (a)  The  prodromal 
stage  is  not  always  present.  Its  "warnings"  are  either  distant  or  imme- 
diate. The  distant  warnings  (in  10  per  cent,  of  cases)  may  precede  the 
seizure  by  hours  or  days  and  take  the  form  of  restlessness,  dispositional 
changes,  depression,  thoracic  or  cephalic  oppression,  insomnia,  vertigo, 
nausea,  grinding  of  the  teeth,  hyperesthesia  of  the  special  senses,  angio- 
neurotic palpitation  or  cerebral  congestion.  The  immediate  warning,  the 
aura  proper,  is  the  beginning  of  the  convulsion  rather  than  a  warning. 
It  is  a  central  cortical  irritation;  its  frequency  is  40  per  cent.;  it  is  rarer 
in  sudden,  stormy,  generalized  seizures.  The  psychical  aura  is  rare  and. 
is  manifested  by  emotional  or  intellectual  alteration  and  anxiety.  The 
sensory  aura  consists  of  paresthesia  and  a  sense  of  deadness  in  a  limb  or 
joint,  attacks  of  migraine  and  epigastric  sensations  (from  the  pneumo- 
gastric  nerve,  pressure  or  irritation  of  which  sometimes  inhibits  the 
convulsion).  The  special  senses  may  be  irritated  or  blunted;  there  may 
be  flashes  of  light  or  colors,  hallucinations,  blackness  before  the  eyes  and 
less  often  anomalies  of  hearing,  taste  or  smell.  The  motor  aurse  are 
circumscribed  clonic  or  much  less  often  tonic  twitchings,  as  in  Jacksonian 
epilepsy,  from  which  they  are  distinguished  by  a  rapid  loss  of  conscious- 
ness; automatic  movements,  like  stamping  or  buttoning  the  coat,  are 
rarer  and  motor  weakness  and  singultus,  coughing  or  sneezing  are  least 
frequent.  Vasomotor  aurse  may  be  localized  or  generalized,  as  rushing  of 
blood  to  the  head,  palpitation,  anesthesia,  increased  temperature,  in- 
creased arterial  tension,  pallor  or  chilling.  The  patient  then  falls,  pale 
and  unconscious,  or  is  thrown  with  force,  often  on  his  face,  when  (b)  the 
convulsive  stage  begins.  First  a  tonic  convulsion  affects  all  voluntary 
muscles,  due  to  infracortical  irritation.  The  initial  cry,  guttural  or 
groaning  from  tonic  abdominal,  thoracic  and  laryngeal  spasm,  is  heard 
in  50  per  cent,  of  cases  The  head  is  held  back;  the  eyes  are  open  and 
staring,  the  jaw  set,  the  face  flushed,  the  neck  tense,  the  bod}^  often 
opisthotonic,  breathing  and  pulse  are  suspended,  the  muscles  are  hard 
but  slightly  vibrating  to  the  palpating  hand,  the  arms  are  turned  tetanic- 


EPILEPSY  921 

ally  inward,  the  hands  are  clenched  with  the  thumb  adducted  and  under 
the  fingers,  the  legs  are  extended,  the  thighs  adducted  and  the  toes 
flexed  or  extended  and  spread  apart.  In  some  cases  the  head,  eyes  and 
e\'en  trmik  deviate  and  in  a  few  instances  the  tetanic  spasm  spreads 
gradually,  instead  of  the  usual  instantaneous  tonic  spasm.  The  tonic 
phase  lasts  ten  to  thirty  seconds,  relaxing  in  inverse  order  from  the  limbs 
to  the  neck  and  face.  The  second  phase  of  clonic  convulsion  occurs 
at  once,  appearing  first  in  the  limbs,  which  are  not  yet  free  of  the  tonic 
spasm.  This  stage  is  bilateral,  highly  irregular  and  violent,  with  very 
short  remissions,  leading  perhaps  to  injury,  fracture,  luxation,  breaking 
of  teeth,  laceration  of  skin,  tongue  and  cheek,  or  rupture  of  muscles. 
It  consists  largely  of  alternating  flexion  and  extension;  the  head  strikes 
the  ground,  the  body  turns  violently,  the  eyes  jerk  and  protrude,  the  face 
is  distorted,  the  tongue  is  bitten  as  it  is  thrust  out,  bloody  saliva  is 
expressed  by  the  masseters,  inarticulate  sounds  arise  from  the  move- 
ments of  the  diaphragm  and  respiratory  muscles  and  gurgling  results 
from  intestinal  movements;  vomiting  movements,  filling  of  the  stomach 
with  air,  cyanosis,  swelling  of  the  jugular  veins,  ecchymoses  in  the 
conjunctiva,  skin,  retina  or  lar\Tix,  involuntary  and  sometimes  forcible 
evacuation  of  the  bladder,  less  often  of  the  rectum,  and  occasionally 
ejaculation,  occur.  The  clonic  phase  lasts  one-half  to  three  minutes, 
ending  in  a  fine  generalized  tremor,  (c)  The  comatose  stage  often  begins 
with  a  deep  sigh;  respiration  and  circulation  become  normal,  the  limbs 
relax  and  the  condition  resembles  a  soimd  sleep,  from  which  the  patient 
awakes  in  from  fifteen  minutes  to  several  hours,  sometimes  suddenly, 
more  often  gradually  and  in  a  more  or  less  dazed  condition.  He  recalls 
nothing  of  the  attack  and  the  loss  of  memory  may  extend  back  of  the 
seizure  (retrograde  amnesia).  He  experiences  pain  in  the  muscles,  joints 
or  head,  nausea,  mental  irritability  or  depression  and  finally  a  group  of 
exhaustion  symjAoms,  viz.,  (i)  sensory  exhaustion,  expressed  by  hypesthesia, 
anesthesia,  h^-palgesia  or  analgesia;  (ii)  exhaustion  of  the  special  senses, 
as  concentric  limitation  of  the  visual  and  color  fields,  dulling  of  hearing, 
taste  or  smell,  and  (iii)  motor  exliaustion  due  to  cortical  fatigue. 

During  the  attack  xasomotor  constriction  often  occurs,  as  shown  by 
the  initial  pallor  of  the  face,  cardiac  overaction  or  perhaps  irregularity. 
The  ecchymoses  and  retinal  congestion  are  due  to  the  convulsion.  The 
impil  is  reactionless,  narrow  at  the  onset,  and  dilated  widely  in  the 
second  stage;  afterward  it  may  oscillate;  the  pupils  are  sometimes 
unequal.  The  tendon  and  skin  reflexes  are  weak  or  lost  in  complete 
attacks  and  for  hours  afterward,  whence  we  may  judge  of  the  severity 
of  the  seizures.  The  temperature  may  be  elevated  2°  or  3°.  Voisin  found 
albumin  in  50  per  cent.,  though  others  consider  it  infrequent.  The 
author  has  often  noted  transient  albuminuria  and  cylindruria  (granular 
casts)  after  marked  paroxysms;  glycosmia  is  imcommon.  The  phos- 
phates and  nitrogen  are  increased;  pohiiria  is  common  in  the  third 
stage.    The  sweat  is  increased. 

T3rpes  of  Epilepsy.- — 1.  The  completely  developed  attack  {epilepsia 
(jravior,  grand  mal)  consists  of  (a)  the  classic  tj-pe  (29  per  cent.),  as  above 
described,  with  loss  of  consciousness,  and  tonic  followed  by  clonic  con- 


922  THE  NEUROSES 

vulsions;  or  (b)  the  slightly  atypical  type  (19  per  cent.),  in  which,  e.  g., 
the  spasm  may  not  always  be  generalized. 

2.  The  rudimentary  attack  (21  per  cent.)  consists  of  loss  of  conscious- 
ness, plus  tonic  or  clonic  spasms.  This  includes  the  apoplectiform  cases, 
especially  the  senile  (arteriosclerotic)  form;  forms  resembling  myo- 
clonus; cases  which  do  not  fall  but  stumble  along  at  the  onset  (epilepsia 
procursiva)  or  turn  (epilepsia  rotatoria). 

3.  The  third  form  is  the  abortive  attack  (epilepsia  mitior,  -petit  mal, 
31  per  cent.).  Its  importance  is  underestimated  by  the  profession  and 
the  public;  two  main  types,  with  endless  variations,  are  distinguished: 
(a)  one  with  loss  of  consciousness  with  few  or  no  motor  signs,  and  (6) 
motor  and  vasomotor  signs  with  no  loss  of  consciousness,  or  very  slight 
clouding  of  the  intellect.  The  loss  of  consciousness  is  often  very  slight 
or  may  last  for  a  few  seconds,  so  that  a  scarcely  perceptible  break  occurs 
in  the  patient's  occupation,  reading,  speaking,  playing  the  piano  or  a 
game  of  cards;  it  is  described  by  the  French  as  "absence"  He  may 
move  his  lips  inarticulately  or  there  is  nystagmus,  a  chewing  or  swallow- 
ing movement,  tremor  or  twitching  of  the  face,  monospasm  or  vertigo. 
A  cry  may  be  the  sole  symptom.  Some  patients  seem  to  fall  suddenly 
asleep.  Nothing,  or  everything,  may  be  remembered.  Aurse  may  con- 
stitute the  whole  attack,  which  aborts  without  unconsciousness  or  spasms. 

4.  The  psychical  equivalent  of  Sammt,  also  known  as  transformed  or 
larvated  epilepsy  or  the  epileptoid  condition  is  often  mistaken.  Mental 
symptoms  may  precede,  succeed,  alternate  with  or  replace  the  ordinary 
convulsive  type,  which  must  be  first  recognized  to  establish  this  variety. 
The  mental  changes  are  slight  {petit  mal  intellectuel)  or  marked  {grand 
mal  intellectuel)  and  include  excitement,  emotional  outbursts,  narcolepsy, 
incoherent  conceptions,  amnestic  attacks  and  mania.  The  patient  may 
act  like  a  hypnotized  subject;  he  may  take  sudden  long  journeys  or 
commit  assault,  arson  or  murder,  whence  the  great  medicolegal  signifi- 
cance of  this  variety. 

The  liiterparoxysmal  State. — Signs  of  psychical  degeneration,  poorly 
differentiated  or  large,  small  or  prominent  ears,  hematoma  of  the  ear, 
deformed  teeth,  lips  or  palate,  coloboma,  strabismus,  nystagmus,  small 
eyes,  irregular  pigmentation  of  the  iris,  deformed  genitals  or  fingers, 
disorders  of  speech  or  irregular  facial  innervation  may  indicate  hereditary 
taint.  Neurasthenic  symptoms  are  not  unusual.  The  expression  is  often 
dull.  When  idiocy  occurs  with  epilepsy,  both  are  coordinate  results  of  a 
common  cause,  or  early  and  repeated  attacks  have  initiated  mental 
degeneration.  However,  many  brilliant  men  have  been  epileptics,  as 
Julius  Csesar,  Napoleon,  Carl  V,  Peter  the  Great,  St.  Paul,  Mohamed, 
Petrarch  and  Rousseau.  The  importance  of  organic  disease  of  the  heart, 
lungs,  stomach  and  kidney  is  difficult  to  estimate.  Epileptics  often  sweat 
profusely,  are  usually  constipated  and  frequently  become  obese  from 
inordinate  eating  and  the  bromide  treatment. 

Diagnosis.— The  diagnosis  concerns  the  convulsive  seizures  and  the 
abortive  types.  Similar  convulsions  must  first  be  excluded  which  occur 
in  (a)  organic  brain  disease,  as  syphilis,  tumors,  vascular  lesions,  paretic 
dementia,   multiple   sclerosis  and  infantile  cerebral  paralysis.     These 


EPILEPSY 


923 


affections  may  produce  generalized  or  Jacksonian  fits.  Jacksonian 
epilepsy  is  more  clonic  (cortical  irritation)  than  tonic  (infracortical 
irritation),  is  often  associated  with  paresis  or  sensory  alteration,  occurs 
less  often  with  coma  and  in  50  per  cent,  of  cases  is  due  to  small  cortical 
tumors.  Epilepsy  rarely  develops  after  thirty  years  of  age  (E.  tarda) 
and  90  per  cent,  of  cases  which  occur  after  thirty — excluding  alcoholism 
and  uremia — are  syphilitic.  After  forty-five,  vascular  lesions  are  a 
very  common  cause.  (6)  Convulsions  may  occur  in  alcoholism,  uremia 
(eclampsia),  plumbism  or  drug  poisonings,     (c)  Reflex  epilepsy  (v.  s.). 

Simulation  of  epilepsy  is  impossible.  In  the  complete  type,  the  tongue 
biting,  cry,  stertor  or  involuntaries  may  be  absent.  Scars  are  often  of 
diagnostic  value.  Nocturnal  epilepsy  occurs  in  33  per  cent.,  often  coming 
on  when  the  patient  drops  off  to  sleep  or  on  awakening  in  the  morning; 
the  depression,  bitten  tongue,  ecchymoses  and  involuntary  evacuations 
are  unmistakable. 

Differentiation  from  hysteria  is  usually  easy: 


Epilepsy. 


-Hysteria. 


Distant  warnings:     few,  mental. 

Aura:  more  frequent,  momentary,  oftenest 

unilateral  or  epigastric. 
Cause:  none. 

Onset:     always  sudden,  often  with  pallor, 
,      cry    which    is    never    verbal,    immediate 

falling     and     complete     unconsciousness, 

with  rigidity,  etc. 

Tongue  biting,  frothing:  very  common. 
Convulsions:    generalized,  tonic  followed  by 

clonic   spasms,    very   rarely   tonic   alone; 

flexor  spasm  predominates. 

Reflexes:  pupils  contracted  at  onset,  dilated 
later,  immobile  (in  clonic  period).  Ten- 
don and  skin  reflexes  absent  during  and 
after  attack. 

Involuntary  evacuations:  frequent. 

The  urine:  solids  always  increased,  both 
nitrogen  and  phosphates. 

Temperature:  sometimes  elevated,  2°-3°. 

Coma:  complete. 

Duration  of  seizure:  very  short. 

Postparoxysmal:  sensory  and  motor  ex- 
haustion, ecchymoses,  absent  reflexes, 
mental  incapacity,  with  no  memory  of 
transpired  events. 


Frequent,  emotional. 

Less  frequent,  longer,  bilateral,  foot  aura, 
globus. 

E^motional. 

More  gradual,  rarely  with  pallor  or  cry, 
which  may  be  repeated  or  verbal,  and 
recur.  Rarely  brusque  falling,  slower  and 
less  complete  unconsciousness,  and  may 
react  to  suggestion. 

Exceptional,  or  seemingly  purposive. 

Rigidity,  to  carry  out  semi-intentional 
movement;  struggling;  clonic,  irregular 
spasms;  extensor  spasm  predominant, 
"arc  de  cercle,"   clownism. 

Pupils  usually  wide  and  react  (may  be 
immobile,  Westphal,  Karplus).  Some- 
times convergent  strabismus.  Reflexes 
rarely  absent;    or  increased. 

Absent  or  most  exceptional. 

Solids  decreased;  altered  ratio  of  earthy 
and  alkaline  phosphates. 

Practically  never. 

No  real  coma. 

Longer,  recurrent,  relapsing. 

Depression,  fatigue,  pain  in  the  head  or 
stomach,  nausea,  some  memory  of 
attack. 


Most  difficult  to  differentiate  are  petit  mal  and  transformed  epilepsy, 
in  which  the  history  of  major  attacks  is  important.  Petit  mal  may  be 
confused  with  cardiac  syncope,  labyrinthine  vertigo,  etc. 

Course  and  Prognosis. — When  one  attack  has  occurred  a  second  may 
be  expected  in  33  per  cent,  of  cases  in  less  than  one  month,  in  33  per 
cent,  in  from  one  to  twelve  months,  in  33  per  cent,  in  over  one  year; 
and  when  epilepsy  is  once  established,  daily  attacks  occur  in  1 1  per  cent., 
in  50  per  cent,  they  occur  at  intervals  of  less  than  two  weeks,  and  in 
75  per  cent,  they  occur  at  intervals  of  less  than  one  month  (Gowers). 


924  THE  NEUROSES 

The  mode  of  life,  stimulation,  excitement,  pregnancy  and  sexual  excesses 
may  increase  their  frequency  and  cessation  during  fevers  is  not  uncommon. 
In  some,  fortunately  rare,  cases  the  attacks  occur  in  quick  succession 
{status  epileiDticus,  Stat  de  mal),  as  many  as  10  or  over  100  occurring 
in  one  day.  In  one  case  2500  seizures  occurred  during  a  month;  the 
stage  of  coma  may  last  from  two  or  three  days  to  a  week,  with  a  tem- 
perature of  105-7°  and  death  then  results.  The  outlook  (a)  as  to  recovery 
is  poor.  Five  to  10  per  cent,  of  cases  may  recover  spontaneously.  The 
prospects  are  best  in  cases  which  begin  before  twenty  in  males,  in  cases 
with  long  intervals  between  attacks  and  in  hereditary  forms.  After  two 
years'  duration  the  outlook  is  unfavorable,  (b)  As  to  life,  the  average 
duration  of  life  is  shorter  than  normal.  A  few  cases  drown,  suffocate 
from  turning  on  the  face  or  are  fatally  burned  during  the  seizure.  Some 
patients  die  during  the  insult  from  vascular  lesions  of  the  brain  or  less 
often  from  heart  rupture,  respiratory  cramp,  edema  of  the  lungs  or 
vomiting  into  the  larynx.  One-sixth  of  epileptic  deaths  are  sudden. 
Epileptics  frequently  become  tuberculous.  In  10  per  cent,  dementia 
occurs.  Bodily  health  and  intellectual  vigor  may  be  remarkably  preserved. 
Treatment. — 1.  Causal. — Syphilitic  epilepsy,  unless  due  to  gummata 
or  secondary  anemia,  does  not  respond  to  antisyphilitic  remedies.  Avoid- 
ance of  alcohol  may  be  almost  curative  in  this  form.  Reflex  factors 
should  be  removed.  In  Sweden  epileptics  cannot  marry;  50  per  cent,  of 
hereditary  epileptics  transmit  some  transformation  of  the  taint  to  their 
offspring. 

2.  Hygienic.^ — Children  should  receive  the  general  care  outlined  under 
the  other  neuroses.  School  work  should  be  limited  and  country  is  prefer- 
able to  city  life.  For  poor  subjects,  institutional  treatment  is  indicated. 
Many  neurologists  restrict  the  consumption  of  meat.  Richet  withdraws 
salt  and  gives  a  milk  and  cereal  diet,  which  promote  the  affinity  of  the 
bromides  for  the  brain  cells. 

3.  Bromides. — Introduced  by  Laycock  (1853)  and  developed  by  Voisin, 
the  bromides  act  directly  on  the  nervous  tissue;  they  depress  the  cortical 
cells,  inhibit  reflex  action  and  lessen  centripetal  conduction.  Untoward 
symptoms  may  result  even  within  therapeutic  limits.  Intellection  may  be 
dulled  and  muscular  depression  occur,  but  these  may  often  be  counter- 
acted by  coffee ;  the  frequent  stomach  symptoms  can  be  avoided  by  free 
dilution  with  water;  diarrhea,  which  results  especially  from  potassium 
bromide,  is  relieved  by  opium  if  marked,  or  if  less,  by  salicylate  of  bis- 
muth, gr.  X,  after  meals;  in  its  elimination  by  the  skin,  acne  is  common, 
which  is  lessened  by  large  quantities  of  water,  small  doses  of  arsenic  and 
washing  the  skin  with  green  soap.  Belladonna  in  small  doses  modifies 
the  respiratory  catarrh  or  salivation.  The  anaphrodisiac  effects  cannot 
be  prevented.  In  some  individuals  there  are  marked  idiosyncrasies,  as 
mental  excitement,  hallucinations,  emaciation  ("bromide  cachexia") 
with  lessened  physiological  resistance  to  acute  diseases.  Toxic  symptoms 
may  be  acute,  but  more  commonly  are  chronic,  resembling  those  of 
paretic  dementia;  hromism  is  most  likely  to  develop  in  those  with  weak 
digestion  or  circulation  and  when  the  drug  is  given  carelessly  for  a  long 
time,  because  its  elimination  is  slow.      In  the  former,  hydrotherapy, 


EPILEPSY  925 

massage  and  tonics  should  be  used  as  preliminary  or  concomitant  measures. 
Cardiac  symptoms  are  due  almost  wholly  to  the  potassium  salt,  but 
especial  care  in  the  use  of  all  bromides  is  indicated  in  senile  epilepsy 
(myocarditis,  arteriosclerosis,  endocarditis)  or  great  nutritive  exhaustion, 
in  which  combination  with  digitalis  or  strychnine  is  indicated.  In  bromism 
the  reflexes  are  decreased;  the  pharyngeal  reflex  is  weak  in  17  per  cent, 
and  absent  in  25  per  cent,  of  normal  individuals,  whence  Ziehen  watches 
the  corneal  reflex,  which  is  never  normally  absent.  In  advanced  bromism 
there  are  low  temperature,  bronzed  skin,  vasomotor  relaxation,  somnol- 
ence, paralytic  speech,  muscular  relaxation,  ataxia,  tremor,  fetor  ex  ore, 
anorexia,  slow  respiration  (the  usual  cause  of  death),  weak  heart,  abolition 
of  sensation  and  of  all  reflexes  and  decrease  or  suppression  of  urine. 
Therapeutically  the  drug  unites  with  the  nerve  cell  and  depresses  its 
activity  and  metabolism  and  toxicologically  it  causes  its  degeneration 
or  atrophy.  The  drug  must  be  used  for  months  or  years  and  the  symp- 
toms above  enumerated  must  be  watched  for;  epileptics  have  a  tolerance 
for  bromides  which  Voisin  regards  almost  as  a  food  in  this  affection. 

Results. — Seguin's  results  were:  cessation  of  attacks  in  23  per  cent., 
notable  decrease  in  40  per  cen^.,  no  great  effect  in  26  per  cent.,  no  effect 
in  10  per  cent.  Gowers  noted  immediate  relief  in  43  per  cent.,  improve- 
ment in  a  short  time  in  47  per  cent,  and  no  effect  in  10  per  cent.  He 
gives  a  dram  a  day  of  the  potassium  salt,  for  two  years,  for  larger  doses 
are  no  more  efficacious;  in'  nocturnal  epilepsy  a  large  dose  should  be 
given  at  bedtime.  Charcot  gave  a  daily  dose  of  one  dram,  which  was 
gradually  increased  to  two,  and  then  slowly  decreased  to  one.  Erlen- 
meyer's  formula  gives  excellent  results  (sodium  and  potassium  bromide, 
each  two  parts  and  ammon.  bromide  one  part).  The  best  results  are 
obtained  in  cases  treated  early  in  their  course  and  early  in  life  and  in 
those  in  which  there  are  long  intervals  between  attacks.  Children 
tolerate  large  doses.  Opium,  belladonna,  digitalis,  thyroid  extract  and 
chloral  are  of  but  secondary  importance.  Nitroglycerin  may  be  useful 
in  petit  mal. 

4.  The  Attack.— This  is  confined  to  cases  in  which  aurse  are  present. 
The  patient  is  placed  on  the  bed  or  ground  to  avoid  injury  and  a  towel 
inserted  between  the  teeth  to  prevent  biting  of  the  tongue.  Compression 
or  manipulation  of  the  limb  in  which  the  aura  is  felt  may  in  a  few  instances 
avert  the  spasm.  Charcot  placed  an  ice-bag  over  the  head  and  one 
over  the  heart.  Inhalations  of  amy]  nitrite,  ether  or  chloroform  are 
sometimes  beneficial. 

5.  Surgical  Indications. — Biswanger's  conclusions  are  (a)  that  only 
a  small  percentage  of  traumatic  cases  recover;  operation  is  indicated 
(b)  when  convulsions  emanate  from  a  small  cortical  focus  or  (c)  are  of  a 
type  intermediate  between  the  Jacksonian  and  generalized  forms;  (d) 
when,  with  generalized  convulsions,  there  is  a  suggestive  scar,  bone 
defect  or  localized  tenderness;  (e)  the  site  of  trephining  should  be  governed 
by  focal  symptoms,  motor  or  sensory  aurse,  or  "exhaustion"  signs; 
(/)  cysts,  tumors,  bone,  membrane  or  scars  may  be  removed,  but  not  the 
cortex;  (g)  operation  must  be  followed  by  the  bromide  treatment;  (h) 
operation  is  contra- indicated  in  ordinary  epilepsy. 


926  THE  NEUROSES 


INFANTILE  CONVULSIONS. 


In  young  children  many  axis-cylinders  are  not  yet  clothed  with  myelin 
sheaths  and  the  lower  dominate  the  upper  segments,  thus  predisposing 
to  disproportionate  nervous  reaction. 

Etiology.— (a)  Rickets  as  a  cause  was  especially  emphasized  by  Wm. 
Jenner.  Many  cases  of  carpopedal  spasm,  tetany  and  laryngismus 
stridulus  have  a  rhachitic  basis;  spasmophilia  occurs  between  the  eighth 
and  twenty-fourth  months  of  life,  is  prone  to  recur  and  disappears  after 
the  second  year,  (b)  Reflex  spasms  may  be  caused  by  peripheral  irritation, 
as  from  dentition  and  worms,  though  this  type  has  been  greatly  over- 
estimated; gastro-intestinal  irritation  or  auto-intoxication,  phimosis  and 
otitis  media  are  possible  causes,  (c)  Gastro-intestinal  intoxication  results 
in  debility,  malnutrition  or  a  "hydrencephaloid"  condition  described 
above  under  various  captions  and  usually  of  most  serious  import,  (d) 
Nervous  affections,  trauma  during  delivery,  meningitis,  tumor,  sinus 
thrombosis,  severe  coughing,  acute  encephalitis  (cerebral  hemiplegia) 
and  acute  poliomyelitis  are  etiological  factors,  (e)  In  acute  infections,  as 
scarlatina,  measles  or  pneumonia,  convulsions  and  vomiting  often 
replace  the  chill  which  is  more  common  in  adults.  (/)  Genuine  epilepsy 
in  12  per  cent.,  according  to  Gowers,  occurs  in  the  first  three  years  of 
life. 

Symptoms. — The  symptoms  resemble  those  of  epilepsy  in  most  of 
its  phases;  the  eclampsia  of  children  usually  begins  in  the  hands  and  the 
seizure  is  partial,  tonic,  intermittent  and  carpopedal  rather  than  general- 
ized. Screaming  and  grinding  of  the  teeth  may  occur.  Laryngeal  spasm 
is  described  under  Affections  of  the  Vagus. 

Treatment.- — The  occurrence  of  the  convulsion  is  the  first  indication 
for  treatment  and  should  be  met  symptomatically  by  inhalations  of 
chloroform  or  nitrite  of  amyl,  followed  by  gr.  v-x  of  chloral  and 
5ss  of  bromide  by  rectum.  The  bromide  is  given  for  several  days,  for 
its  effects  are  cumulative  rather  than  immediate.  Opiates  should  gener- 
ally be  avoided  in  children  under  five  years,  especially  in  nurslings, 
weak  or  marantic  infants;  the  hot  bath  is  of  little  service. 

The  ca^ise  is  then  determined  and  treated,  as  rickets,  tetany,  peripheral 
irritation;  lancing  of  the  gums  is  practised  less  and  less;  in  gastro- 
intestinal intoxication  the  stomach  should  be  emptied  by  ipecac  or 
the  stomach-tube;  lavage  of  the  bowel  is  indicated  in  acute  cases  and 
stimulants  may  be  indicated. 

CHOREA  AND  CHOREIFORM  AFFECTIONS. 

Chorea  or  St,  Vitus's  dance,  known  to  Paracelsus,  and  endemic  in  the 
middle  ages  is  now  known  as  chorea  major;  it  was  hysteria.  Chorea 
in  its  usually  accepted  sense  was  described  by  Sydenham  and  is  known  as 
Sydenham's  chorea  or  chorea  minor. 

Definition. — Sydenham's  chorea  is  (a)  a  neurosis  of  late  childhood; 
(b)  it  is  characterized  by  subacute  onset,  limited  duration  and,  usually, 
recovery;  (c)   it  is  probably  cortical  in  localization,  as  indicated   (d) 


CHOREA  AND  CHOREIFORM  AFFECTIONS  927 

by  involuntary  irregular  spasmodic  movements,  and  (e)  increased  in- 
coordination on  voluntary  efforts;  (/)  it  is  always  associated  with  some 
psychical  weakness  or  irritability  and  (g)  is  frequently  associated  with 
rheumatism  and  endocarditis. 

Etiology. — (a)  Age:  80  per  cent,  of  cases  occur  between  the  fifth  and 
fifteenth  years;  90  per  cent,  between  the  fifth  and  twentieth  years;  it 
is  most  frequent  at  the  sixth  and  seventh  years  of  life  or  at  puberty. 
(b)  Sex:  Sevent}^  per  cent,  of  cases  are  in  girls,  (c)  Rheumatism  has  been 
considered  a  cause  since  Bright's  time,  especially  by  English  and  French 
writers.  Rheumatism  is  a  factor  in  at  least  20  to  25  per  cent.  (Hughes  and 
See);  endocarditis,  rheumatism  and  chorea  are  too  frequently  associated 
to  escape  serious  attention;  they  are  probably  correlated,  i.  e.,  due  to  a 
common  virus.  Rheumatism  occurs  usually  before  the  chorea;  in  but 
4  per  cent,  of  cases  do  the  two  occur  simultaneously,  (d)  Other  acute 
infections  are  causes  in  43  per  cent,  of  cases  (Neumann),  e.  g.,  gonorrhea, 
puerperal  fever,  sepsis,  pertussis,  measles,  typhoid,  etc.  (e)  Pregnancy 
is  a  predisposing  cause,  particularly  before  the  twenty-fifth  year.  Chorea 
occurs  in  the  first  three  months,  especially  in  first  pregnancies,  and  is 
most  severe  in  character.  It  rarely  occurs  postpartum.  Giles  de  la 
Tourette  justly  holds  that  many  cases  classified  as  chorea  are  really 
hysteria.  (/)  Neuropathic  heredity  is  observed  in  16  per  cent,  of  choreic 
subjects,  particularly  among  Hebrews,  {g)  Other  causes  are  sometimes 
operative,  as  fright,  trauma  and  reflex  irritation  from  nasal  or  digestive 
disease.  It  occurs  more  largely  in  the  lower  classes,  is  sometimes  due  to 
iodoform  or  mercurial  poisoning  and  is  influenced  by  the  poor  hygiene, 
excitement,  exhibition  and  competition  of  the  school-room,  the  "school- 
made  chorea"  of  Sturges. 

Pathology  and  Pathogenesis. — The  disease  is  a  provisional  neurosis, 
since  no  constant  pathological  findings  exist.  The  following  changes 
have  been  recorded:  hyperemia,  exudation  about  the  arteries,  areas 
of  softening,  punctate  hemorrhages,  round  hyaline  bodies  in  the  peri- 
vascular lymph  sheaths  and  swelling  of  the  large  pyramidal  cells  of  the 
cortex;  none  of  these  are  characteristic  or  constant.  In  fatal  cases 
endocarditis  is  the  most  frequent  finding  (90  per  cent.)  and  Osier  notes 
that  its  frequency  is  greater  even  than  in  rheumatism.  Kirke's  theory 
of  cerebral  embolism  has  been  abandoned.  The  bacteriological  reports 
are  conflicting.  The  irritation,  due  to  exhaustion  or  toxemia,  is  probably 
cortical  or  in  the  basal  ganglia. 

Symptoms. — 1.  Onset. — Prodromes  are  infrequent,  as  irritability, 
restlessness,  depression,  disturbed  sleep,  headache,  anorexia,  rheumatic 
pains,  or  sensory  irritation.  The  affection  usually  begins  with  motor 
disturbance  in  the  form  of  involuntary  movements  and  incoordinate  volun- 
tary movements;  the  latter  are  often  misunderstood  and  punished,  for 
the  child  cannot  sit  still  or  breaks  or  drops  things. 

2.  Chorea  Movements. — These  are  involuntary,  although  they  may 
seem  voluntary,  as  the  thrusting  out  of  the  tongue  or  the  reaching 
of  the  arm  at  an  object.  They  are  "irregular  in  time,  character  and 
degree,''  are  not  usually  attended  by  fatigue  or  pain,  are  incomplete  and 
without  motivcj,  are  increased  by  attention  being  drawn  to  them  and  by 


928  THE  NEUROSES 

excitement  and  cease  during  sleep.  They  usually  begin  in  the  arms  and 
later  extend  to  the  face  and  legs.  Chorea  very  often  begins  on  one  side, 
especially  the  right,  whence  it  extends  to  the  other  side,  but  sometimes 
remains  largely,  though  never  entirely  unilateral  (hemichorea) .  The  face 
is  contorted  with  varying  expressions,  now  grimaces  or  again  motiveless 
smiles,  the  fades  choreatica  of  Sachs.  The  eyes  roll,  and  diplopia  is  not 
uncommon.  The  pupils  are  often  wide  and  react  slowly.  The  author 
recently  saw  a  case  in  which  many  of  the  teeth  were  broken.  Speech 
is  involved  in  25  per  cent,  of  cases,  due  rather  to  difficult  articulation  by 
the  tongue  and  lips  than  to  phonation.  Speech  is  quicker  than  normal 
and  may  be  aggravated  by  irregular  movements  of  the  glottis  and  respira- 
tory muscles,  resulting  in  panting,  irregular  inspiration  or  expiration  or 
sobbing  sounds  in  which  the  diaphragm  participates.  Aphasia  is  less 
frequent.  The  arvis  are  most  involved;  they  are  flexed,  extended,  pronated 
and  supinated  in  tireless  succession — Bouillaud's  folie  musculaire.  The 
trunk  is  sometimes  involved  in  light  cases  and  distinctly  so  in  severe 
types.  The  violent  movements  may  throw  the  patient  out  of  bed.  The 
legs  are  less  involved;  there  is  a  zig-zag  gait  and  walking  may  be  im- 
possible. Besides  hemichorea,  other  irregularities  are  encountered,  as 
monochorea,  chorea  paraplegica  or  chorea  alternans.  The  muscular 
power  and  endurance  are  said  to  be  normal  (Wallenberg),  but  Gowers 
and  Osier  speak  of  marked  muscular  weakness.  Two  forms  are  dis- 
tinguished: (a)  paresis  with  chorea,  in  which  the  muscular  power  is 
reduced,  as  in  the  usual  case,  and  (b)  limp  or  paralytic  chorea  (choree 
molle).    The  paresis  may  be  of  the  mono-,  para-  or  hemiplegic  type. 

3.  Psychic  changes  are  constant  and  the  irritability  and  ready  fatigue 
resemble  an  acute  neurasthenia.  The  subject  is  wilful,  forgetful, 
emotional,  irritable,  unable  to  concentrate  the  attention  or  to  remember 
perfectly.  Marked  alteration  may  occur,  as  complications,  viz.,  delirium, 
mania,  melancholia  or  hallucinations;  chorea  insaniens  has  a  most 
unfavorable  prognosis.  Combination  with  hysteria  is  frequent,  with 
epilepsy  infrequent.  Hughlings  Jackson  found  paroxysmal  headache  in 
90  per  cent,  of  cases. 

4.  Sensation. — Sensation  is  normal  or  slightly  blunted.  Tenderness 
over  the  spine  and  peripheral  nerves  is  not  common,  though  S.  Weir 
Mitchell  and  Triboulet  described  a  painful  chorea.  Occasionally  there 
is  a  tingling   sensation  and  numbness. 

5.  The  reflexes  are  normal  in  light  cases  but  may  be  decreased 
or  absent.  The  bladder  and  rectum  are  normal  save  in  the  severest 
forms. 

6.  Electrical  Reactions. — The  electrical  reaction  and  mechanical 
irritability  of  the  muscles  are  with  few  exceptions  unaltered. 

7.  The  Heart. — Irregularity  is  common  and  is  often  due  to  irreg- 
ularity in  breathing  (pseudo-arrhythmia).  A  slight  increase  in  rate 
is  due  to  the  general  neurosis.  Ollivier,  Roger  and  Simon  claim  that 
chorea  may  affect  the  "muscles  of  organic  life",  but  a  cardiac  chorea  is 
improbable.  Functional  murmurs  are  frequent,  especially  in  thin,  nervous 
children,  from  anemia,  toxemia  and  tachycardia.  Great  conservatism 
must  be  exercised  in  their  prognosis  and  diagnosis  (see  page  358). 


CHOREA   AXD  CHOREIFORM  AFFECTIONS  929 

Endocarditis  has  been  mentioned  in  the  definition  of  the  disease  and 
its  causation  and  pathology  (90  per  cent,  of  fatal  cases).  It  was  foimd  in 
66  per  cent,  of  Osier's  cases  without  rheumatism.  It  is  rarely  malignant, 
but  may  produce  embolism.  ^Mitral  lesions,  especially  insufficiency, 
are  the  most  common  form.  The  importance  of  endocarditis  without 
clinical  s^^nptoms  is  vast.  Pericarditis  is  not  frequent.  Heart  disease 
follows  50  per  cent,  of  cases  having  two  attacks  of  chorea,  and  100  per 
cent,  of  those  having  over  three. 

8.  The  Skix. — Herpes  and  pigmentation  result  from  arsenic.  Urti- 
caria, eni:hema  nodosmn,  purpura  and  rheumatic  nodes  (r.  page  284) 
are  sometimes  observed. 

9.  Gexeral  SniPTOMS. — Emaciation  occurs  chiefly  in  severer  tj'pes. 
The  iu"ea  and  phosphates  are  often  increased.  Albuminuria  is  rare, 
except  as  a  result  of  renal  embolism.  The  temperature  is  not  often 
elevated,  save  from  cardiac  and  other  complications;  even  in  chorea 
insaniens  it  rarely  passes  102°. 

Course  ajid  Prognosis.- — The  average  com-se  of  mild  cases  is  from  six 
to  ten  weeks,  and  six  weeks  to  six  months  is  the  average  duration  of  all 
varieties.  In  very  rare  instances  the  disease  may  last  years.  Three 
main  types  are  distinguished:  (a)  The  mild  type,  in  which  the  patient  is 
nervous,  irritable,  has  but  slight  choreic  movements  and  is  often  dyspeptic 
and  sometimes  anemic;  (b)  the  severe  form  in  which  the  spasmodic  move- 
ments are  severe  and  general;  (c)  the  maniacal  type  (chorea  insaniens) , 
which  is  most  often  observed  in  adult  or  pregnant  women,  and  sometimes 
at  puberty.  The  movements  are  incessant,  extreme  and  often  associated 
with  fever,  constant  insomnia  and  great  psychical  disturbance.  As ' 
a  rule,  the  shorter  the  duration  the  more  intense  are  the  s^Tuptoms. 
Sydenham  noted  the  tendency  to  recurrence  (in  25  to  33  per  cent.). 
One  year  is  the  average  interval  and  when  there  is  no  recurrence  within 
one  and  one-half  years,  relapse  is  improbable  (Gowers).  Recovery  is  the 
rule;  the  mortality  averages  between  2  and  3  per  cent.  Twenty  to  25 
per  cent,  of  pregnant  cases  die.  Fatality  is  greatest  at  the  age  of  puberty 
and  in  adults.  As  Charcot  remarked,  death  occurs  less  often  from  com- 
plications, as  endocarditis,  than  from  toxemia,  fever,  emaciation,  delirium 
and  coma.  Fever  or  obstinate  insomnia  is  ominous.  Though  the  im- 
mediate outlook  is  not  influenced  by  endocarditis,  it  is  a  most  important 
feature  in  the  ultimate  prognosis  of  a  complete  recovery.  Intercurrent 
fevers  may  dissipate  the  spasms.  In  rare  instances  distinct  psychical 
changes  (Jolly)  or  permanent  chorea  remain  (v.  s.). 

Diagnosis. — Recognition  of  the  disease  is  usually  most  easy  when  one 
bears  in  mind  the  conception  (definition)  of  the  disease. 

DiFFEREXTiATiox. — Simple  tremor  or  the  intention  tremor  of  multiple 
sclerosis  is  easily  separable.  The  hemichorea  of  hemiplegia  (see  page  722) 
or  the  bilateral  chorea  of  infantile  cerebral  paralysis  (q.  v.)  is  distinguished 
by  the  history  and  course.  Friedreich's  ataxia  is  differentiated  by  its 
slow,  irregular,  incoordinate  movements,  nystagmus,  its  frequent  family 
incidence,  the  scoliosis,  talipes,  and  slow,  scanning  speech.  Hysterical 
chorea  (so-called)  is  rhythmic,  more  regular  and  frequently  produces 
sudden  ("electrical")  movements,  as  bowing  or  salaaming,  nodding  the 
59 


930  THE  NEUROSES 

head,  etc.  Chorea  major  in  the  original  sense  is  of  historical  interest;  it 
was  a  pandemic  or  epidemic  hysteria  provoked  by  religious  excitement. 
Its  victims  made  pilgrimages  to  the  shrine  of  St.  Vitus.  Similar  out- 
breaks occurred  in  Kentucky  among  the  early  settlers.  This  form  closely 
resembles  the  saltatoric  spasm  described  by  Bamberger,  in  1859,  in  which 
the  legs  contract  on  attempting  to  stand,  causing  jiunping  or  springing 
movements.  It  may  be  transitory  or  may  last  for  years.  Beard  and 
Thornton  described  a  similar  neurosis  endemic  in  Canada  among  the 
"jiunping  Frenchmen."  The  "holy  rollers,"  and  Jumpers  of  Russia  and 
Java  come  under  this  head  or  under  impulsive  tic  (v.  i.). 

Huntingdon's  chorea  has  no  connection  with  Sydenham's  tj-pe.  Chronic 
chorea  comprises  two  forms:  (a)  The  senile  form,  in  which  the  mind  is 
less  involved,  the  course  more  benign  than  in  (h)  the  hereditary  form  of 
'Huntingdon  who,  in  1872,  brought  out  the  cardinal  features  of  the  disease 
as  obserA'ed  on  Long  Island,  A'iz.,  (i)  the  late  and  gradual  onset  after  the 
thirtieth  year,  especially  in  males;  (ii)  its  hereditary  character,  sometimes 
involving  25  or  50  per  cent,  of  the  family,  sometimes  skipping  generations 
or  lasting  for  generations  or  even  for  two  centuries  in  a  family  (Osborn) ; 
(iii)  its  progressive  character,  and  (iv)  the  ultimate  slow  dementia,  often 
with  epileptiform  attacks  or  suicidal  tendencies.  The  precise  j^athology 
of  Huntingdon's  type  is  not  known.  Pachymeningitis,  hematoma  of  the 
diua,  or  less  often  chronic  encephalomeningitis,  vascular  disease  and 
atrophy  of  the  convolutions  are  present  in  the  isolated  autopsies.  The 
etiology  is  unkno^m.  Clinically  it  is  characterized  by  irregular  move- 
ments, which  usually  begin  in  the  hands,  are  somewhat  controlled  by 
volimtary  effort  and  are  more  irregular,  incoordinate  and  slow  than  in 
acute  chorea.  Slow,  spasmodic  facial  contortions  are  observed,  and  the 
speech  becomes  first  slow  and  hesitating,  and  later  quite  indistinct. 
The  gait  is  unsteady  and  swajdng.  Writing  is  interfered  with,  the  reflexes 
are  moderately  increased,  sensation  is  normal,  save  that  the  muscular 
sense  is  somewhat  blimted,  and  dementia  develops.  The  disease  is  in- 
curable. 

Tic- — The  term  is  now  used  to  designate  an  "habitual,  conscious, 
convulsive  movement  resulting  in  the  involimtary  contraction  of  one 
or  more  muscles,  abruptly  reproducing  some  reflex  or  automatic  action 
of  every-day  life"  (G.  Guinon).  There  are  three  forms:  (a)  In  simple 
tic,  (i)  localized  spasm,  habit  spasm  or  habit  chorea,  which  is  said  by 
S.  Weir  ^Mitchell  to  occur  in  girls  between  seven  and  fourteen  years 
of  age,  may  result  from  lesions  of  the  nose  or  throat  or  possibly  from 
eye-strain,  and  includes  movements  such  as  winkmg,  drawing  of  the 
mouth,  sniffing,  shaking  the  head  and  shrugging  the  shoulders.  It 
usually  ceases,  but  may  last  into  adult  life;  the  child's  attention  should 
not  be  dra^\Ti  to  the  mo^'ements,  although  the  writer  believes  that  judi- 
cious reminders  and  disciplme  inhibit  these  habits.  Arsenic  may  be 
beneficial,  (ii)  The  electric  chorea  (Henoch  and  Bergeron)  consists  of 
short,  hghtning-like  contractions  in  special  muscles,  as  those  of  the  neck 
or  shoulders,  as  though  the  muscles  were  electrically  stimulated,  (iii) 
Buhini's  disease  (1846)  consists  of  contractions  of  the  arms  and  legs, 
followed  by  hj-peresthesia,  pam  in  the  head  and  back,  muscular  atrophy, 


CHOREA  AND  CHOREIFORM  AFFECTIONS  931 

paresis  and  sometimes  fever  and  convulsions.  It  is  endemic  in  Lombardy, 
its  cause  is  unknown,  and  it  is  usually  fatal  from  apoplexy  or  coma. 
(iv)  Paramyodonus  imdtiplecc,  or  myoclonia,  described  by  Friedreich, 
in  1881,  is  an  affection  of  sudden  onset,  with  symmetrical,  involuntary, 
arrhythmic,  quick,  clonic  contractions  of  the  upper  parts  of  the  arms, 
legs  and  trunk,  sometimes  of  the  face  and  tongue,  and  occurs  without 
loss  of  consciousness.  The  contractions  number  from  10  to  150  a  minute 
and  may  terminate  in  a  tetanic  contraction.  It  affects  male  adults 
chiefly  (75  per  cent.)  and  follows  mental  or  emotional  agitation,  so  that 
some  would  classify  it  under  hysteria.  The  myotatic  irritability  and 
reflexes  are  increased,  the  mind  is  usually  normal,  though  sometimes 
fixed  ideas  are  observed,  hiccough  is  occasional  from  involvement  of  the 
glottis  or  diaphragm,  voluntary  movement  is  decreased  or  sometimes 
arrested,  there  are  no  sensory  symptoms  and  the  outlook  is  usually  good. 
Treatment  consists  of  administration  of  voltaic  electricity,  nervines  and 
bromides.  The  family  form  (Unverricht)  with  epilepsy  and  spasms  of  the 
tongue  and  pharynx,  is  probably  a  subt\'pe  of  hereditary  chorea. 

Tic  and  Chorea. 

Form  of  movement:  pseudo-intentional,  -with       Incoordination  and  great  variabilitj'. 

repetition. 
Bhythm:      rhythmic,    brusque,    short,    syn-       Arrhythmic,  slow,  not  synchronistic. 

chronistic. 
Will:  suspends  movements.  No  effect. 

Accessory  signs:    muscular  power  preserved;        Myasthenia;  modified  reflexes  and  sensation. 

normal  tendon  reflexes. 
Etiology:  hereditary  degeneration.  Neuropathic  tendency. 

(b)  Tic  with  explosive  utterances,  impulsive  tic  or  Giles  de  la  Tourette's 
disease,  is  closely  afiiliated  with  hysteria  and  monomania.  It  occurs  in 
neurotic  individuals  between  the  sixth  year  and  puberty.  The  cardinal 
features  of  the  psychosis  are:  (i)  Involuntary  movements  in  the  face  and 
arms  or  in  all  the  muscles  in  severe  types,  when  the  movements  become 
violent  or  explosive,  (ii)  Explosive  utterances,  resembling  a  bark;  the 
patient  repeats  words  he  hears  (echolalia),  mimics  movements  (echo- 
praxia)  or  uses  obscene  or  profane  words  (coprolalia),  (iii)  The  subject 
has  fixed  ideas,  as  arithmomania,  in  which  every  action  is  preceded  by 
counting  or  doing  a  certain  thing  a  given  number  of  times;  a  fear  of 
contamination  (delere  du  toucher) ;  onomatomania,  or  repetition  of  a  given 
word  or  name;  jolie  pourquoi,  demanding  the  reason  for  everything. 
The  prognosis  is  usually  unfavorable. 

(c)  In  complex  coordinate  tic,  as  thumb-sucking,  rocking  in  the  bed 
and  bumping  the  head,  the  outlook  is  favorable,  except  in  feeble-minded 
children. 

Treatment  of  Acute  Chorea. — 1.  Pkophylaxis. — Sensible  methods  of 
education  should  be  adopted,  the  hours  in  the  overheated,  foul  school- 
room should  be  short,  and  the  useless  forcing  of  children  by  marks,  prizes 
and  exhibition  abandoned.  Children  can  be  taught  more  in  an  hour 
or  two  of  judicious  individual  instruction  than  in  the  five  or  six  confining 
hours  which  their  wandering  attention  must  endure.  Prevention  may 
concern  other  etiological  factors  (7.  v.). 


932  THE  NEUROSES 

2.  Rest. — ^The  results  obtained  by  rest  in  bed  and  isolation  are  as 
rapid  as  those  of  any  medicinal  therapy.  It  not  only  saves  tissue  waste, 
but  is  the  best  treatment  of  endocarditis. 

3.  Skin.- — The  dry  and  harsh  skin  must  be  given  special  attention — 
stimulation  of  the  skin  by  proper  covering,  refrigerant  diaphoretics  and 
full  warm  baths.  The  skin  must  be  kept  clean  and  in  severe  cases  the 
water-bed  must  be  used. 

Trai^ia. — Trauma  is  prevented  in  severe  types  by  padding  the  bed 
by  mattresses  and  pillows,  since  the  violent  movements  may  throw  the 
patient  to  the  floor.  Sepsis  is  a  frequent  and  most  dangerous  occurrence. 
The  temperature  must  be  taken  by  rectum. 

5.  Exhibition  of  Drugs. — (a)  Fowler's  solution  is  the  most  frequently 
used  and  the  oldest  remedy.  It  should  be  given  in  increasing  doses 
(see  page  677);  children  tolerate  large  doses  of  arsenic  exceptionally 
well.  It  may  be  administered  hypodermically  or  by  clyster  when  the 
digestive  tract  is  irritable.  Arsenic  is  not  without  its  dangers.  C.  Gamble, 
Jr.,  records  an  mstance  of  fatal  arsenical  poisoning  in  a  case  to  whom 
about  1|  ounces  of  Fowler's  solution  was  given  in  three  weeks.  Rest 
in  bed  gives  equally  good  results.  (6)  Salicylates  are  of  benefit  only 
when  rheumatism  actually  coexists  and  acetanilide  is  mdicated  only 
in  the  initial  stages,  i.  e.,  antirheumatic  remedies  are  less  important  in 
the  treatment  than  is  rheumatism  in  the  etiology,  (c)  Depressomotors: 
The  bromides  rarely  cure  the  movements,  although  they  often  quiet 
mild  psychic  manifestations.  Chloral,  given  in  large  and  continued 
doses  to  produce  continuous  sleep,  merely  demonstrates  the  tolerance 
of  the  body  for  dangerous  remedies  and  chloral  camiot  be  given  safely 
in  amounts  exceeding  a  dram  for  adults  in  three  divided  doses  at  intervals 
of  an  hour.  ^Morphine  is  generally  dangerous  and  inferior  to  chloral. 
Small  doses  often  accentuate  the  mental  agitation,  but  if  combined 
with  chloral,  hyoscine  and  bromide,  it  may  give  some  temporary  relief. 
(d)  Strychnine  is  valuable,  especially  when  recovery  is  slow,  (e)  In 
chorea  graindarnm,  abortion  or  premature  delivery  is  indicated. 

OCCUPATION  OR  FATIGUE  NEUROSES;  WRITER'S  CRAMP. 

The  continuous,  hard,  improper  use  of  coordinate,  functionally  asso- 
ciated muscles  may  result  in  their  cramping.  Writer's  cramp  (grapho- 
spasmus,  mogigraphia)  was  first  described  by  Charles  Bell  (1830)  and 
especially  studied  by  Duchenne  and  Benedict.  Neuropathic  tendencies 
are  noted  in  most  cases;  83  per  cent,  occur  in  males,  93  per  cent,  occur  in 
those  between  twenty  and  sixty  years  of  age  and  most  cases  develop 
between  twenty-five  and  thirty-five.  Worry  is  a  frequent  factor ;  toxemia, 
cold,  trauma,  neuritis  and  neiu-algia  are  possibly  factors.  The  disease 
practically  never  occurs  in  those  who  write  properly,  i.  e.,  move  the  arm 
from  the  elbow  or  the  shoulder,  but  develops  in  those  who  use  the  little 
finger  or  wrist  as  the  basis  of  movement.  Some  accuse  the  coordinating 
cortical  or  subcortical  centres;  the  occasional  atrophy  and  paresis 
suggest  localization  in  the  cord  or  nerves.  ]\Ieige  terms  it  a  functional 
anarchy. 


MYOTONIA  933 

Symptoms. — Gradually  fatigue,  paiii  and  cramping  in  the  muscles  of 
the  forefinger  and  thumb,  may  extend  to  the  forearm  or  shoulder.  There 
may  be  the  "lock  spasm"  of  Mitchell,  in  which  the  pen  is  spastically 
held  or  thro\Yn  from  the  fingers.  On  rest,  the  tonic  spasm  disappears, 
but  reappears  with  attempts  to  write.  In  Benedict's  classification  we 
find  the  spasmodic,  paralytic,  tremulous  and  neuralgic  forms,  which  are 
of  less  interest  as  types  than  as  showing  the  various  symptoms,  which 
are  often  combined  in  a  single  case.  Vasomotor  symptoms  may  occur, 
as  flushing  or  glossy  skin. 

Differentiation.— Differentiation,  according  to  the  type,  from  hemiplegic 
weakness,  paralysis  agitans,  musculospiral  paralysis  and  neuralgia,  is 
easy.  Similar  cramps  are  observed  in  telegraphists,  milkmaids,  weavers, 
cigarette  rollers,  tailors,  shoemakers,  miners,  athletes,  watchmakers  and 
violin  and  piano  players.  Neuroses  of  the  throat  in  public  speakers, 
jaw  spasms  in  gum  chewers  and  lumbar  spasm  in  physicians  who  drive 
much  are  described. 

The  outlook  is  poor,  because  the  unfortunate  sufferer  is  often  com- 
pelled to  write  until  the  affection  is  firmly  fixed  and  when  able,  usually 
returns  to  the  same  work.    In  some  cases  the  muscles  may  waste. 

Treatment. — Rest  is  essential  to  recovery,  because  treatment  for  the 
usual  nervous  sjonptoms  alone  never  succeeds.  Plaster  casts  are  some- 
times successfully  employed.  Even  when  the  subject  learns  to  write 
with  the  other  hand  it  often  develops  there.  Prevention  is  possible  by 
writing  free-hand  from  the  shoulder;  holding  the  pen  between  the  first  and 
second  fingers,  use  of  pens  with  large  handles,  of  quills  and  of  forearm 
splints  with  the  pen  attached  to  the  extremity,  are  also  helpful.  Active 
systematic  gymnastics,  passive  manipulations  and  weak  phenol  solutions 
injected  into  tender  neuritic  spots  are  helpful. 

MYOTONIA  (THOMSEN'S  DISEASE). 

Myotonia  is  usually  called  myotonia  congenita  from  its  leading  causal 
element,  heredity.  It  was  described  by  Leyden  but  more  fully  by  Thom- 
sen  (1876),  who  was  a  victim  among  20  cases  in  his  own  family  in  five 
generations.  This  rare  affection,  of  which  there  are  102  reported  cases 
(Koch,  1904),  occurs  chiefly  in  males  and  in  Germany  and  Scandinavia. 
Its  pathology  is  obscure,  for  the  only  two  necropsies  showed  no  nervous 
alteration.  Muscle  fibers,  excised  during  life,  show  hypertrophy,  de- 
creased striation,  nuclear  multiplication  and  slight  interstitial  increase 
suggesting  a  myopathic  process. 

Symptoms. — ^A  peculiar  transient  tonic  muscular  rigidity  develops 
when  the  muscles  are  first  used,  which  limits  or  arrests  movement, 
but  wears  off  as  their  use  is  persisted  in.  It  is  intense  when  a  new  kind 
of  movement  is  undertaken.  The  longer  the  muscles  are  rested  the 
more  severe  is  the  initial  spasm  on  exertion.  Rigidity  does  not  follow 
passive  muscle  movement,  although  firm  pressure  or  a  sharp  blow  mitiates 
it.  It  appears  perhaps  "in  the  cradle,"  but  generally  between  the  ages  of 
foiu-  and  ten;  it  increases  as  the  muscles  develop  and  then  becomes 
stationary  for  life.     In  one  case  improvement  was  observed.     The  legs 


934  THE  NEUROSES 

are  more  affected  than  the  arms,  but  in  exceptional  cases  the  face,  tongue, 
bladder  or  the  respiratory  muscles  may  be  affected.  They  are  usually 
stronger  and  sometimes  larger  than  normal.  Sedgwick  noted  von  Graefe's 
sign  in  five  generations. 

Though  the  tendon  reflexes  and  the  mechanical  and  electrical  excit- 
ability of  the  nerves  are  practically  normal,  application  of  the  galvanic 
current  to  the  muscles  produces  sluggish,  prolonged  closing  contractures, 
with  either  pole  and  become  tetanic  with  strong  currents,  the  myoto7iic 
reaction  of  Erb.  Undulatory  contractures  follow  strong  faradic  stimula- 
tion.   Subjects  of  myotonia  are  frequently  irritable  or  hypochondriacal. 

Treatment. — Thomsen  believed  that  exercise  retarded  the  disease. 
Strychnine  is  apparently  of  value.  Cold,  dampness,  excitement  and 
fatigue  are  to  be  avoided. 

The  following  are  allied  affections:  the  congenital  paramyotonia  of 
Eulenberg,  consisting  of  tonic  spasms,  which  occur  especially  in  the 
arms,  and  often  affect  the  eyes  and  mouth;  the  ataxic  paramyotonia  of 
Gowers,  in  which  tonic  spasms  may  last  the  entire  day,  with  muscular 
weakness,  ataxia,  especially  in  the  hands  and  disturbed  sensation  or 
anesthesia  in  the  fingers.  In  myotonia  atrophica,  there  are  (1)  weakness 
and  wasting  of  the  orbicular  muscles  of  the  mouth  and  eyes;  the  temporals 
and  masseters;  the  vasti  muscles  of  the  thighs  with  the  recti  femoris 
frequently  escapiug  completely;  the  muscles  of  the  anterior  tibial  groups, 
resulting  in  bilateral  foot-drop.  (2)  The  myotonic  phenomenon  evidenced 
more  particularly  by  a  marked  difficulty  in  extending  the  fingers  from 
a  flexed  position.  (3)  The  deep  reflexes  are  depressed  according  to  the 
degree  of  muscle  wasting. 

PARALYSIS  AGITANS. 

This  affection  is  also  known  as  shaking  palsy  or  Parkinson's  disease; 
it  was  first  described  by  Parkinson  in  1817. 

Etiology. — (a)  Most  cases  occur  between  the  ages  of  forty  and  sixty- 
five,  (b)  Sixty-six  per  cent,  of  cases  are  men.  (c)  A  neuropathic  tendency 
is  present  in  15  per  cent. 

Pathology.- — It  is  classed  among  the  neuroses,  because  of  the  absence 
of  any  constant  pathological  finding.  Arteriosclerosis  is  often  found, 
since  paralysis  agitans  occurs  in  the  early  degenerative  period;  Gordinier 
shows  that  (a)  general  arteriosclerosis  is  less  marked  than  that  of  the 
nervous  tissue;  (6)  the  arteries  in  the  cord  are  markedly  changed  and 
around  them  are  (c)  neurogliar  sclerosis  and  {d)  pigmentation  and  atrophy 
of  the  nerve  fibers.  Camp  found  swelling,  increased  nucleation,  hyaloid 
changes  and  atrophy  of  the  muscle  fibers. 

Symptoms.— The  cardmal  symptoms  are  tremor  and  stiffness,  slowness 
of  movement,  shortening  and  weakening  of  the  muscles,  (a)  Tremor 
in  66  per  cent,  of  cases  is  the  first  symptom;  it  is  sometimes  absent 
(paralysis  agitans  sine  agitatione).  It  is  most  marked  in  the  hands. 
It  affects  first  one  hand  and  usually  next  reaches  the  leg  of  the  same 
side,  then  the  opposite  hand,  the  opposite  leg,  and  lastly  the  trunk,  so 
that   it  is  successively  a  monoplegic,  hemiplegic  or  finally  a  diplegic 


PARALYSIS  AGITANS 


935 


tremor.  It  is  slow  (4  to  7  oscillations  per  second),  rhythmic,  fine  at  the 
onset  but  somewhat  coarser  later,  persists  during  rest,  ceases  during  sleep 
and  ceases  momentarily  on  volmitary  action.  In  rare  cases  it  appears 
only  on  movement,  as  intention  tremor.  In  the  hands  it  may  affect 
chiefly  the  flexors  and  extensors  at  the  metacarpal  joints  or  the  interossei, 
which  give  the  spinning  or  pill-rolling  movement.  The  T\Tists  may  be 
abducted  and  adducted,  rarely  supinated  and  pronated,  and  the  arms 
and  shoulders  are  implicated  but  little.  The  \\Titing  is  tremulous.  The 
feet  are  mostly  involved  at  the  ankles 
and  the  toes  but  little.  The  thigh 
adductors  often  tremble.  Trembling 
is  infrequent  in  the  face,  neck  and 
back,  while  the  abdomen  entirely  es- 
capes. The  head  and  body  may  of 
themselves  tremble,  but  much  of  it  is 
imparted  to  them  from  the  limbs. 
In  the  rarest  cases  the  tongue,  palate, 
larynx  and  epiglottis  tremble. 

(b)  Muscular  rigidity  and  shorten- 
ing, weakness  and  slowness  of  move- 
ment usually  follow  the  tremor;  slight 
symptoms  are  detected  early  and 
anticipate  tremor  or  exist  without  it. 
These  changes  result  in  the  follow- 
ing: (i)  The  mask-like  Parkinson 
fades,  which  is  devoid  of  lines  or  ex- 
pression; the  eyelids  wufl^;  seldom. 
The  forehead  shows  transverse 
folds  because  of  the  bowed  head  and 
body.  The  eyes  move  tardily  in 
reading,  and  the  entire  body  must  be 
turned  to  enable  the  patient  to  look 
laterally.  There  is  also  slow,  mo- 
notonous, monosyllabic  speech,  with 
hesitation  at  first,  but  hiu-ried  at 
the  finish,  (ii)  The  attitude  is  char- 
acteristic, because  of  the  flexor  posi- 
tions assumed ;  the  head  and  the  chin 
are  held  forward,  the  neck  is  ex- 
tended and  rigid,  the  body  is  inclined 

forward,  the  elbows  are  fixed  and  brought  somewhat  forward  and  away 
from  the  body;  the  forearms  are  brought  toward  the  body,  the  trembling 
thumb  and  index-finger  are  apposed,  or  the  fingers  deviate  toward  the 
ulnar  side  as  in  arthritis  deformans,  and  in  standing  the  knees  are  some- 
what bent  and  at  times  closely  apposed.  The  body  expression,  we  may  say 
is  like  that  of  the  face,  (iii)  The  gait  is  equally  characteristic.  Like  the 
speech,  it  is  initiall}^  hesitant,  later  hurried.  The  patient,  when  once 
started,  may  not  be  able  to  stop  himself.  Trousseau  spoke  of  the  patients 
as  "chasing  their  centre  of  gravity."     This  destination  or  yropulsion  is 


Fig.  78. — Side  view  of  a  case  of  par- 
alysis agitans,  showing  forward  inclination 
of  the  trunk.  Tendency  to  propulsion. 
(Dercum.) 


936  THE  NEUROSES 

purely  mechanical  from  the  forT\-ard  bodily  inclmation,  although  inter- 
preted by  Charcot  as  a  forced  movement.  To  comiteract  the  throwing 
forward  of  the  centre  of  gravity  the  arms  may  be  carried  behind  the  back. 
In  some  cases,  if  the  patient  is  pushed  backward  or  sidewise,  he  may  not 
be  able  to  stop  for  some  steps;  this  is  retro-  and  laterojmlsion.  (iv)  The 
yalsy  is  often  slight  and  rarely  extreme,  although  simulated  hy  the  help- 
lessness caused  by  rigidity.  The  patient  is  not  inclined  to  exertion, 
"moves  like  a  piece  of  machinery,"  as  Parkinson  describes  it,  and  may 
not  be  able  to  turn  over  m  bed.  Patients  have  drowmed  from  fallmg 
on  the  face  in  a  small  puddle  of  water.  ]\Iuscular  reaction  requires 
40  per  cent,  more  time  than  normal. 

The  mind  is  clear,  but  stiff  like  the  face  and  limbs,  and  a  certain  rest- 
lessness, irritability  or  apathy  may  be  detected;  insomnia  is  common. 
Sensation  is  essentially  normal,  although  pains,  pruritus,  paresthesia  and 
hj-pesthesia  are  seen  in  35  per  cent,  of  cases.  Vasomotor  disturbance 
most  often  assiunes  the  form  of  a  feeling  of  heat;  mdeed  the  peripheral 
temperature  may  be  increased  several  degrees.  Severe  sweats  are  common. 
The  pupillary,  cutaneous,  tendon  and  organic  reflexes  are  normal. 

Course  and  Prognosis. — The  onset  is  usually  gradual  and  the  course 
covers  several  decades.  The  outlook  is  most  favorable  in  atypical 
cases.  Remissions  may  occur,  but  the  disease  progresses  steadily.  Death 
occurs  from  intercurrent  pneumonia,  arteriosclerosis,  cerebral  softening, 
myocardial  insufficiency,  nephritis  and  kindred  lesions. 

Diagnosis. — Confusion  is  possible  in  the  early  hemiplegic  forms,  but 
the  absence  of  a  parahlic  stroke  and  the  later  course  are  distmctive. 
Charcot  and  Ordenstein  (1868)  clearly  differentiated  the  affection  from 
imdtijjie  sclerosis  (q.  r.).  The  fine,  senile  tremor,  the  hereditary  tremor 
of  Dana,  tremors  due  to  overexertion  or  excitement,  to  toxic  causes 
(alcohol,  nicotine,  lead,  mercury,  coffee,  opiiun  or  chloral),  weakness  of 
convalescence  from  acute  infections,  paretic  dementia  or  epilepsy, 
Graves's  disease,  hysteria  and  neurasthenia  are  excluded  by  the  absence 
of  the  Parkinson  rigidity,  facies  and  festmation. 

Treatment. — Treatment  of  the  probably  fundamental  arteriosclerosis 
may  possibly  retard  the  disease,  but  prophylaxis  is  possible  m  the  early 
stages  only.  All  mental  and  physical  fatigue  should  be  avoided.  The 
administration  of  full  doses  of  iodide,  chloral,  opiates,  bromides,  hyoscine, 
or  duboisin  may  mitigate  the  tremor,  but  lower  vitality  and  disturb 
function.     Parathyroid  gland  is  recommended. 

PERIODIC  FAMILY  PARALYSIS. 

This  affection  was  first  described  by  Cavare  (1853)  and  more  fully 
by  Westphal  (1885;;  Holzapple  collected  70  cases  (1905);  Goldflam 
collected  11  cases  in  one  family  and  E.  W.  Taylor  12  in  another.  ^Nlost 
cases  occur  in  adolescence,  chieflj'  under  twenty-five;  it  recurs  every 
few  weeks  or  months,  possibly  ever\'  day,  or  only  at  intervals  of  j^ears. 
Its  symjjtoms  are  almost  wholly  motor,  producing  a  flaccid  paralysis  in 
the  legs  and  arms,  less  often  in  the  trunk,  and  exceptionally  in  the  face, 
neck,  tongue  and  tliroat.     It  occurs  without  apparent  cause,  usually 


MIGRAINE  937 

during  sleep,  from  which  the  patient  awakes  with  a  sense  of  weakness  or 
duhiess  which  develops  into  paralysis  within  twenty-four  hours.  Mental, 
sensory,  cranial  nerve  and  special  sense  symptoms  are  rare.  The  pulse 
is  often  slow  and  cardiac  dilatation  has  been  observed.  Sudden  death 
sometimes  occurs  in  an  attack.  The  deep  reflexes  are  decreased  or 
abolished,  often  also  those  of  the  skin,  and  the  faradic  excitability  of 
the  nerves  and  muscles  is  lessened  or  absent.  The  patient  is  well  in  a 
few  hours  or  days,  until  another  attack  occurs.  The  disease  usually 
subsides  spontaneously  after  the  fiftieth  year  of  life.  Goldflam's  theory 
of  auto-intoxication  is  supported  (a)  by  J.  K.  Mitchell,  Flexner  and 
Ebersoll,  who  found  increased  secretion  of  kreatin  before  and  during  the 
attack;  (6)  by  Crafts  and  Irwin,  who  isolated  toxins  from  the  feces; 
(c)  possibly  by  the  fact  that  potas.  citrate  sometimes  lessens  or  aborts 
the  seizure.  Bernhardt  and  others  consider  the  disease  affiliated  with 
tnj'otonia  and  progressive  muscular  atrophy.  Holzapple  administers 
potas.  bromide  in  doses  of  thirty  grains. 

MIGRAINE. 

Hemicrania,  megrim,  is  an  hereditary  neurosis,  with  paroxysmal  aurte, 
headache  and  vomiting. 

Etiology. — (a)  Heredity  is  a  conspicuous  cause  (90  per  cent.  Mobius), 
directly  as  migraine  or  indirectly  from  neurotic,  gouty  or  epileptic  ante- 
cedents. (6)  Thirty-three  per  cent,  of  cases  begin  between  the  fifth  and 
tenth,  40  per  cent,  between  the  tenth  and  twentieth  years,  and  the 
remainder  usually  before  the  thirtieth  year,  (c)  Exciting  causes  are 
constipation,  dyspepsia,  overexertion,  alcohol  or  sexual  abuse,  emotional 
factors,  pelvic  disorders  and  lactation. 

Symptoms. — ^As  preliminary  symptoms  the  patient  may  feel  depressed, 
or,  in  some  cases,  especially  well  and  energetic.  They  occur  in  cases  in 
which  the  sensory  symptoms  are  least  marked.  Sometimes  the  pupils 
are  dilated.    Most  attacks  develop  during  the  night. 

AuE^. — In  over  50  per  cent,  of  cases,  aurse  are  (a)  sensory,  as  visual 
aurse,  a  cloudiness  before  the  eyes,  sparks,  lightning,  zig-zag  forms, 
etc. ;  they  are  most  often  bilateral  and  affect  the  homologous  half-fields ; 
taste  and  smell  may  be  similarly  affected ;  paresthesia  may  occur,  usually 
as  hemiparesthesia ;  (6)  motor  aurse  are  much  less  common,  as  aphasia, 
dysphasia  or  motor  weakness  on  the  contralateral  side;  in  the  very  rare 
ophthalmoplegic  migraine,  there  are  fugitive  ptosis,  outward  strabismus, 
double  vision  and  a  dilated  immobile  pupil;  mental  aurse  are  uncommon, 
as  anxiety,  confusion  and  double  consciousness.  The  aurse  last  for  ten 
to  fifteen  minutes. 

The  Attack. — (a)  Headache,  the  cardinal  symptom,  at  first  is  intense 
and  circumscribed,  over  the  eye,  temple,  occiput  or  forehead;  then  it 
spreads  over  one  side  {hemicrania),  sometimes  affects  the  opposite  side 
or  rarely  reaches  the  neck  or  arm.  The  pain  is  deep,  being  most  often 
boring,  and  even  as  intense  as  in  brain  tumor  or  meningitis.  It  is  in- 
creased by  movement,  stooping  or  lying  down.  The  special  senses  are 
hyperesthetic.     The  mind   is  usually  clear  and  often  acutely  active. 


938  THE  NEUROSES 

sometimes  there  is  double  consciousness,  and  in  rare  cases  stupor.  (6) 
Nausea  follows,  often  with  vomiting  of  undigested  food  and  finally  of 
bile — "bilious  headache."  Feeding  and  medication  are  impossible  in 
severe  cases.  Vomiting  may  be  attended  by  hyperacidity  or  moderate 
collapse,  as  in  sea-sickness,  (c)  Vasomotor  symjjtoms  may  be  present, 
of  the  spastic  type  with  pallor,  coldness,  wide  pupils  and  retraction  of  the 
eye-balls.  Thoma  found  the  temporal  artery  sclerotic  on  the  side  of  lesion, 
and  de  Giovanni  noted  a  marked  arcus  senilis  on  the  same  side.  The 
pulse  may  be  slow  and  tense  and  the  breathing  superficial.  In  the 
paretic  type,  there  are  redness  of  the  skin,  small  pupils,  sweating  and 
increased  flow  of  saliva  or  tears.  Very  rarely  is  there  erythromelalgia, 
edema  or  ecchymosis.  It  is  best  to  regard  these  sympathetic  symptoms 
rather  as  a  result  than  as  a  cause  of  the  attack. 

The  attack  ends  with  the  vomiting,  after  which  the  patient  frequently 
sleeps,  or  with  almost  critical  sweating,  lachrymation,  polyuria  or  epistaxis. 
The  attack  lasts  from  ten  to  twelve  hours;  the  term  status  heviicranicus 
is  used  for  cases  of  long  duration  or  those  in  which  the  attacks  overlap. 
Most  attacks  are  atypical,  as  headache  alone,  vomiting  alone,  or  headache 
with  vomiting;  in  a  few  cases  the  attack  aborts  with  the  aura.  The 
aurse,  pain,  gastric  and  cardiac  inhibition,  vasomotor  symptoms  and 
vomiting  prove  that  migraine  is  a  functional  cerebral  affection. 

Course  and  Prognosis. — ^When  the  disease  is  established  in  youth  its 
attacks  become  more  frequent  in  adolescence  and  usually  last  until  the 
forty-fifth  or  fiftieth  year.  The  periodicity,  noted  by  Tissot,  Trousseau 
and  Liveing,  has  not  been  explained.  Overwork,  worry,  menstruation 
or  change  of  routine  may  precipitate  an  attack  at  a  regular  or  irregular 
interval.  Attacks  may  cease  during  an  intercurrent  pregnancy,  tabes  or 
gout.  The  school  of  Charcot  emphasized  the  fortunately  rare  danger 
of  transformation  into  epilepsy,  labyrinthine  vertigo  or  some  psychosis. 
Complete  cases  are  more  obstinate  and  dangerous  than  light  forms. 

Diagnosis. — ^With  a  history  of  heredity  and  development  in  childhood, 
the  full  attack  is  most  characteristic.  "Sick  headache"  is  practically 
always  migraine.  Atypical  forms  may  be  confused  with  various  head- 
aches, classified  as  follows: 

1.  From  nervous  affections,  as  (a)  cerebral  neurasthenia,  in  which  there 
is  a  sense  of  constant  pressure  rather  than  actual  headache,  without 
nausea,  but  with  paresthesia,  and  in  location  frontal  or  general,  some- 
times occipital  or  temporal;  (6)  hysteria,  which  is  less  common  (clavus 
headache,  "neuralgic  headache"),  and  sometimes  is  precisely  like  mi- 
graine; (c)  epilepsy,  which  some  consider  as  identical  with  migraine; 
the  epilepsy  aura  is  shorter  and  loss  of  consciousness  is  the  most  con- 
stant symptom;  {d)  meningitis,  which  in  all  types  is  early  and  severe; 
(e)  hydrocephalus,  which  is  often  severe,  especially  in  acquired  forms;  (/) 
brain  tumor,  which  is  constant,  generalized,  often  very  severe  and  some- 
times typically  hemicranic ;  {g)  paretic  dementia,  in  which  migraine  is  fre- 
quent; care  is  necessary  when  migraine  occurs  after  syphilitic  infection. 

2.  From  affections  of  the  special  senses,  as  eye-strain,  hypermetropia; 
glaucoma,  which  most  often  produces  frontal  headache;  nasal  disease, 
which  may  cause  sinus  involvement  with  frontal  headache. 


NEURALGIA  939 

3.  From  toxemia,  (a)  Those  due  to  acute  infections  are  usually  frontal 
and  dull,  but  sometimes  occur  in  other  locations  and  are  severe,  deep- 
seated  and  increased  by  stooping;  the  rheumatic  or  indurative  headache 
is  oftenest  occipital,  attended  by  tenderness,  often  by  induration  and 
pain  on  motion;  it  is  severe;  (b)  intoxication  by  alcohol,  nicotine, 
lead,  nitroglycerin  and  opimii,  and  (c)  constitutional  states,  as  gout  or 
arthritis,  (d)  In  nephritis  they  are  usually  frontal,  remittent  or  contin- 
uous, but  sometimes  sharply  hemicranic.  (e)  In  gastric  affections  they  are 
exceedingly  common,  mostly  occipital,  but  sometimes  vertical  or  frontal. 

4.  From  circulatory  causes,  as  from  wearing  a  tight  collar,  repeated 
coughing,  cardiac  disease  or  arteriosclerosis  (with  vertigo),  and  usually 
increased  by  lying  down. 

5.  From  anemia,  especially  from  chlorosis,  as  a  "tugging"  sensation 
back  of  the  eyes  or  frontal  or  generalized  headache,  and  often  relieved 
bj'  lying  down. 

Treatment.- — Prophylaxis  is  said  to  be  of  little  value,  but  many  subjects 
recognize  the  warnings  and  avert  the  attacks  by  resting,  on  noting  unusual 
mental  or  physical  capacity  for  work  or  an  unusual  appetite,  which  ushers 
in  some  attacks.  IMigraine  subjects  should  observe  moderation  in  eating, 
especially  of  meat,  in  work,  exercise  or  recreation,  narcotics,  stimulants, 
as  coffee  or  tobacco,  and  in  sexual  matters.  Immoderation  is  a  neurosis 
in  itself.  Hurry,  worry  and  tension  must  be  avoided  and  their  first 
manifestations  must  be  learned  and  treated.  The  extract  of  cannabis 
indica,  gr.  |-|,  given  for  weeks  or  months,  after  Seguin's  plan,  is  almost 
the  only  remedy  which  helps  the  condition,  and  then  only  in  some  cases. 
Mobius  finds  that  salicylate  of  soda,  gr.  xv,  in  black  coffee,  given  the  even- 
ing before  the  attack,  often  wards  it  off.  Nitroglycerin  in  full  doses 
sometimes  aborts  it,  as  may  washing  out  the  stomach  and  following  the 
lavage  with  a  saline. 

In  the  treatment  of  the  established  attack,  bromides  constitute  the  best 
remedy;  they  are  given  not  only  during  the  attack  in  the  mild  type, 
but  continuously,  as  in  epilepsy,  when  the  type  is  severe  and  frequently 
repeated  (Livemg  and  Charcot).  Phenacetin  often  helps  mild  forms 
and  those  with  initial  rise  of  blood-pressure.  Morphine  is  to  be  avoided. 
The  stomach  sometimes  rejects  all  medication,  which  must  then  be 
given  by  rectum.  Application  of  cold  to  the  head,  hot  foot-baths  and 
sinapisms  to  the  nape  of  the  neck  and  epigastrium  are  subordinate  helps. 


NEURALGIA. 

Pain  is  only  a  symptom,  usually  of  an  affection  of  a  peripheral  sensory 
nerve,  although  in  rare  cases  affections  of  the  cortex,  pons,  medulla  or 
parts  near  the  thalamus  may  cause  peripheral  pain.  The  pain  of  neuralgia 
and  neuritis  may  be  confused. 

Etiology.^ — (a)  Neuralgia  occurs  mostly  in  adult  life  (twenty  to  sixty) 
and  rarely  before  puberty  or  after  sixty,  in  which  case  it  is  usually  severe 
and  intractable,  (b)  Most  cases  occur  in  women,  (c)  Heredity  is  an 
apparent  factor  in  25  per  cent,  of  cases,  especially  in  neuropathic,  weakly 


940  THE  XEVROSES 

or  gouty  families,  (d)  Debility  from  exhausting  conditions,  as  lactation, 
anemia,  overwork,  sensory  fatigue,  as  from  eye-strain,  sexual  or  other 
excesses,  emotional  conditions  and  traimaa  may  cause  it.  (e)  It  may 
result  from  acitte  infections,  notably  influenza,  tj^hoid  at  its  onset, 
malaria,  the  causal  importance  of  which  has  been  much  overestimated, 
rheumatism  (from  exposure  to  cold)  particularly  of  the  fascial  t\"pe,  and 
sometimes  s;^'philis.  (/;  Alcoholism,  diabetes,  plumbism,  gout  and  neph- 
ritis may  produce  it;  most  of  these  are  also  causes  of  neuritis,  differentia- 
tion from  which  may  be  difficult,  {g)  Nerve  affections,  as  sciatica  and 
neuritis,  herpes  zoster,  reflex  irritation,  as  radiated  from  a  carious  tooth, 
compression  of  a  nerve  trunk  by  varices,  aneurysms  or  neuromata  or  the 
root  pains  of  tabes,  may  cause  neuralgia,  (h)  Arteriosclerosis  may  affect 
the  nutrient  nerve  vessels. 

General  Symptoms. — ^The  jjain  presents  the  followmg  characteristics: 
(a)  It  is  always  paroxysmal,  with  intervals  of  total  or  relative  relief; 
intense  pain  is  never  constant.  (6)  It  recurs  irregularly  at  intervals 
varying  from  hours  to  months  or  with  surprising  periodicity  on  a  given 
day  or  hour,  perhaps  at  the  menstrual  period;  periodicity  is  as  frequent 
in  non-malarial  as  in  malarial  cases,  (cj  It  is  usually  unilateral,  generally 
constant  in  its  seat,  and  most  often  found  over  the  distribution  of  a  single 
nerve  or  several  nerves;  bilateral  pain  is  usually  sjTnmetrical.  The  pain 
may  shift  from  place  to  place,  especially  when  due  to  systemic  causes. 
It  is  probable  that  the  spinal  cord  may  be  the  medium  of  radiation  of 
pain  from  one  region  to  another  and  that  pain  may  follow  the  distribution 
of  the  spinal  segments  rather  than  that  of  the  peripheral  nerves,  as  in 
herpes  zoster,  (d)  Its  onset  and  cessation  are  sudden  and  spontaneous; 
an  imminent  attack  may  be  precipitated  or  existing  pain  may  be  aggra- 
vated bj'  muscular  movements,  a  breath  of  air  or  a  simple  touch;  the 
character  of  the  pain  is  sharp,  stabbing,  rarely  pulsating;  if  it  travels 
along  the  nerve  trunk  its  shooting  direction  is  usually  centrifugal,  rarely 
centripetal;  if  it  is  localized  it  is  commonly  burning  or  boring,  (e) 
The  pain  is  usually  deepj,  but  the  skin  is  very  h\-peresthetic.  (j)  The 
"tender  points"  of  VaUeix  (1811),  later  called  maximal  points  by  Head, 
are  found  in  the  nerve  (50  per  cent.)  both  in  the  attack  and  the  free 
interval,  especially  where  the  nerve  emerges  from  the  bone  or  fasciae,  lies 
on  hard  surfaces,  divides  or  anastomoses.  The  occasional  tenderness  over 
the  spine  at  the  origin  of  a  nerve  (Trousseau's  pjoint  apophysaire)  occurs 
in  man}'  other  conditions.  In  neuritis  the  nerve  trunk  along  its  entire 
accessible  course  is  tender,  (g)  Vasomotor  constriction,  followed  by  dilata- 
tion, is  fairly  common.  Edema,  erythema,  blanching  or  falling  out  of  the 
hair,  secretory  disturbances,  herpes,  pigmentation,  nimibness  or  tingling, 
trophic  alteration  of  the  skin,  localized  hj-pertrophies  and  reflex  twitch- 
ings  of  the  muscles  are  much  less  frequent  than  in  neuritis.  Persistent 
pain  or  its  etiological  factors  may  reduce  the  general  nutrition. 

Local  CLLnical  Varieties. — 1.  Teifaclil  XEtRALGiA  (prosopalgia,  tic 
douloureux)  is  the  most  important,  severe  and  frequent  t^'pe,  because 
the  fifth  nerve  is  most,  exposed  to  trauma,  compression  and  infection,  by 
way  of  the  eye,  nose  and  ear.  The  entire  nerve  is  not  usually  affected, 
though  pain  may  radiate  from  one  division  into  another;  indeed  only  the 


NEURALGIA  941 

secondary  branches  of  a  single  division  may  be  involved.  The  general 
features  of  neuralgia  are  present,  as  already  described,  {a)  Involvement 
of  the  first  hrmicli  is  the  most  common  form;  pain  occurs  over  the  eye, 
forehead  and  frontal  sinus  (in  which  the  familiar  pain  is  experienced 
after  eating  ice-cream) ;  it  sometimes  radiates  into  the  second  and  third 
branches;  there  are  "tender  points"  over  the  lower  edge  of  the  nasal 
bone,  the  supra-orbital  notch,  less  often  over  the  supra-orbital  nerve, 
even  to  the  vertex,  sometimes  over  the  occiput  or  over  the  cervical  spines ; 
cold,  carious  teeth,  disease  of  the  sinus,  glaucoma,  hypermetropia,  etc., 
are  causal  factors.  (6)  When  the  second  branch  is  involved  there  is  pain 
over  the  side  of  the  nose  and  cheek  from  the  infra-orbital  region  to  the 
upper  lip;  there  are  "tender  points''  over  the  lower  border  of  the  nasal 
bone,  the  malar  bone,  the  infra-orbital  foramen,  the  gums  over  the 
canine  teeth,  and  sometimes  in  the  hard  palate;  among  other  causes  is 
the  dental  alveolitis  in  the  aged,  due  to  sclerosis.  Diseased  teeth  may 
cause  neuralgia  without  local  dental  symptoms  and  in  every  severe  case 
the  dentist  should  be  consulted,  (c)  Involvement  of  the  third  branch 
is  the  least  frequent  form;  inframaxillary  pain,  along  the  lower  teeth, 
tongue,  chin,  external  ear  and  maxillary  region;  and  tenderness  over 
the  auriculotemporal  nerve  and  inferior  dental  foramen  may  occur. 
In  old  persons  the  loss  of  the  teeth  brings  the  jaws  closer  and  therefore 
stretches  the  inf.  dental  nerve;  it  is  relieved  by  proper  plates.  In  severe 
forms  vasomotor  symptoms  and  increased  secretion  from  the  eyes,  nose 
and  salivary  glands  are  usually  present.  Hyperalgesia  is  such  that  the 
face  cannot  endure  simple  contact,  and  drinking,  mastication  and  wiping 
the  nose  cause  great  suffering.  Herpes  and  trophic  changes  are  probably 
neuritic  rather  than  neuralgic  symptoms.  In  rare  instances  facial  spasm, 
transient  reflex  ptosis,  internal  strabismus  or  myosis  coexists.  Differ- 
entiation: In  headache  and  migraine  there  are  no  tender  points;  intra- 
cranial disease,  as  tumor  or  syphilis,  is  usually  excluded  by  systematic 
examination.  The  prognosis  is  doubtful  in  severe  forms,  which  are  often 
life-long  in  duration  and  agonizing  in  degree. 

2.  Cervico-occipital  Neuralgia. — ^There  is  pain  in  the  first  four 
cervical  nerves,  especially  the  inferior  occipital  and  auricularis  magnus; 
this  pain  sometimes  radiates  into  the  fifth  nerve;  there  is  tenderness 
half-way  between  the  mastoid  and  spine,  over  the  parietal  eminence  and 
over  the  cervical  plexus  between  the  sternomastoid  muscle  and  trapezius; 
this  form  is  often  bilateral  and  is  less  intermittent  than  other  neuralgias, 
which  facts  are  explained  by  its  frequent  connection  with  cervical  caries 
and  syphilis,  and  with  tumors,  meningitis,  root  disease  and  affections 
of  the  ear. 

3.  Phrenic  Neuralgia.- — Phrenic  neuralgia  is  rare;  it  sometimes 
occurs  in  pericarditis  and  diaphragmatic  pleurisy;  it  is  usually  left-sided, 
with  pain  and  tenderness  over  the  insertion  of  the  diaphragm  and  nerve 
trunk  in  the  neck;  movements  involving  the  diaphragm  are  painful. 
Differentiation  is  usually  uncertain. 

4.  Cervicobrachial  Neuralgia. — Any  nerve  may  be  involved, 
especially  the  ulnar  and  circumflex.  Pain  may  radiate  over  the  entire 
plexus  and  chest;  the  tender  points  are  most  often  in  the  axilla,  shoulder 


942  THE  NEUROSES 

and  ulnar  distribution;  it  is  often  confused  with  neuritis  from  trauma, 
compression,  rheumatoid  arthritis  or  other  organic  disease. 

5.  Intercostal  neuralgia  ranks  third  in  frequency  after  trifacial 
and  sciatic  neuralgias  (neuritis).  Pain  is  felt  along  the  intercostal  nerve 
and  tenderness  over  the  points  of  emergence  of  its  three  branches,  over  the 
angle  of  the  ribs,  in  midaxilla  and  near  the  mammary  line.  It  is  more 
easily  distinguished  in  the  upper  than  lower  interspaces.  Differentiation 
may  be  difficult  in  muscular  rheumatism  in  which  movement  is  more 
painful.  Peritoneal  disease,  ulcer,  spinal  caries,  aneurysm  and  tabes 
must  be  distinguished.  It  is  most  common  in  gastrohepatic  affections 
and  neurotic  women. 

Ileryes  zoster  is  an  acute  inflammation  of  the  posterior  root  ganglia 
(Barensprung  and  Charcot)  which  are  the  seat  of  a  cellulohemorrhagic 
exudation;  its  fibers  to  the  posterior  column  degenerate.  It  is  mentioned 
in  this  connection  because  of  the  acute  pain  preceding  and  associated 
with  the  rash,  which  appears  after  three  or  four  days;  the  pain  is  often 
protracted  and  intractable;  the  pain  on  the  trunk  follows  the  distribution 
of  the  spinal  segments  rather  than  that  of  the  intercostal  nerves.  J. 
Ramsay  Hunt  collected  15  cases  of  herpes  of  Gasserian  origin,  associated 
with  ocular  palsies,  and  60  palsies  associated  with  herpetic  inflammation 
of  the  geniculate  ganglion,  and  also  describes  herpes  zoster  of  the  face 
and  neck  with  auditory  symptoms  and  facial  palsy. 

6.  Lumbar  Neuralgia. — This  infrequent  type  occurs  in  the  ilio- 
hypogastric, ilio-inguinal  and  genitocrural,  sometimes  in  the  ext.  cutane- 
ous, obturator  and  crural  nerves.  The  pain  is  felt  over  the  iliac  crest, 
inguinal  canal,  labium  or  testis  (irritable  testicle). 

7.  Sacral  Neuralgia. — Coccygodynia  is  neuralgic  and  occurs  mostly 
in  women.  The  pain  is  increased  by  sitting,  coitus  and  defecation;  it  is 
obstinate  and  resists  even  operative  measures. 

8.  PoDODYNiA. — Neuralgia  of  the  heel  is  termed  pododynia;  plantar 
neuralgia,  which  is  mostly  neuritic,  occurs  in  acute  infections  and  caisson 
disease.  Morton's  metatarsalgia,  regarded  as  bony  compression  of  the 
fourth  metatarsophalangeal  nerve,  usually  occurs  in  one  foot  and  mostly 
in  women;  operation  is  usually  indicated. 

9.  Visceral  Neuralgias. — (See  Diseases  of  the  Heart,  Stomach  and 
Kidneys,  Hysteria  and  Neurasthenia).  Under  this  caption  may  be  given 
Head's  areas  of  pain  referred  to  visceral  disease :  the  organ  is  first  given, 
and  following  it  is  the  area  to  which  its  pain  is  reflected:  Heart:  1st, 
2d,  3d  dorsal  segments.  Lungs:  1st,  2d,  3d,  4th,  5th  dorsal  segments. 
Stomach:  6th,  7th,  8th,  9th  dorsal;  cardiac  end  from  6th  and  7th. 
Pyloric  end  from  9th.  Intestines:  (a)  Down  to  upper  part  of  rectum,  9th, 
10th,  nth  and  12th  dorsal,  (h)  Rectum,  2d,  3d,  and  4th  sacral.  Liver 
and  gall-bladder:  7th,  8th,  9th,  10th  dorsal;  perhaps  6th  dorsal.  Kidney 
and  ureter:  10th,  11th  and  12th  dorsal.  The  nearer  the  lesion  lies  to  the 
kidney  the  more  is  the  pain  and  tenderness  associated  with  the  10th 
dorsal.  The  lower  the  lesion  in  the  ureter  the  more  does  the  1st  lumbar 
tend  to  appear.  Bladder:  (a)  Mucous  membrane  and  neck  of  bladder, 
1st,  2d,  3d,  4th  sacral.  (5)  Overdistention  and  ineffectual  contraction, 
11th  and  12th  dorsal  and  1st  lumbar.    Prostate:  10th,  11th,  12th  dorsal, 


NEURALGIA  943 

1st,  2d,  3d  sacral  and  5tli  lumbar.  Epididymis:  llth  and  12th  dorsal 
and  1st  lumbar.  Testis  and  ovary:  lOtli  dorsal.  Appendages:  llth  and 
12th  dorsal  and  1st  lumbar.  Uterus:  (a)  In  contraction.  10th,  llth, 
12th  dorsal  and  1st  lumbar,     (b)  Os  uteri.    1st,  2d,  3d  and  4th  sacral. 

Treatment. — Logically,  the  treatment  of  the  cause  (g.  v.)  should  precede 
that  of  the  symptoms,  but  practically,  pain  is  the  prime  indication  for 
therapeutic  measures. 

1.  Local  Measures. — Pressure  on  tender  points  may  diminish  or 
abolish  pain.  As  in  sciatica,  blisters  and  sinapisms  (both  of  which  may 
leave  permanent  pigmentation  on  the  face),  the  cautery,  local  heat, 
acupuncture  or  injections  of  water  or  cocaine  may  give  relief.  Freezing 
the  skin  by  ethyl  chloride  often  gives  better  results.  Menthol,  camphor- 
chloral  (equal  parts)  and  liniments  are  of  some  value  (tr.  aconiti,  tr. 
chloroformi,  tr.  belladonnse  aa  5ij,  linimentum  saponis  giv).  Lijections 
of  1  per  cent,  solution  of  osmic  acid  into  the  nerve  trunk  are  very  success- 
ful; they  were  recommended  by  Billroth  and  Neuber  (1884).  Schlosser 
(1900)  recommended  alcohol  injections;  Patrick  treated  75  cases  without 
a  failure  and  Kiliani  190,  with  5  failures.  Massage  is  often  beneficial, 
for  the  muscles  and  nerves  have  common  veins. 

2.  Nutrition. — A  full  diet,  with  milk  and  cod-liver  oil,  the  Mitchell 
rest-cure,  hydrotherapy  and  massage,  are  often  beneficial,  especially  with 
change  of  climate  or  surroundings.  Alcohol,  which  is  always  dangerous, 
is  most  often  indicated  in  older  subjects.  The  beneficial  effects  of  castor 
oil  are  often  great,  probably  because  it  promotes  elimination.  Gouty 
subjects  may  thrive  on  a  vegetable  diet. 

3.  General  Drug  Treatment. — Dana  gives  strychnine  hypoder- 
mically  in  doses  of  -^^  gr.  even  up  to  ^  gr.  Arsenic,  iron  and  phos- 
phorus are  excellent  in  anemic,  malarial  and  degenerative  types;  quinine 
is  beneficial  in  non-malarial  as  well  as  malarial  types  and  in  trifacial 
neuralgia  especially,  although  its  value  is  overestimated.  Valerian, 
cannabis  indica  and  bromides  should  be  given  for  irritability ;  salicylates 
for  rheumatism  and  colchicum  for  gout ;  iodides  are  sometimes  of  benefit 
to  non-syphilitic  subjects;  full  doses  of  nitroglycerin  are  frequently  helpful. 

4.  Analgesics. — Acetanilide  (gr.  v)  and  the  other  coal  tars  should 
be  used  in  fresh  cases.  Extr.  cannabis  indicse  (gr.  |)  and  fluidextr. 
gelsemii  (ITlij-iv)  should  be  administered  every  three  to  six  hours  in 
the  less  severe  cases.  In  acute  febrile  or  rheumatic  cases,  fluidextr. 
aconiti  (TUj-ij)  should  be  given  every  two  hours  until  tingling  in  the 
mouth  or  extremities  and  slowing  in  the  pulse  intervene.  Liebreich 
advocates  croton-chloral,  gr.  v,  or  with  care  even  gr.  xx,  for  several 
doses.  Finally,  in  severe  cases,  morphine,  as  far  as  possible,  should  be 
avoided;  sometimes  its  administration  is  inevitable;  though  some  writers 
find  that  it  tends  to  prevent  recurrence,  the  pain  often  develops  again, 
intensified;  atropine  sometimes  more  permanently  controls  the  pain  than 
does  morphine. 

5.  Electrotherapy  sometimes  relieves  pain,  as  galvanization  with  a 
weak  current,  just  strong  enough  to  produce  a  sensation  of  burning  and 
applied  with  the  sponges  warm  and  with  the  anode  to  the  painful  area, 
especially  in  newly  developed  cases. 


944  THE  NEUROSES 

6.  Surgical  therapy  includes  nerve  section,  resection,  stretching 
or  divulsion;  these  procedures  often  fail.  In  incoercible  trigeminal 
neuralgia  the  Gasserian  ganglion  may  be  extirpated  (Rose,  1890),  but 
this  operation  entails  a  high  mortality,  and  loss  of  the  eye  may  result, 

VASOMOTOR  AND  TROPHIC  NEUROSES. 

Vasomotor  centres  exist  in  the  cerebral  cortex  and  medulla.  The 
fibers  probably  run  in  the  lateral  columns  of  the  cord  and  leave  by  the 
anterior  roots.  Vasomotor  paralysis  occurs  independently  or  with  func- 
tional or  organic  disease.  Paralysis  of  the  cervical  sympathetic  may 
result  from  trauma,  aneurysm,  tuberculous  apical  or  glandular  disease' 
or  disease  of  the  cord.  It  is  attended  by  redness,  rise  of  temperature, 
pulsation  and  tortuosity  of  the  vessels,  sweating,  unrest,  ringing  in  the 
ears  and  palpitation.  In  paralysis  of  the  cervical  sympathetic  there 
are  pupillary  narrowing  from  the  unopposed  action  of  the  third  nerve, 
slight  ptosis,  narrowing  of  the  interpalpebral  fissure  from  paresis  of 
Miiller's  muscle,  salivation,  lachrymation  and  in  cases  of  long  standing, 
retraction  of  the  eye  and  flattening  of  the  cheek.  The  pupil  reacts 
somewhat  to  light  but  not  to  stimulation  by  pain  or  pinching  of  the  skin 
of  the  neck  (Mobius);  the  pupil  can  be  widened  by  atropine,  but  to  a 
less  degree  than  the  normal  eye. 

Vasomotor  spasm  presents  converse  symptoms — pallor,  coldness, 
small  vessels  and  frequently  a  sense  of  tingling  or  arterial  pain.  Two 
examples  are  nervous  angina  pectoris  and  Raynaud's  disease;  spasm 
(contraction,  irritation)  of  the  cervical  sympathetic  produces  wide 
pupils,  an  increased  interpalpebral  fissure  and  exophthalmos. 

Little  is  known  of  the  trophic  nerves,  if  indeed  separate  nerves  sub- 
serve nutrition.  If  they  exist  they  are  probably  closely  related  to  the 
vasomotor  tracts.  Trophic  changes  may  be  symptomatic  of  disease  of 
the  nerves  or  cord,  as  in  neuritis  or  nerve  trauma,  facial  hemiatrophy, 
tabes,  syringomyelia  and  myelitis. 

Erythromelalgia. — Erythromelalgia,  described  by  Graves  (1843)  and 
S.  Weir  Mitchell  (1872),  indicates  redness  and  pain  in  the  extremities. 
It  occurs  mostly  between  the  years  of  twenty-five  and  forty  and  is  slightly 
more  frequent  in  males.  Pathologically,  Mitchell  and  Spiller  find  neuritis 
and  sclerosed  arteries.  The  toes  (less  often  the  fingers)  and  balls  of  the 
toes  are  the  seat  of  severe,  paroxysmal  pain,  swelling  and  redness,  par- 
ticularly when  the  limbs  depend;  the  arteries  throb  and  the  veins  are 
engorged;  the  color  is  sometimes  blue.  Pain  is  occasionally  experienced 
in  the  head  or  neck  and  vertigo  and  muscular  weakness  may  be  noted. 
The  symptoms  occur  mostly  in  warm  weather  and  generally  disappear 
in  winter.  The  clinical  course  is  long,  the  prognosis  doubtful  and  the 
treatment  consists  of  electrotherapy,  cool  baths,  acetanilide  and  iodides. 

Acroparesthesia. — Closely  related  to  erythromelalgia,  it  was  described 
first  by  Nothnagel,  and  F.  Schultze  (1890)  named  this  very  frequent 
affection;  its  derivation  signifies  paresthesia  of  the  extremities.  More  than 
90  per  cent,  of  cases  occur  in  women  between  thirty  and  sixty  years  of 
age.     The  etiology  is  doubtful   (stasis  or  arteriosclerosis).     The  chief 


VASOMOTOR  AND   TROPHIC  NEUROSES  945 

feature  is  an  unpleasant  crawling,  tingling  sensation,  sometimes  amount- 
ing to  actual  pain  in  the  fingers  or  hands,  less  often  in  the  toes  or  feet. 
The  discomfort  is  greatest  at  night  and  in  the  early  morning;  it  is  per- 
ipheral and  symmetrical  but  does  not  correspond  with  any  nerve  area. 
Generally  there  are  no  objective  findings  other  than  occasional  vasomotor 
disturbance  or  slight  sensory  blunting.  The  outlook  is  favorable,  the 
course  is  chronic  and  the  faradic  brush  frequently  afi^ords  relief. 

Spontaneous  Symmetrical  Gangrene. — Raynaud's  disease  was  first 
described  by  Raynaud  (1862).  Sixty-six  per  cent,  of  cases  occur  in 
women,  who  are  usually  delicate,  anemic  and  neurotic,  and  most  cases 
develop  in  persons  between  twenty  and  forty-five  years  of  age.  In  10 
per  cent,  it  is  hereditary.  Other  causal  factors  are  uncertain,  as  expo- 
sure to  cold  and  dampness,  exhaustion  and  acute  infections.  Occasional 
coexistence  is  noted  with  hysteria,  neurasthenia,  epilepsy,  tabes,  syringo- 
myelia, angioneurotic  edema,  neuritis,  acute  mania,  etc.  Its  pathology 
is  not  established,  but  arterial  spasm,  endarteritis  and  neuritis  are  said 
to  exist.  There  are  three  stages:  (a)  Local  ischemia  (or  syncope)  begins 
with  pallor  and  coldness  of  one  or  two  fingers,  perhaps  of  the  entire 
hand  or  of  the  toes  and  is  attended  by  numbness  or  severe  pains.  The 
"dead  fingers"  or  toes  appear  on  exposure  to  slight  cold  or  on  emotion 
and  reaction  occurs  after  a  variable  period.  The  process  may  not  pass 
this  stage.  (6)  Local  asphyxia  (or  cyanosis)  develops  in  the  parts  in- 
volved, at  times  with  some  swelling  or  anesthesia.  It  is  most  severe 
in  winter  and  chilblains  are  regarded  as  the  mildest  type  of  this  stage, 
(c)  Local  gangrene,  which  is  spontaneous,  symmetrical  and  fortunately 
rare,  is  the  last  stage.  It  is  dry,  sometimes  vesicular  and  its  extent  is 
always  less  than  the  area  of  ischemia  and  asphyxia.  The  tips  of  the 
fingers  or  toes  dry  up,  fall  off  and  scars  mark  successive  attacks.  Less 
often  the  tip  of  the  nose,  ear,  buttock,  heel,  shoulder  or  abdomen  is 
involved  and  very  rarely  the  tongue,  penis,  elbow  or  knee.  In  some 
instances  there  is  severe  general  disturbance,  as  fever,  chill,  enlarged 
spleen,  colic,  hemoglobinuria,  uremia,  stupor,  coma,  convulsions,  transient 
hemiplegia,  neuritis  and  spastic  retinal  vessels.  The  severe  or  fatal 
cases  occur  especially  in  children.  The  course  is  chronic  and  consists  of 
repeated  attacks,  which  often  abate  in  summer. 

Differentiation. — Differentiation  is  usually  easy  from  hysterical  gangrene 
(self-injury),  diabetic,  arteriosclerotic  or  embolic  gangrene,  syringomyelia, 
leprosy,  ergotism  and  acute  arteritis,  as  in  typhoid. 

Treatment. — Narcotics  are  given  for  pain;  warmth  and  elevation 
promote  venous  return  and  nitroglycerin  dilates  the  arteries.  Gushing 
advised  Esmarch's  constrictor  for  a  few  minutes.  In  actual  gangrene 
surgical  interference  should  be  postponed  until  complete  demarcation 
develops,  because  the  area  is  much  more  circumscribed  than  at  first 
indicated. 

Acute  Angioneurotic  Edema.— It  was  first  fully  described  by  Quincke 
(1882),  although  Milton  (1876)  described  "giant  urticaria."  It  occurs 
most  frequently  between  the  years  of  twenty  and  thirty-five  and  is 
slightly  more  frequent  in  women  than  in  men.  It  is  allied  to  urticaria, 
erythema  nodosum  and  possibly  to  some  forms  of  purpura,  and  consists  of 
60 


946  THE  NEUROSES 

a  circumscribed  edema,  which  is  sudden  in  onset  and  in  disappearance,  is 
tense  and  pale,  does  not  pit  on  pressure,  sometimes  causes  burning  and 
appears  mostly  on  the  eyelids,  lips,  cheek,  tongue,  hands  or  genitalia,  some- 
times on  the  buttocks,  in  the  pharynx,  larynx,  lung  or  digestive  tract.  It 
sometimes  attacks  several  areas  simultaneously.  Gastro-intestinal  symp- 
toms occur  in  33  to  50  per  cent,  of  cases,  as  epigastric  pain,  vomiting,  colic 
or  diarrhea  (see  p.  693).  Hemoglobinuria,  albuminuria  and  polyuria  are 
less  frequent.  The  outlook  is  good,  except  that  laryngeal  or  pharyngeal 
localization  may  cause  sudden  death.  Recurrence  is  not  uncommon, 
perhaps  with  considerable  periodicity. 

Treatment. — Treatment  is  symptomatic;  nitroglycerin  is  recom- 
mended. Bloodgood  employed  deep  incisions  with  great  benefit.  Wright 
exhibited  calcium  lactate   (gr.  xx)  with  success. 

Herz  described  a  pseudoperiostitis  angioneurotica,  occurring  especially 
on  the  thoracic  bones;  it  is  periodic,  transitory,  painful,  tender  and 
associated  with  neurotic   cardiac  disturbance. 

Chronic  Hereditary  Trophedema. — Twenty-two  cases  of  chronic 
hereditary  trophedema  in  six  generations  were  described  by  Milroy 
(1893)  of  Omaha,  8  cases  in  four  generations  by  Meige  (1898)  and  13 
cases  in  five  generations  by  Hope  and  French  (1898).  A  firm,  pale, 
painless  edema,  chiefly  below  the  hip  or  knee,  develops  toward  puberty, 
without  cardiac,  renal  or  apparent  local  cause.  It  may  appear  in  the 
arm  and  leg  of  the  same  side,  including  probably  some  of  the  so-called 
local  hemihypertrophies.  The  first  cases  recorded  were  thought  to  be 
phlebitis.  Health  and  life  are  not  threatened,  although  treatment 
produces  no  results. 

Hydrops  Articulorum  Intermittens. — Hydrarthrosis  intermittens  occurs 
in  71  per  cent,  in  persons  between  ten  and  forty  years  of  age;  about 
70  cases  are  on  record.  Its  etiology  is  not  known.  Some  cases  present 
malarial,  gonorrheal  or  traumatic  antecedents.  The  knee  is  usually 
involved  when  several  joints  are  affected  and  in  33  per  cent,  is  alone 
involved.  The  effusion  wholly  disappears  after  two  or  three  days,  but 
it  reappears  obstinately  every  one  to  four  weeks.  There  is  no  fever  and 
usually  no  pain.      Treatment  is  general. 

Scleroderma. — Described  by  Lusitanus  and  Alibert,  Thirial  (1845) 
gave  the  first  full  account.  It  is  a  chronic  thickening  and  hardening  of 
the  skin,  followed  by  atrophy.  It  is  a  rare  affection,  but  is  more  common 
than  is  generally  recognized.  The  localized  form  usually  develops  before 
and  the  generalized  form  after  the  twenty-fifth  year.  Seventy-five  per 
cent,  of  cases  occur  in  women.  The  causation  is  obscure;  erysipelas, 
trauma,  cold  and  neuropathic  disposition  are  sometimes  considered 
etiological  and  association  with  other  neuroses,  general  and  vasomotor, 
is  frequent.  Anatomically  the  skin  and  all  the  contained  structures  are 
fibrosed.  In  the  localized  form  it  occurs  in  spots  or  streaks,  which  often 
correspond  to  the  course  of  given  nerve  trunks  or  spinal  segments.  In 
the  general  form  the  body  may  be  literally  "hide-bound."  Its  distribu- 
tion in  order  of  frequency  is  the  upper  extremities,  trunk,  head  and  face, 
lower  extremities,  and  generalized.  The  skin  is  usually  first  painful  and 
sensitive,  then  reddened  and  thickened,  and  finally  pale,  glossy,  dry. 


VASOMOTOR  AND   TROPHIC  NEUROSES  "947 

atrophic  and  parchment-like.  It  is  rigid  and  without  folds,  inhibiting 
the  mimetic  play  of  the  features.  The  nose  is  peaked,  the  lids  cannot 
close  over  the  eye-ball  and  may  become  everted.  The  mouth  is  so  small 
as  to  sometimes  necessitate  extraction  of  some  of  the  teeth  and  rigidity 
in  the  neck  may  render  swallowing  difficult.  In  the  fingers  it  occurs  in 
5  per  cent,  of  cases  {sclerodactylia,  Ball).  The  close  skin  produces  decided 
deformity  and  loss  of  function.  Sensation  is  usually  preserved,  the  secre- 
tion of  sweat  is  usually  reduced  and  pigmentation  and  trophic  changes 
in  the  hair  and  nails  are  occasionally  seen.  In  some  cases  it  occurs 
with  herpes  (the  herpetiform  morphea  of  Hutchinson).  Circumscribed 
atrophy  of  the  bones  is  said  to  occur.  Only  30  per  cent,  of  cases  improve 
and  15  per  cent,  recover. 

Treatment. — Treatment  is  unsatisfactory.  Improvement  has  followed 
administration  of  salol  and  inunctions  with  oil ;  thyroid  extract,  especially 
if  used  early  in  the  disease,  may  promote  recovery. 

Ainhum. — Ainhum  was  first  observed  by  Clark  (1860),  then  by  Da 
Silva  Lima  (1866).  It  is  a  chronic  affection,  usually  limited  to  the  great 
toe,  which  at  its  plantodigital  fold  suffers  a  slow,  painless,  non-inflam- 
matory circular  constriction  and  spontaneous  amputation.  Ainhum 
is  chiefly  found  in  the  colored  races  of  Brazil,  Africa,  India  and  sometimes 
in  this  country.  Its  nature  is  disputed;  an  ingrowth  of  the  epidermis 
and  scleroderma  have  been  thought  to  be  causes.  It  is  not  amputating 
leprosy,  as  has  been  claimed. 


SECTION  X. 

DISEASES  OF  THE  LOCOMOTOE  SYSTEM, 


DISEASES  OF  THE  MUSCLES. 


MYOSITIS. 

Inflammation  in  the  muscles  may  be  single  or  multiple;  it  may  be 
an  independent  or  a  secondary  affection.  It  may  reach  the  muscles  by 
contiguity  from  adjacent  disease,  may  result  from  trauma,  trichinosis, 
cysticercus,  echinococcus,  myxo-  sarco-  and  microsporidia,  sepsis,  puer- 
peral fever,  rheumatism,  scarlatina,  gonorrhea,  syphilis  or  erythema 
multiforme.  The  muscles  are  the  seat  of  serous,  sometimes  hemorrhagic 
or  diffuse  purulent  exudation  in  septic  forms  and  of  fatty  degeneration. 
In  a  form,  endemic  in  Japan,  the  Staphylococcus  pyogenes  aureus  occurs 
in  pure  culture.  The  muscles  are  usually  friable  and  sometimes  frag- 
mented. Polymyositis,  first  described  by  Wagner  (1887),  Hepp  and 
Unverricht,  occurs  most  often  in  youth  and  adolescence  and  is  attended 
by  pain,  especially  near  the  tendons,  swelling  and  often  edema  in  the 
muscles,  and  decreased  tendon  reflexes.  The  skin  may  participate, 
with  herpes,  erythema,  bullae  or  purpura  {dermaiomyositis);  the  infection 
may  involve  the  tissue  in  which  the  afferent  nerves  originate  (muscle 
spindles),  {neuromyositis,  Senator).  In  some  cases  there  is  arthritis  or 
phlebitis.  Oppenheim  describes  a  case  of  dermatomucomyositis  with 
stomatitis,  iritis  and  conjunctivitis.  The  inflammation  occasionally 
reaches  the  tongue,  pharynx,  larynx  or  respiratory  muscles  and  may  cause 
difficult  mastication  or  swallowing,  ptosis  or  dyspnea.  The  systemic 
reaction  is  severe,  marked  by  fever,  chills,  sweats,  splenic,  tumor,  some- 
times by  angina,  bronchitis,  albuminuria  or  leukocytosis.  Death  is  the 
usual  issue. 

In  muscular  fihrositis,  the  morbid  process  is  an  infiammatory  exuda- 
tion into  the  fibrous  tissues;  the  swelling  and  thickening  may  be  slight 
and  impalpable;  severe  and  definitely  tumor-forming;  acute  and  trans- 
ient; chronic,  and  eventuating  in  hard,  fibrous  lumps.  The  most  con- 
stant s\Tnptoms  are  pain  and  tenderness ;  if  vigorously  rubbed,  the  swelling 
and  the  pain  are  greatly  increased.  If  a  patient  presents  himself  with 
any  of  the  ordinary  manifestations  of  chronic  rheumatism,  as  a  lumbago, 
sciatica,  pleurodynia,  or  a  cephalalgia,  and  with  any  obscure  myalgic 
or  neuralgic  pain  in  any  part  of  the  body.  Telling  urges  that  a  careful 
investigation  should  be  made  of  the  fibromuscular  tissues  of  the  affected 
areas. 


950  DISEASES  OF   THE  MUSCLES 

Differentiation. — Differentiation  concerns  miihiiAe  neuritis  (tenderness 
over  the  nerve  trunks,  motor  and  sensory  findings) ;  trichinosis  (trichinee 
in  the  tender,  swollen  muscles,  eosinophilia  and  digestive  s^Tnptoms); 
and  periarteritis  nodosa  (q.  v.). 

Treatment. — Treatment  is  s\TQptomatic  and  is  identical  with  that  of 
sepsis.    Sweats  and  salicylates  are  beneficial. 

Myositis  Ossificans. — ^Myositis  ossificans  usually  develops  acutely 
in  the  muscles  of  the  neck  or  back  before  the  fifteenth  year  and  leaves 
residual  foci  of  infiltration,  partly  in  the  periosteum  and  partly  in  the 
fasciae  and  tendons,  which  gradually  calcify.  The  thigh  and  arm  are 
most  severely  and  permanently  affected.  The  process  occurs  in  the 
strongest  muscles  and  at  an  age  when  they  develop  most  actively;  it  may 
affect  man}^  muscles  and  runs  a  chronic  course,  perhaps  of  several  decades. 
Schutz  collected  275  cases  of  the  localized  form  and  A.  R.  Elliott,  107 
cases  of  the  progressive  inflammatory  type,  often  associated  with  infan- 
tilism,  microdactylia,   etc.     ^Massage  is  sometimes  beneficial. 

MUSCULAR  RHEUMATISM   (MYALGIA). 

This  includes  many  vague  but  important  affections.  It  occurs  par- 
ticularly in  men,  promoted  by  cold,  dampness  and  certain  occupations, 
^luscular  overexertion,  as  straining  and  lifting,  is  frequently  a  part  of  the 
history.  Rheumatic  and  gouty  subjects  are  specially  and  recurrently 
exposed.  Disorders  of  metabolism  or  mental  as  well  as  physical  over- 
work mark  some  cases.  Other  forms  are,  as  Leube  insists,  probably 
infectious,  for  fever  occurs  in  33  per  cent,  and  occasionally  endocarditis; 
muscular  rhemnatism  in  this  sense  does  not  generally  involve  many 
muscles,  but  usually  one  muscle  or  .a  single  group.  The  pain  is  not 
paroxysmal,  as  in  neuralgia,  and  is  experienced  in  the  muscle  or  reaches 
it  from  its  tendons  or  fasciae.  In  some  cases  it  is  a  mild  neuromyositis. 
Its  varieties  are :  Myalgia  capitis,  affecting  the  fascia  of  the  head;  omalgia, 
involving  the  muscles  of  the  shoulder,  or  rheiunatic  torticollis,  which  is 
usually  unilateral;  pleurodynia,  which  affects  the  pectoralis,  intercostals 
and  serratus,  limits  respiratory  movements  and  is  likely  to  be  confused 
with  intercostal  neuralgia,  pleurisy,  periostitis  of  the  ribs  or  vertebral 
disease;  lumbago,  which  involves  the  lumbar  muscles,  and  is  the  most 
frequent,  painful  and  obstinate  form,  causing  great  pain  on  movement 
or  on  efforts  of  the  uninvolved  muscles  to  maintain  quiet;  it  is  probably 
due  in  some  cases  to  muscular-rupture,  as  after  lifting.  In  the  abdominal 
muscles  and  glutei  it  may  simulate  pelvic  disease.  In  treatment,  rest  is 
indicated,  for  use  of  the  affected  muscles  aggravates  pain  and  protracts 
the  condition.  Involuntary  movement  is  prevented  by  careful  strapping 
with  adhesive  plaster.  A  hypodermic  of  morphine  into  the  muscle  is 
often  indicated.  Deep  injection  of  w^ater  into  the  muscles  of  the  affected 
part  may  relieve  pain.  Ringer's  method  of  acupuncture  with  long  needles 
which  are  pushed  three  inches  into  the  back  and  left  there  for  from  five 
to  ten  minutes  is  beneficial,  but  is  usually  vigorously  opposed  by  the 
patient.  Very  energetic  massage,  with  the  local  application  of  heat, 
probably  gives  the  best  results.    The  actual  cautery  and  constant  cur- 


ARTHRITIS  DEFORMANS  AND  CHRONIC  RHEUMATISM         951 

rent  give  good  results.     Belladonna  plasters  afford  relief.     Gelsemium 
aeetanilide  and  salicylates  may  relieve  certain  cases. 

Chronic  cases,  with  vague,  fugitive  pains  which  come  on  with  change 
of  weather,  are  treated  in  the  same  way.  Confusion  is  frequent  with 
chronic  alcoholism,  tabes,  gout  and  diabetes. 

AMYOTONIA  CONGENITA. 

Of  Oppenheim's  disease,  Griffith  (1910)  collected  49  cases.  Some 
cases  are  apparently  myopathies  and  others  of  spinal  origin.  This  con- 
genital condition  is  characterized  by  extreme  flaccidity  and  weakness, 
smallness  and  softness  of  the  muscles,  oftenest  of  the  legs  and  most  rarely 
of  the  face.  The  deep  reflexes  are  lost,  the  faradic  excitability  of  the 
muscles  is  lessened  and  contractures  are  likely  to  develop.  There  is  a 
tendency'  toward  slow  improvement. 

Myotonia,  paramyoclonus  multiplex  and  myasthenia  gravis  are  de- 
scribed elsewhere. 


DISEASES  OF  THE  JOINTS. 

ARTHRITIS  DEFORMANS  AND  CHRONIC  RHEUMATISM. 

ExcLUDiXG  gouty,  traumatic,  trophic,  tuberculous,  syphilitic,  gonor- 
rheal and  hemophilic  affections,  there  remains  a  group  of  articular 
affections  of  which  the  chief  are  arthritis  deformans  and  the  so-called 
chronic  rheimiatism.  Several  totally  different  affections  are  most  un- 
satisfactorily gathered  under  these  names. 

Arthritis  deformans  is  a  progressive  or  at  least  chronic  affection, 
marked  by  changes  in  the  sjaiovial  sac,  cartilages  and  bone,  causing  func- 
tional disturbance  and  usually  s^Tametrical  and  polyarticular  deformity. 

Etiology. — (a)  The  predisposing  factors  are  (i)  heredity,  which  is  causa- 
tive in  13  per  cent.  (Garrod) ;  (ii)  age;  55  per  cent,  of  cases  occur  between 
twenty  and  fifty  years  of  age;  5  per  cent,  under  twenty  years  and  40 
per  cent,  over  fifty  years  of  age  (Garrod);  (iii)  sex;  Stewart  and  ^NlcCrae 
consider  that  the  sexes  are  equally  involved;  (iv)  fatigue,  cold,  dampness, 
poor  hygiene  or  trauma  may  be  predisposing  factors.  (6)  The  immediate 
cause  is  unknown;  the  infective  theory  is  based  upon  finding  bacteria 
in  the  joint,  enlarged  spleen  and  lymph  glands  and  its  occasional 
development  after  infections;  some  cases  can  be  traced  to  disease  of 
the  tonsils,  sinuses,  gall-bladder,  appendix,  tubes,  prostate,  pyorrhea 
alveolaris,  etc. 

Pathology  and  Symptoms. — Whether  the  synovia  or  cartilages  are  first 
involved  is  undetermined;  the  .r-rays  do  not  solve  the  question;  prac- 
titioners, who  see  cases  early,  hold  that  the  serous  sac  is  first  affected  and 
surgeons  find  the  cartilages  most  often  diseased.  The  s^aiovial  villi 
hypertrophy  and  the  cartilage  slightly  fibrillates,  cleaves  and  finally 
atrophies.     The  bone  becomes  thin  in  some  places  and  tuberous  in  others 


952  DISEASES  OF  THE  JOINTS 

from  periosteal  proliferation  (Haygarth's  nodosities);  the  joint  surfaces 
become  eroded  and  in  part  grow  together, 

1.  Diffuse  Progressive  Type. — (a)  The  acute  form  is  less  common. 
There  is  some  fever,  rise  in  the  pulse-rate  and  general  depression  and  the 
joints  become  red  and  swollen,  resembling  acute  articular  rheumatism, 
but  differing  from  it  in  that  arthritis  deformans  is  less  fugitive,  involves 
the  small  joints  less  frequently,  is  attended  by  less  sweating,  and  seldom 
by  heart  complications,  does  not  react  to  salicylates  and  runs  a  longer 
course.  In  some  cases  it  even  resembles  typhoid,  because  the  fever  and 
splenic  enlargement  antedate  the  arthritis.  (6)  The  more  frequent 
chronic  form  develops  insidiously,  with  uncomfortable  sensations  in  the 
joints  or  racking  nocturnal  pains  about  the  joints  and  vasomotor  skin 
symptoms.  It  begins  most  often  in  the  small  joints  of  the  hands,  with  or 
without  swelling,  and  remits  and  recurs.  The  hands  often  sweat.  The 
fingers  become  fusiform  from  joint  changes,  capsular  thickening  and 


Fig.  79. — Rheumatoid  arthritis.     (Musser.) 

collateral  edema  which  separate  the  fingers  from  each  other.  The  edema 
often  disappears,  showing  more  clearly  the  osseous  and  capsular  thicken- 
ing. The  cartilages  become  uneven  and  crackle  on  movement,  loosened 
villi  may  become  free  bodies  and  the  adjacent  bursse  and  tendons  may 
swell.  The  fingers  deviate  and  become  angular  from  flattening  of  the 
saddle-shaped  epiphyses  and  extensor  or  flexor  muscular  contractures. 
Extension  to  other  joints  occurs;  the  elbow  becomes  flexed,  the  shoulder 
often  crackles  and  becomes  fixed ;  the  large  toe  is  bent  out  and  lies  under 
the  other  toes,  which  are  often  extended  at  their  first  and  flexed  at  their 
two  distal  articulations;  the  ankle  is  often  abducted;  the  knee  is  swollen, 
shapeless  and  flexed  from  effusion  or  contracture;  in  a  few  cases  the  hip, 
jaw  and  spine  are  involved.    The  vertebrae  may  be  affected  {v.  i.). 

Motion  is  limited  by  the  swefling,  muscular  contractures  or  articular 
fixation  by  interlocking  extracapsular  nodosities  and  capsular  induration. 
The  contiguous  muscles  atrophy  from  disuse,  local  inflammatory  in- 
vasion or  reflex  influence  on  the  cord.     The  skin  may  become  puffy, 


ARTHRIT-IS  DEFORMANS  AND  CHRONIC  RHEUMATISM  953 

glossy  or  atrophic.  The  reflexes  are  increased.  Neuritis  is  not  uncommon. 
The  heart  was  not  affected  in  any  of  Garrod's  500  cases.  Anemia,  epi- 
scleritis and  other  complications  are  uncommon.  The  majority  of 
patients  do  not  improve  or  recover  and  recurrence  of  the  disease  is  very 
common.  In  some  cases  the  process  is  arrested.  Aside  from  atheroma 
and  nephritis  few  intercurrent  diseases  develop. 

2.  Monarticular  Type. — Pathologically,  this  type  resembles  the 
form  described,  but  differs  from  it  in  that  it  presents  more  profound 
changes  and  is  limited  to  one  or  few  articulations.  There  is  the  same 
capsular  thickening  and  cartilaginous  fibrillation;  the  cartilage  often 
softens,  ossifies  or  hypertrophies;  the  bone  rarefies  or  becomes  cystic 
and  soft  in  some  places,  with  flattening  of  the  bone  heads  and  widening 
of  the  sockets,  particularly  in  the  shoulder  and  hip;  in  other  places  bony 
overgrowths  form,  known  as  Haygarth's  nodes  or  a  new  socket  may 
develop;  the  bone  may  eburnate  and  the  joint  may  be  either  smooth  or 
ridged.  As  a  rule  the  atrophic  prevail  over  the  hypertrophic  changes. 
They  resemble  the  extreme  senile  change  {morbus  coxas  senilis);  trauma 
or  a  nervous  basis  is  considered  causal;  it  occurs  in  old  persons  and 
largely  in  males.  Clinically,  compared  with  the  general  progressive  t}^e, 
it  is  single  or  at  least  rarely  symmetrical,  occurs  in  the  proximal  large 
joints  (hip  and  shoulder),  and  is  less  often  attended  by  subluxation. 
The  elbow,  spine  and  smaller  joints  are  less  involved. 

3.  Vertebral  Type. — Striimpell  (1885)  named  this  type  chronic 
ankylosing  spondylitis;  vertebral  arthritis  deformans  occurs  with  anky- 
losis of  the  spine,  shoulders  and  hips.  Marie  (1898)  made  it  a  separate 
type  (sjpondylose  rliizomyelique) ,  characterized  by  complete  vertebral 
ankylosis,  scoliosis,  ankylosis  of  shoulders  and  hips,  exemption  of  all 
other  joints,  incidence  almost  exclusively  in  males,  and  its  appearance 
in  the  young  immediately  after  bony  development  has  ceased.  Von 
Bechterew  (1892)  described  a  similar  type  due  to  heredity,  trauma  or 
meningeal  inflammation  and  characterized  by  paresis  of  the  muscles  of 
the  neck,  trunk  and  extremities,  some  atrophy  of  the  back  and  shoulder, 
involvement  of  the  spinal  nerves  (hyperesthesia,  pain  and  paresthesia) 
and  an  ascending  degeneration  in  the  cord.  These  are  probably  subtypes 
of  arthritis  deformans. 

4.  Juvenile  Type  of  Still. — (a)  The  ordinary  progressive  form 
may  be  observed  in  children,  as  in  adults,  and  often  with  almost  uni- 
versal ankylosis;  in  some  cases  the  great  toes  are  lengthened,  ih) 
"Still's  type"  occurs  largely  in  poor  children;  70  per  cent,  of  cases  are 
girls;  30  per  cent,  occur  between  the  second  and  seventh  years,  32  per 
cent,  between  the  seventh  and  thirteenth  years,  and  20  per  cent,  between 
the  thirteenth  and  seventeenth  years.  The  onset  is  often  subacute.  The 
multiple  arthritis  affects  chiefly  the  extracapsular  tissues  and  there  is 
seldom  crepitus.  The  spleen  is  always  enlarged  and  the  lymph  glands 
near  the  affected  joints  are  hard  and  large.  Anemia  and  retarded  develop- 
ment are  common. 

5.  Heberden's  Nodes. — Bony  nodes  develop  on  the  sides  of  the 
end  phalanges  near  the  joints.  They  begin  between  thirty  and  forty 
years,  but  are  seen  chiefly  at  about  sixty  years  of  age.     At  first  soft 


954  DISEASES  OF   THE  JOINTS 

and  sometimes  painful  and  red,  they  become  hard,  indolent  and  as  large 
as  a  pea.  Their  growth  is  more  intermittent  than  continuous.  Dis- 
turbance in  function  is  not  uncommon,  but  only  in  extreme  cases  is 
deformity  observed,  as  flexion  of  the  end  phalanges  into  the  palm  or 
deviation  toward  the  radial  side.  Involvement  of  the  large  joints  is 
rather  uncommon,  whence  the  prognosis  is  favorable. 

Diagnosis. — (a)  In  gout,  the  history,  localization,  fine  (not  coarse) 
crackling  in  the  knee-joint  and  radial  articulation  of  the  elbow,  greater 
spontaneous  pain,  infrequent  generalization,  and  symmetry,  the  uratic 
deposits  and  tophi  in  the  ear  are  characteristic,  (b)  Acute  rheumatism 
{v.  s.  Acute  Form),  (c)  Multijjle  tuberculous  arthritis  may  cause  ,diag- 
nostic  difficulty,  particularly  in  children,  for  pulmonary  tuberculosis  may 
complicate  arthritis  deformans;  but  the  tuberculous  hip  and  knee  in- 
volvement, the  fusiform  fingers,  the  hectic  fever,  involvement  of  the 
glands  and  serous  membranes  are  generally  distinctive.  Poncet's  anky- 
losing tuberculous  pseudorheumatism  may  cause  confusion  {v.  p.  182). 


Fig.  80. — Heberden's  nodes.     (Musser.) 

(d)  Syphilis  (q.  v.)  of  the  joints  occurs  particularly  in  persons  between 
four  and  fifteen  years  of  age  and  in  about  40  per  cent,  of  hereditary 
forms;  the  epiphyses  are  irregularly  deformed,  (e)  Hemophilic  arthritis 
is  distinguished  by  the  family  history  and  its  three  stages,  hemarthros, 
panarthritis  and  adhesions,  erosions,  deformity  and  ankylosis.  (/) 
Chronic  articular  injections,  especially  subchronic  gonorrheal  arthritis 
{q.  v.),  begin  acutely,  usually  affect  the  knees  first,  then  possibly  after 
months  the  ankles,  hands  (in  women  particularly),  sternoclavicular  and 
other  joints;  similar  chronic  arthritides  may  follow  scarlatina,  pneumonia, 
tonsillitis  (v.  s.),  etc.  (g)  Nervous  arthropathies  exhibit  much  the  same 
pathology;  (i)  the  arthropathies  of  tabes  (q.  v.)  occur  rapidly  and  early, 
without  pain,  tenderness  or  other  inflammatory  evidence;  are  attended 
by  much  effusion,  are  atrophic  or  flail-like  rather  than  hypertrophic, 
in  80  per  cent,  involve  the  lower  extremities  and  are  accompanied  by 
other  signs  of  tabes,  (ii)  In  syringomyelia  (q.  v.)  the  effusions  are  great, 
painless,  in  80  per  cent,  involve  the  upper  extremities  and  are  accom- 
panied by  panaritia  and  dissociated  anesthesia.    (/?)  "  Chronic  rheumatism" 


ARTHRITIS  DEFORMANS  AND  CHRONIC  RHEUMATISM      955 

rarely  follows  acute  rheumatism;  the  changes  involve  less  the  bone, 
cartilage  and  serous  sacs  than  the  capsule  which  becomes  fibrous.  The 
cartilage  may  become  somewhat  fibrillated  and  fibrous,  but  is  seldom 
hypertrophied  or  destroyed.  The  vascular  bands  become  callous  (Jac- 
coud's  fibrous  rheumatism)  and  ankylosis  ma}'  result.  Some  maintain 
that  ankylosis  by  connective  tissue  and  the  joint  obliteration  differentiate 
fibrous  rheumatism  from  arthritis  deformans,  but  clinical  differentiation 
is  often  impossible. 

X-ray  examinations  detect  the  synovial  or  periarticular  changes  (the 
so-called  rheumatoid  arthritis),  the  atrophy  of  bone  or  cartilage  and  the 
hypertrophic  alterations  (osteo-arthritis) . 

Treatment. — Arrest  of  the  process  results  rather  from  spontaneous  ex- 
haustion of  the  disease  than  from  therapeutic  efforts,  (a)  Possible  causal 
conditions  should  be  corrected,  as  pyorrhea,  tonsillar  or  antral  disease, 
otitis  or  genito-urinary  infections.  Autogenous  vaccines,  in  the  writer's 
hands,  have  proved  futile.  (6)  "  Rheumatic"  influences,  as  exposure 
to  cold  and  dampness,  overheating  while  at  work  and  resting  in  damp 
garments  are  to  be  carefully  avoided.  Woolen  underwear  should  be  worn. 
General  hydrotherapeutic  measures  are  illy  borne.  A  warm  climate 
benefits  especially  those  cases  resembling  (or  including)  chronic  fibrous 
rheumatism,  as  Mexico,  West  Virginia  and  Arkansas,  (c)  Diet  is  not 
of  such  importance  as  in  .gout;  liberal  feeding  always  is  strongly  indicated. 
id)  In  acute  exacerbations  rest,  salicylates  and  coal-tar  derivatives  are 
indicated,  (e)  Passive  movements  and  massage  relieve  stiffness  and 
muscular  contractures.  Massage  reduces  the  edema  and  adhesions. 
In  some  cases  forcible  pressure,  as  with  the  thumb,  will  cause  absorption 
of  the  fresh  osteoplastic  nodes;  it  may  be  easily  overdone,  and  once  every 
day  or  two  on  the  same  area  is  sufficient.  Cautious  active  exercise  is 
essential.  (/)  Extension  by  pulley  weights  sometimes  produces  wonderful 
results,  according  to  Hoffa,  in  lessening  pain  and  exostosis,  though  the 
author  has  never  observed  any  benefit,  (g)  Local  measures.  The  a;-rays, 
local  applications  of  warm  water  and  strong  electric  lights  may  afford 
temporary  alleviation  from  pain  but  do  not  seem  to  affect  the  basic  change; 
fibrous  rheumatism  is  more  benefited  than  arthritis  deformans.  Hot 
air  causes  hyperemia  of  the  parts  and  is  sometimes  of  real  benefit;  cages 
of  wire,  asbestos  and  felt  are  devised  to  enclose  the  joint,  leaving  around 
it  an  air  space;  the  temperature  is  gradually  raised  by  a  lamp  placed 
under  a  connecting  elbow  to  200°  or  250°  F.  and  then  gradually  lowered. 
Bier's  method  of  venous  hyperemia,  used  in  tuberculous  joints,  is  also 
advocated;  the  Esmarch  constrictor  above  the  joint  should  produce 
swelling  but  not  pain.  "Firing"  the  skin  with  the  Paquelin  is  beneficial 
in  lighter  grades.  Operation:  resection  may  be  considered  in  non- 
progressive, monarticular  forms,  but  the  general  poor  health  and  age 
of  the  patient  rather  contra-indicate  it.  {h)  Internal  medication,  as  cod- 
liver  oil,  arsenic,  thyroid  extract  and  syrup  of  iodide  of  iron  ma}'  help 
a  few  cases.  Luff  uses  guaiacol  carbonate;  the  initial  dose  of  five  grains, 
t.  i.  d.,  is  increased  two  grains  every  week  till  a  single  dose  of  twenty 
grains  is  given. 


956  DISEASES  OF  THE  BONES 


DISEASES  OF  THE  BONES. 

For  hypertrophic  pulmonary  arthropathy,  leontiasis  ossea  and  osteitis 
deformans,  see  page  722. 


OSTEOMALACIA. 

Etiology. — Osteomalacia  is  a  chronic  nutritive  disorder,  characterized 
by  decalcification  and  progressive  softening  of  the  bones,  with  bend- 
ing, fracture  or  deformity.  It  occurs  especially  in  adults  and  women 
(90  per  cent.),  particularly  nursing  or  pregnant  multiparse. 

Pathology  and  Symptoms. — The  pelvis,  vertebrae  and  ribs  are  oftenest 
affected,  with  pain  which  is  considered  "rheumatic,"  disturbances  in 
walking,  etc.,  and  deformities.  The  osteomalacic  pelvis,  often  first  de- 
tected by  a  pelvic  examination  during  pregnancy,  exhibits  an  approach 
of  the  sacral  promontory  and  the  acetabula;  scoliosis,  lordosis  or  kyphosis 
develops;  the  bones  of  the  leg  curve  and  spontaneous  fractures  occur. 
The  flaccid  and  atrophic  muscles  exhibit  tremor  or  fibrillation.  Radio- 
graphic and  autopsy  examination  reveals  decalcification  in  the  spongy 
and  compact  bones,  with  replacement  by  vascular,  gelatinous,  perhaps 
cystic  or  hemorrhagic  tissue.  The  urine  contains  an  excess  of  calcium 
and  phosphorus. 

Prognosis  and  Treatment. — The  chronic,  usually  progressive,  course 
covers  five  to  ten  years;  it  is  sometimes  acute  or  at  times  arrested. 
Asthenia  or  intercurrent  disease  is  the  usual  cause  of  death.  Calcium 
and  phosphorus  are  beneficial.  That  the  disease  may  be  related  to  the 
ductless  glands,  is  shown  by  occasional  cures  by  ovariotomy  in  advanced 
cases  and  by  full  doses  of  adrenalin  (Bossi). 


ACHONDROPLASIA. 

Pathology. — From  unknown  causes,  perhaps  from  pituitary  or  thyroid 
disease,  there  is  a  dystrophy  of  the  epiphyseal  cartilages  (chondrodystro- 
phia  fetalis) ;  connective-tissue  invasion  from  the  periosteum  prematurely 
unites  the  diaphyses  and  epiphyses,  thereby  preventing  development  of 
the  long  bones.  The  intermediary  cartilage  is  narrowed,  irregular  and 
zig-zag  and  stray  nests  of  cartilage  cells  may  develop  into  chondromata, 
exostoses  or  rapidly  growing  malignant  osteocartilaginous  tumors.  The 
a!-rays  show  the  small  or  deformed  epiphyses. 

Symptoms. — In  achondroplastic  dwarfism,  intelligence  is  normal, 
the  head  and  trunk  are  nearly  normal  but  the  decreased  stature  (3-4 
feet)  is  due  to  the  short  extremities.  The  hiunerus  and  femur  may 
measure  less  than  the  tibia  and  ulna.  The  fingers  are  nearly  equal  in 
length  and  diverge.  The  hand  is  short  and  the  fibula  is  longer  than 
the  tibia.  The  pelvis  is  contracted  and  lumbar  lordosis  follows  tilting 
forward  of  the  sacrum.    The  root  of  the  nose  is  depressed. 


OXYCEPHALY  957 


FRAGILITAS  OSSIUM. 


Ostheim  (1914)  collected  193  cases,  "including  two  types  of  cases,  (1) 
the  fetal  type  found  either  at  birth  or  soon  afterward,  associated  with 
imperfect  bone  formation  and  multiple  fractures  (imperfect  osteogenesis 
or  periosteal  dysplasia),  these  cases  commonly  not  surviving  beyond  the 
second  year  of  life;  and  (2)  the  congenital  type,  found  in  infants  and 
children,  at  birth  or  later,  with  fractures  recurring  often  until  puberty 
or  even  until  adult  life,  associated  with  similar  bone  changes  (idiopathic 
osteopsathyrosis),  which  children  if  well  cared  for,  survive,  but  often  in 
a  badly  crippled  condition." 

The  bone  trabeculse  are  produced  by  calcification  of  the  cartilage 
cells,  whereas  normally  new  bone  is  produced  by  osteoblasts  on  a  car- 
tilaginous matrix,  the  periosteum  forming  imperfectly  laminated,  dense 
bone  with  large  spaces;  the  bones  contain  little  calcium.  Fractures  occur 
in  the  diaphyses  only.  The  fetus  exhibits  imperfect  cranial  ossification, 
apparently  shortened,  bowed  extremities  and  many  fractures. 

OXYCEPHALY. 

Steeplehead,  thiirmschadel,  tete  a  la  Thersite,  caput  turritum,  is 
usually  congenital  and  is  due  to  early  synostosis,  especially  of  the  cor- 
onal and  sagittal  sutures,  whence  the  head  grows  sloping  upward  to 
compensate  for  the  lack  of  growth  laterally  and  anteroposteriorly. 
The  .r-rays  show  a  dimpling  of  the  inner  table,  considered  characteristic 
by  Fletcher,  who  collected  under  90  cases  (1910).  Intelhgence  is  normal, 
the  eyes  are  prominent  or  actually  exophthalmic  and  headache  and  optic 
neuritis  or  atrophy  are  usual.     Decompressive  operation  is  indicated. 


SECTION  XI. 

INTOXICATIONS.    SUNSTROKE, 


ALCOHOLISM. 


I.  Acute  Alcoholism. — (a)  The  highest  brain  centres  are  first  affected, 
judgment  (emotion  predominating),  motility  next  (disordered  speech, 
gait  and  vision),  then  the  lower  centres  (respiratory,  circulatory  and 
spinal).  (6)  The  pulse  becomes  more  rapid,  though  alcohol  does  not 
stimulate  the  heart.  Full  doses  make  the  pulse  slow  and  small.  The 
face  is  flushed  and  the  vascular  tone  is  lax;  for  this  reason  alcoholics 
suffer  little  shock  from  traumatism,  (c)  Respiration  is  slow,  deep, 
seldom  stertorous,  (d)  The  ywpils  are  more  often  dilated  than  narrow 
and  reactionless.  (e)  The  temperature  may  fall  markedly,  even  as  low  as 
75°,  from  vasoparesis,  usually  with  cyanosis  and  failing  of  the  bulbar 
centres.     Involuntary  evacuations  occur  in  the  severest  cases. 

Dipsomania  is  intermittent,  acute  alcoholism,  an  hereditary  psychosis 
in  which,  after  intervals  of  abstinence  and  no  craving  for  liquor,  the 
subject  becomes  intoxicated. 

Diagnosis. — The  alcoholic  breath  is  usually  suggestive  but  epileptics 
and  uremics  while  drunk  may  suffer  skull  fracture  or  apoplexy.  Many 
mistaken  diagnoses  result  from  carelessness,  but  many  are  unavoidable; 
the  apparently  drunk  patient  should  be  treated  for  alcoholism,  while 
other  possibilities  are  carefully  considered.  As  a  rule  the  patient  can  be 
aroused,  but  in  "dead  drunks"  this  is  not  the  case  and  incomplete  coma 
may  occur  from  other  causes.  The  pupils  are  usually  dilated  in  alcoholic, 
contracted  in  opium  and  uremic,  and  unequal  in  apoplectic,  coma.  Ster- 
torous breathing  is  strongly  indicative  of  apoplexy  or  uremia.  Convul- 
sions following  delirium  and  muscular  twitchings  are  less  common  than 
in  other  similar  conditions,  but  at  the  time  of  writing  the  author  observed 
uni-  and  then  bilateral  convulsions.  The  urine  rarely  contains  alcohol, 
as  at  the  most  5  per  cent,  of  ingested  alcohol  is  excreted  by  the  lungs  and 
kidneys.  Sudden  death  may  occur  without  adequate  necropsy  findings. 
One-third  of  all  fatal  poisonings  are  acute  alcoholism. 

Treatment. — Gastric  lavage  is  sufficient  in  most  cases.  The  convulsions, 
when  severe,  yield  to  a  few  whiff's  of  chloroform.  Acute  mania  yields 
to  a  hypodermic  of  apomorphinse  hydrochloridum  (gr.  |).  Collapse, 
cold  extremities  and  cardiac  and  respiratory  failure  are  relieved  by  hot 
coffee,  strychnine,  atropine,  aromatic  spirits  of  ammonia  and  local 
heat  {v.  i.  Acute  Opium  Poisoning). 


960  INTOXICATIONS— SUNSTROKE 

n.  Chronic  Alcoholism. — ^This  is  less  an  hereditary  tendency  than  a 
lack  of  character,  though  Plutarch  said  that  drunkards  beget  drunkards. 
Some  people  can  take  beer,  wine,  spirits  or  patent  medicines  throughout 
life  without  apparent  injury;  in  others,  even  the  mildest  alcoholic  drinks 
may  induce  visceral  alterations,  so  that  as  in  liver  cirrhosis,  it  would 
seem  that  there  is  some  other  etiological  factor.  Alcohol  in  health  is  a 
bad  food,  an  injurious  narcotic  or  stimulant,  a  protoplasmic  poison  to 
the  parenchymatous  organs  and  arteries,  and  a  check  on  metabolism. 

Symptoms. — (a)  Nervous  manifestations.  Functional  changes  include 
the  alcoholic  tremor,  a  most  common  symptom;  mental  dulness  and 
weakness ;  nervousness,  jumping  from  slight  stimuli,  irritability,  impaired 
judgment  and  feeble  will-power;  neuralgias  and  muscular  rheumatism. 
The  alcoholic  is  suspicious,  cruel,  conceited  and  degenerate.  Quinquad's 
sign  is  elicited  by  having  the  patient  place  his  fingers  vertically  to  the 
examiner's  hand  or  body,  when  a  series  of  jerking  shock-like  movements 
is  noted;  (i)  if  it  is  absent,  alcoholism  is  absent;  (ii)  if  it  is  moderate 
there  is  uncertainty  and  (iii)  if  it  is  marked,  in  3  cases  out  of  5,  the  patient 
is  an  alcoholic.  Of  organic  nervous  manifestations,  multiple  neuritis 
is  the  most  common;  it  may  result  from  small  amounts  of  alcohol, 
when  there  is  a  coincident  metallic  poisoning;  epilepsj^  may  result  from 
alcoholism;  hemorrhagic  pachymeningitis,  chronic  leptomeningitis,  acute 
polioencephalitis,  degeneration  in  the  anterior  horns  or  Clark's  columns, 
degeneration  of  the  cerebral  nervous  tissue,  slight  optic  neuritis  and  even 
immobile  pupils  may  be  more  or  less  direct  sequences.  (6)  Circulation. 
Arteriosclerosis  often  develops  with  its  train  of  sequences,  cardiac  hyper- 
trophy and  dilatation,  angina  pectoris,  cerebral  softening  or  hemorrhage. 
(c)  Chronic  hronckitis,  emphysema,  chronic  pharyngitis  and  laryngeal 
thickening  are  frequent  collateral  findings,  {d)  Digestixe  organs.  Alcoholic 
gastritis  {q.  v.)  is  common;  the  quite  characteristic  vomitus  matutinus  is 
quieted  only  by  another  dose  of  its  cause.  Beer  drinkers  usually  have 
large  stomachs.  Alcoholic  cirrhosis  has  been  discussed ;  fatty  degeneration, 
arterial  congestion  and  hypertrophy  may  antedate  or  accompany  cirrhosis. 
Beer  drinkers  have  lax  bowels,  while  consumers  of  spirits  are  constipated. 
Hemorrhoids  are  common,  (e)  The  kidneys  undoubtedly  suffer.  Dickin- 
son, Formad  and  Pitt  think  that  renal  disease  is  less  common  than  is 
usually  believed;  the  kidneys  are  h^^pertrophied  without  other  change 
in  43  per  cent.;  several  factors  may  be  necessary  to  produce  indurated 
kidneys.  Sterility  is  common.  (/)  Metabolic  maladies,  as  gout,  obesity 
and  some  forms  of  diabetes  may  result  from  chronic  alcoholism,  {g) 
The  skin.  Acne  rosacea  is  a  very  common  but  not,  as  Trousseau  says, 
an  "indelible  stigma."  The  vessels  of  the  nose,  cheeks  and  other  parts 
are  suggestively  dilated;  the  conjunctivae  are  injected  and  the  eyes  water. 

Prognosis. — The  prognosis  is  unfavorable,  both  from  the  standpoint 
of  curability  and  complications.  English  life  insurance  companies 
estimate  that  the  risk  is  33  per  cent,  less  in  abstainers  than  in  alcoholics. 
The  general  resistance  is  lowered,  thus  favoring  infections,  as  tuberculosis, 
and  raising  greatly  the  death-rate,  most  notably  in  pneumonia.  Twenty 
per  cent,  of  suicides  are  alcoholics.  The  oft'spring  of  inebriates  are 
disposed  to  numerous  nervous  affections. 


ALCOHOLISM  961 

Treatment. — Treatment  consists  of  correction  of  the  habit  and  care 
of  the  compHcations,  the  latter  of  which  have,  in  great  part,  already 
been  considered.  The  cnre  of  the  habit  is  largely  personal.  Its  prophyl- 
axis is  better  than  its  cure.  No  person,  however  intellectual  or  strong- 
willed,  can  safely  drink  with  any  regularity.  Institutional  treatment  is 
generally  necessary.  The  vomiting  should  be  treated  as  in  acute  and 
chronic  gastritis;  lavage  is  probably  the  most  reasonable  measure;  a 
mixture  of  bismuth  (page  55)  and  small  doses  (mfli-ij)  of  Fowler's 
solution  and  tr.  nucis  vom.  (TTlx)  are  valuable  just  before  the  adminis- 
tration of  hot  milk  with  tr.  capsici,  lUx.  Hyoscinae  hydrobromidum 
(gr.  yW)  should  be  given  two  or  three  times  at  three-hour  intervals, 
chloral  hydrate  (gr.  x)  and  sod.  bromide  (5ss)  for  three  or  four  doses, 
before  bedtime,  or  sulphonal  (gr.  xx)  in  hot  milk  before  bedtime,  in  order 
to  induce  sleep.  (See  Lambert's  treatment,  page  964).  Sipping  ice- 
water,  sucking  lemons  or  drinking  water  with  tr.  quassise  may  satisfy 
the  desire  to  "drink  something."  Cocaine  and  morphine  are  avoided, 
lest  a  substitution  or  succession  of  habits  develop.  Relapse  is  very 
common. 

m.  Delirium  Tremens. — Mania  a  potu  is  an  acute  accident  of  chronic 
alcoholism  and  almost  never  follows  an  acute  debauch  in  an  otherwise 
temperate  individual.  It  was  noted  among  sailors  by  Sutton,  of  Green- 
wich, in  181.3,  but  was  probably  best  described  by  Ware,  of  Boston,  in 
1831.  Sixt3'-six  per  cent,  of  cases  occur  in  men,  while  multiple  neuritis 
is  more  common  in  women.  The  patient,  usually  between  thirty  and 
forty  years  of  age,  has  been,  on  the  average,  an  alcoholic  for  eight  years 
before  delirium  tremens  develops;  strong  spirits,  rather  than  beer  or 
wine,  are  the  cause,  as  they  are  of  alcoholic  convulsions.  It  may  be 
precipitated  by  trauma  to  the  chest,  fractures,  mental  shock,  sudden 
failure  of  the  stomach  to  assimilate  food,  acute  withdrawal  of  alcohol  or, 
in  70  per  cent,  of  cases,  the  shock  of  onset  of  an  acute  infection. 

Symptoms. — It  develops  with  restlessness  and  insomnia,  which  re- 
newed drinking  fails  to  allay;  for  a  day  or  two  the  mind  wanders,  but 
can  be  brought  back  to  realities.  The  patient  may  be  facetious,  but  is 
soon  disturbed  by  horrible  hallucinations.  There  is  "great  versatility 
of  ideas."  The  patient  talks  volubly,  turns  suspiciously  to  the  head  of 
his  bed,  drives  his  horses  vigorously  and  brushes  aw'ay  the  vermin  from 
the  coverlet;  hallucinations  of  hearing  are  also  common.  He  at  first 
knows  that  the  bugs  and  snakes  are  unreal,  but  they  soon  become  actual 
torments,  so  that  unless  watched  he  will  leap  from  the  window  after 
waiting  for  his  opportunity.  The  pulse  is  rapid  and  soft,  the  skin  is 
flushed  or  slightly  cyanotic  and  covered  with  sweat,  the  tongue  is 
tremulous  and  white,  the  urine  scanty  and  often  albuminous  and  sleep 
is  constantly  absent.     There  may  be  moderate  fever,  101  °  to  103°. 

Diagnosis  and  Prognosis. — The  diagnosis  is  rarely  uncertain.  The 
chief  danger  of  error  is  in  overlooking  coincident  trauma,  and  infection. 
In  heavy  and  constant  drinkers,  a  delirium  may  be  delirium  tremens 
or  an  associated  delirium,  as  from  pneumonia. 

The  ovtlooh  is  always  uncertain.  Early  convulsions  are  of  no  great 
moment.  The  prognosis  is  determined  by  the  pulse,  general  nutrition 
61 


962  INTOXICATIONS— SUNSTROKE 

and  complicating  alcoholic  or  other  lesions.  Rigidity  of  the  muscles 
of  the  neck  is  ominous  and  indicates  edema  of  the  brain.  The  average 
mortality  is  15  to  20  per  cent.,  but  varies  as  the  affection  is  (a)  uncompli- 
cated (1  per  cent,  die,  Lambert);  (b)  associated  with  other  affections 
(grave  outlook)  or  (c)  occurs  in  the  aged  or  debilitated  (probably  fatal 
outlook).  Recurrence  is  frequent,  27  attacks  being  recorded.  In  fatal 
cases  death  usually  results  from  exhaustion  and  heart  failure;  the  tongue 
becomes  dry,  the  delirium  constant  and  the  skin  cold  and  clammy. 
The  autopsy  shows  edema  of  the  brain  (''wet  brain,"  Dana),  degenerative 
changes  in  the  brain  and  cord  (Bonhoffer),  arterial  alteration  (Collins) 
and  hypostasis  of  the  bases  of  the  lungs. 

Treatment. — (a)  The  patient  should  be  kept  in  bed  and  watched  con- 
stantly lest  he  escape.  Strapping  the  ankles  and  wrists  and  confinement 
by  a  straight  jacket  is  a  harsh  procedure  and  invites  trauma  to  the  hands 
and  feet,  but  is  inevitable  when  the  family  is  indulgent  or  the  nurses 
are  negligent.  (6)  Withdrawal  of  alcohol  is  usually  advocated  but  is  a 
severe  measure;  the  temporary  continuance  of  moderate  doses  seems  to 
steady  the  pulse  and  favor  digestion,  (c)  Sleep  is  induced  with  great 
difficulty  and,  as  Ware  first  pointed  out,  comes  when  the  disease  runs  its 
course.  Excessive  medication  should  be  avoided.  Sod.  bromide  (5ss), 
tr.  capsici  (TIlv)  and  whisky  (3ij),  hi  hot,  peptonized  milk  should  be 
given  every  three  hours,  by  mouth  if  possible,  or  by  the  nasal  catheter, 
for  nutrient  enemata  are  difficult  to  give  and  are  seldom  retained.  Chloral 
is  always  dangerous  in  inveterate  alcoholism.  Moller  administers 
veronal,  gr.  xv,  repeated  once.  Hyoscine  with  strychnine  may  be  bene- 
ficial. Morphine  should  be  given  only  by  the  hypodermic  method, 
for  its  absorption  can  then  be  measured.^  Protracted  warm  baths  may 
quiet  the  patient  but  they  are  hard  to  administer.  In  6  cases  in  which 
the  violent  delirium  became  ominous  the  writer  etherized  the  patient, 
and  in  three  instances  with  excellent  results,  (d)  The  circulation  should 
be  treated  as  in  pneumonia.    Large  doses  of  digitalis  are  tolerated  only 

1  In  the  treatment  of  500  cases  of  delirium  tremens,  S.  W.  Ranson's  conclusions  are  as 
follows:  (1)  In  incipient  cases  the  patients  respond  readily  to  treatment  with  chloral,  ergot, 
bromides  and  whisky.  (2)  Delirious  patients  are  very  resistant  to  treatment.  Sedatives 
increase  the  mortality  (scopolamin,  13  per  cent.) ;  15  to  30  grains  of  chloral  in  twenty-four 
hours  may  be  given  with  good  results,  but  larger  doses  increase  the  death-rate.  (3)  The 
only  drug  which  reduced  the  mortality  was  ergot;  the  death-rate  was  reduced  21.6  per 
cent.  (4)  When  whisky  was  given  the  mortality  was  increased  1.8  per  cent.  Ranson's 
cases  were  divided  into  two  classes,  incipient  and  delirious.  The  incipient  cases  showed  only 
insomnia,  restlessness  and  tremor.  The  fully  developed  cases  were  noisy,  delirious,  and 
had  well-defined  hallucinations.  Of  the  sedative  drugs  the  bromides  were  most  extensively 
used  and  severe  cases  showed  a  mortality  of  45.5  per  cent. ;  of  incipient  cases  treated  with 
bromides,  only  32.6  per  cent,  became  delirious;  while  of  similar  cases  not  treated  with 
bromides,  52.8  per  cent,  became  delirious.  Chloral  is  of  no  value  after  active  delirium  has 
set  in;  chloral  is  of  great  value  in  the  treatment  of  incipient  cases;  chloral  is  superior  to 
bromides  because  of  the  greater  speed  of  its  action.  Morphine  has  no  effect  in  delirious  cases 
and  is  far  inferior  to  small,  repeated  doses  of  the  sedatives  used  in  the  incipient  cases.  Scopo- 
lamin, jio—so  of  a  grain,  in  incipient  cases  has  no  controlling  action,  and  proved  extremely 
dangerous  when  given  to  actively  delirious  cases.  '  In  those  cases  in  which  ergot,  fluid- 
extract,  in  dram  doses,  repeated  every  four  hours  was  used  the  mortality  was  only  30  per 
cent.,  while  among  those  patients  treated  without  ergot  it  was  51.6  per  cent.  Ergot  is  of 
value  in  the  incipient  cases,  the  percentage  of  patients  developing  delirium  being  reduced 
23.3  per  cent,  by  its  use,  possibly  by  decreasing  the  cerebral  hyperemia.  Whisky  is  of  use 
in  the  treatment  of  incipient  cases,  lowering  the  percentage  of  patients  becoming  delirious 
by  20.2  per  cent.     In  the  delirious  patients  it  is  useless. 


OPIUM  POISONING  963 

because  they  are  not  absorbed;  the  origmal  treatment  by  digitaHs  is 
based  on  the  fact  that  a  nurse  by  mistake  gave  a  toxic  dose  of  digitaHs; 
the  patient  improved  and  the  "digitaHs  treatment"  was  thus  insti- 
tuted, (e)  Cold  affusions  upon  the  neck  and  chest  are  recommended 
by  Broadbent.     (See  Lambert's  treatment,  page  964.) 

OPIUM  POISONING. 

I.  Acute  Poisoning. — ^This  is  important  chiefly  from  a  diagnostic 
standpoint.  In  the  second  stage  it  is  strongly  characterized  by  profound 
sleep,  dry,  flushed  skin,  narrow  pupils,  slow,  strong  "digitalis  pulse" 
and  slow,  deep,  stertorous  breathing.  The  third  or  terminal  stage  is  differ- 
ent; the  skin  becomes  cyanotic  and  clammy,  the  narrowed  pupils  may 
dilate,  the  pulse  becomes  weaker  (though  the  heart  centres  live  after  the 
other  bulbar  centres  fail),  respiration  is  very  slow  and  halts.  Mistakes 
in  diagnosis  are  made  by  attributing  undue  importance  to  the  "  pin-point 
condition  of  the  pupils.  Morphine  may  be  detected  in  the  stomach  washings. 

Treatment. — This  consists  of  (a)  evacuation  by  repeated  gastric  lavage. 
(b)  Chemical  antidotes,  such  as  large  amounts  of  tannic  acid,  should  be 
given  with  the  lavage  and  removed,  as  the  tannates  formed  may  dissolve; 
1  to  1000  permanganate  of  potash  (Moor)  may  be  given  by  mouth  or 
hypodermically.  (c)  Resjyiration  must  be  sustained  by  walking  the 
patient,  but  fatigue  must  he  guarded  against;  phrenic  faradization  is 
indicated,  but  care  is  necessary  lest  too  strong  a  current  produce  paralysis 
instead  of  stimulation;  strychnine  plus  atropine  may  be  given  hypo- 
dermically, but  the  total  dose  of  atropine  should  not  exceed  gr.  -g^; 
pulling  slowly  and  rhythmically  on  the  tongue  may  help  respiration; 
artificial  respiration  and  oxygen  inhalation  may  be  used,  {d)  The  heart 
is  stimulated  by  coffee,  strychnine,  heat  and  digitalis. 

II.  Chronic  Morphinism. — The  use  of  morphine  for  pleasure  only,  so 
common  in  Asia,  is  rare  with  us;  those  taking  morphine  for  pain  and 
resisting  its  attractions  are  called  morphinists ;  those  using  it  for  pleasure 
only  are  morphinomaniacs.  The  habit  is  contracted  by  its  use  for  in- 
somnia or  for  mental  or  physical  pain.  Forty-seven  per  cent,  of  morphine 
victims  are  said  to  be  physicians;  women,  particularly  prostitutes  and 
nurses,  druggists  and — in  Germany — officers  rank  next.  It  may  be  taken 
for  years  without  mental  or  physical  deterioration,  but  increase  in  the 
daily  dose  becomes  necessary  and  the  half-oxidized  alkaloid  produces 
symptoms  which  are  only  allayed  by  larger  doses.  Wlorphine  acts  as  a 
nerve  poison.  The  victim  becomes  restless  and  irritable  without  his 
dose.  The  mental  and  moral  attributes  are  anesthetized  and  there  is  a 
"moral  insanity."  The  patients  lie  by  choice,  neurotic  symptoms  are 
common,  muscular  and  mental  asthenia  develop,  the  pupils  are  contracted, 
the  sweat  and  saliva  are  decreased,  the  teeth  decay,  the  appetite  fails, 
the  skin  becomes  sallow,  itchy  and  dry,  the  hair  coarse  and  gray,  con- 
stipation is  usual  and  slight  ataxia  may  develop. 

Prophylaxis. — Physicians  should  not  give  opiates  freely.  When  admin- 
istered for  severe  pain  the  habit  is  less  often  contracted  than  when  given 
to  neurotics.    At  least  20  per  cent,  of  cases  relapse  after  a  "cure," 


964  IX  TOXIC  A  TIOXS—S  UX  STROKE 

Treatment. — Treatment  is  almost  impossible  without  (a)  institutional 
confinement,  which  must  of  course  be  voluntary.  The  patient  -^-ill  obtain 
morphine  if  possible,  (h)  The  moi'ijMne  may  be  intlidrav:n  abruptly, 
rather  suddenly  or  very  gradually;  the  second  method  is  the  best,  stopping 
the  morphine  entirely  in  four  to  seven  days.  Its  T\-ithdrawal  is  attended 
by  awakening  of  dormant  anesthetized  functions;  there  is  at  first 
parox^-smal  yawning  and  sneezing;  roughening  of  the  voice,  paresthesia, 
neuralgias  especially  in  the  legs,  clammy  skin  or  rapid  pulse,  wide  pupils, 
tremor,  sexual  excitement,  extreme  irritability,  vomiting,  colic  and  diar- 
rhea also  occur.  The  symptoms  were  attributed  by  ]\Iarme  to  di-oxy- 
morphine,  the  antidote  to  which  is  morphine;  Hitzig  believes  that  they 
are  largely  due  to  h^-perchlorhydria,  for  the  gastric  nerves  under  the 
influence  of  morphine  secrete  little  hydrochloric  acid;  relief  is  obtained 
by  washing  out  the  stomach  with  a  solution  of  Carlsbad  salts,  (c)  The 
jjcitient  should  he  kept  in  bed  for  a  week  to  obA'iate  vasoparetic  cardiac 
collapse,  (d)  Symptomatic  treatment  is  indicated  Ci)  by  the  collapse 
(aromatic  spts.  of  ammonia,  TUxx,  strychnine,  gr.  -^,  heat) ;  (iij  by  nervous- 
ness (warm  baths,  sodium  bromide  in  doses  of  one  dram  every  four  hours) ; 
(iii)  by  the  insowtnia  fhyoscine,  gr.  -ywtj  CA'ery  two  hours  for  two  to  four 
doses,  sulphonal  or  trional,  gr.  xx) ;  Tiv)  by  the  gastralgia  (gastric  lavage 
with  alkaline  salts) ;  (v)  by  diarrhea  and  colic  (as  in  enteritis,  but  vege- 
table astringents,  large  doses  of  bismuth,  and  no  opiates  should  be  used) ; 
(vij  by  neuralgia  (acetanilide,  gr.  v,  fluidextr.  gelsemii,  TUiij).  AMiatever 
treatment  is  instituted,  alcoholism,  chloralism,  bromism  or  cocainism 
should  not  be  substituted.  Alexander  Lambert's  treatment  aims  to 
eradicate  the  craving  for  narcotics.^ 

1  Lambert's  prescription   consists  of: 

Tf — TinctiiTEe  belladonnse  ri5  per  cent.)         ....       20  c.c.  flSv 

Fluidextracti  hj'oscyami 10  c.c.      or 

Flmdextracti  xanthoxj-li 10  c.c.        aa  fl  3iiss 

M.  et  Sig. — Administer  as  directed. 

He  emphasizes  the  necessity  of  carrj-ing  out  his  treatment  absolutelj-  to  the  letter,  and 
emplojing  profuse  catharsis.  In  alcoholics  6  to  8  drops  are  given  everj'  hour,  day  and  night, 
until  either  the  patient  shows  sjonptoms  of  belladonna  excess,  or  from  the  cathartics  the 
characteristic  stool.  The  dose  is  increased  by  2  drops  given  everj'  six  hours  until  14  to  16 
drops  are  taken.  Usually  an  alcoholic  can  be  given  four  compound  cathartic  pills  at  the 
same  time  that  the  specific  is  begun.  After  the  drops  have  been  given  for  fourteen  hours, 
a  further  dose  of  compound  cathartic  pills  is  given,  either  two  or  four,  depending  upon  the 
amount  of  action  obtained  from  the  pre^-ious  pUls.  If  the  first  pills  have  caused  abundant 
action,  only  two  are  now  necessarj-.  At  the  twentieth  hour  of  the  drops,  from  two  to  four 
more  compound  cathartic  pills  are  given,  and  after  these  have  acted,  the  stools  should  begin 
to  be  green.  An  oimce  of  castor  oil  should  now  be  given,  and  a  few  hours  later  the  char- 
acteristic thick,  green,  mucous,  puttj'-Like  stool  wiU  appear.  Usually  the  drops  must  be 
continued,  and  at  the  thirty-second  hotir  from  two  to  four  compound  cathartic  pUls  are 
again  given,  and  a  few  hours  later  the  castor  oil.  The  drops  can  now  be  discontinued.  In 
the  first  twenty-four  hours  with  an  older  patient,  or  one  in  the  midst  of  a  spree,  whisky 
should  be  given  four  or  five  times,  in  one-  or  two-teaspoonful  doses,  in  milk.  The  whisky' 
should  not  be  continued  after  the  first  twentj'-four  hours,  and  in  younger  patients  it  is 
iistially  not  necessarj-  to  give  it  at  all.  An  alcohoUc  is  le.ss  tolerant  of  belladonna  than  a 
morphine  patient,  but  if  they  are  sensitive  to  this  drug  they  will  show  it  in  the  first  six  or 
eight  hours  of  the  treatment.  After  the  patient  has  been  through  with  this  treatment 
the  desire  for  alcohol  has  ceased,  and  it  is  a  question  for  the  next  few  days  of  proper  nutri- 
tion, and  .sometimes  the  administration  of  a  drug  for  sleep.  He  finds  the  best  hjT^notics 
for  these  alcoholics  are  chloral  and  bromides.  Whatever  tonic  is  given  of  course  must  be 
non-alcoholic.     In  treating  morphinism,  patients  do  not  suffer  more  than  a  bearable  amount 


LEAD  POISONING  965 


LEAD  POISONING. 

Etiology. — The  importance  of  plumbism  or  saturnism  is  increasing. 
(a)  Industrial  plumbism  is  very  common.  Workers  in  white-  or  red- 
lead  factories  usually  acquire  the  disease.  Miners  of  the  metal  generally 
escape,  but  smelters  of  lead  ore  and  even  animals  and  birds  near  the 
furnaces  are  frequently  affected.  Painters,  plumbers,  glaziers,  less  often 
tinners,  printers,  cameo  polishers,  cartridge  makers,  etc.,  may  be  poisoned. 
(6)  Accidental  contamination  of  food  or  drink.  Poisoning  may  result 
from  the  action  of  acids  in  canned  foods  on  the  tin  or  solder,  as  in  cans 
of  sardines;  wine  or  cider  may  become  poisonous  in  the  same  way,  as 
happened  in  Devonshire  and  Poitou  {colica  yictonum).  Chromate  foil, 
covering  hams  or  candy,  rubber  nipples,  bullets  in  pickled  game,  bread 
ground  in  lead  vessels,  chromate  used  to  color  buns  (D.  D.  Stewart's 
report  of  the  fatal  Philadelphia  epidemic),  Seltzer  or  other  charged 
waters,  wine  and  eau  de  vie  sweetened  or  cleared  with  litharge,  are  a  few 
of  the  many  subtle  causes  of  saturnism.  Drinking  water  conveyed 
through  lead  pipes  is  generally  protected  by  the  deposit  of  lime,  and  other 
salts,  but  poisoning  is  possible  when  the  water  is  exceptionally  pure  or 
soft,  thereby  depositing  little  lime  in  the  pipes,  or  when  it  is  saturated 
with  organic  matter  or  collected  from  lead  roofs,  (c)  Less  frequent 
sources  of  plumbism  are  in  the  environment,  and  in  hair-dyes,  powders 
or  cosmetics,  linen,  freshly  painted  walls,  candles,  sealing  wax,  brightly 
tinted  toys,  false  teeth  and  thread,    (d)  Therapeutic  and  criminal  plumh- 

of  discomfort  in  breaking  away  from  the  drug.  First,  the  patient  is  made  comfortable  with 
his  accustomed  dose  of  morphine,  and  then  given  four  or  five  compound  cathartic  pills. 
Then  the  drops  should  be  given  as  prescribed  for  alcoholics.  If  there  is  a  hypersensitiveness 
to  belladonna  the  drops  must  be  stopped  and  later  begun  again  with  a  smaller  dose.  After 
the  drops  have  been  started  and  the  time  has  come  for  the  patient's  usual  dose  of  morphine, 
he  receives  from  one-half  to  two-thirds  of  the  kind  of  opium  that  he  has  been  taking,  and 
administered  in  the  manner  that  he  has  been  administering  it.  After  fourteen  hours  of  the 
drop  treatment,  the  patient  should  be  given  four  compound  cathartic  pills  and  five  grains 
of  blue  mass,  or  some  other  form  of  vigorous  cathartic  such  as  the  vegetable  cathartic  pills 
of  the  Pharmacopceia  with  ginger  and  capsicum  and  ^r,  of  a  drop  of  croton  oil  to  each  pill. 
Four  or  five  of  these  last  pills  should  be  administered,  if  preferred  to  the  compound  cathartic 
pUls  and  blue  mass.  After  the  twentieth  hour  of  the  drop  treatment  the  patient  should 
receive  fom-  or  five  more  of  the  vegetable  cathartic-ginger-capsicum-and-croton-oil  pills 
and  blue  mass,  and,  if  these  do  not  qmckly  act,  they  should  be  followed  by  four  or  five 
compound  cathartic  pills  and  then  an  ounce  of  Epsom  salt  or  Hunyadi  water  every  half- 
hour  for  four  or  five  doses.  If  in  an  hour  or  two  these  do  not  act,  four  or  five  more  of  the 
vegetable  cathartic  pills,  followed  by  the  salts,  should  be  persisted  in  until  the  bowels  act. 
Lambert  states  that  this  cathartic  treatment  will  appear  to  be  extraordinary,  and  it  is  sur- 
prising that  the  withdrawal  of  the  morphine  does  not  of  itself  produce  a  diarrhea.  The 
inhibition  can  only  be  due  to  the  atropine.  If  by  the  twentieth  hour  the  cathartics  do  not 
act  the  symptoms  of  the  reduction  of  the  morphine,  \'iz.,  sneezing,  nervousness  and  pain, 
come  on  in  full  force,  and  the  patient  begins  to  suffer.  If  the  cathartics  do  act  well,  a  second 
dose  of  morphine  or  opium  should  be  given  of  about  one-third  or  one-sixth  of  what  was 
given  as  the  initial  dose  at  the  beginning  of  the  treatment.  Twelve  hours  after  this  second 
dose  of  morphine  or  opium  the  patient  should  again  have  four  of  the  vegetable  cathartic  pills, 
each  with  ginger  and  capsicum  and  55  of  a  drop  of  croton  oil,  or  four  compound  cathartic 
pills  with  the  5  grains  of  blue  mass,  and  follo-^vang  this  the  stools  will  begin  to  be  green. 
After  the  liquid  green  stools  have  occurred  following  the  thirty-second  hour  cathartic,  an 
ounce  of  castor  oil  should  be  administered,  and  will  cause  the  thick,  green  stool  as  described 
under  alcoholic  treatment.  After  this  movement,  the  patient  feels  suddenly  relaxed  and 
comfortable  and  the  nervousness  ceases.  Most  patients  then  go  to  sleep.  After  the  thirtieth 
hour  of  such  treatment,  and  he  well  says  earlier  if  the  patient  is  in  a  weak  condition,  stimu- 
lation with  strychnine,  from  tt's-iV  of  a  grain,  is  advisable. 


966  INTOXICATIONS— SUNSTROKE 

ism.  is  rare;  it  may  result  from  the  acetate  of  lead  when  given  internally 
or  externally,  and  from  impure  subnitrate  of  bismuth;  its  criminal  use 
is  very  uncommon,  (e)  Predisyosing  factors  are  alcoholism,  age  (from 
thirty  to  forty)  and  sex  (75  per  cent,  are  females,  Olivier) .  Susceptibility 
varies  greatly;  plumbism  may  cause  death  within  a  week  or  may  not 
develop  until  after  forty- two  years  of  work  in  the  metal  (Tanquerel  des 
Planches,  1838).  Absorption  of  lead  usually  occurs  (i)  by  the  digestive 
mucosa;  most  of  the  metal  is  precipitated  by  the  albumin  of  the  food 
and  eliminated  without  absorption;  (ii)  by  the  respiratory  mucosa, 
by  inspiration,  as  dust  in  white-lead  factories;  or  (iii)  by  the  sound  or 
diseased  skin  (cosmetics)  or  even  the  conjunctiva  or  vagina  (lead  douches). 
It  is  eliminated  chiefly  by  the  urine;  Putnam  found  lead  in  25  per  cent, 
of  150  persons  who  had  no  evidence  of  plumbism;  the  liver  and  alimen- 
tary mucosa  eliminate  smaller  quantities. 

I.  Acute  Poisoning. — This  is  uncommon ;  its  symptoms  are  (a)  gastro- 
intestinal; a  styptic,  burning  taste  occurs  in  the  mouth,  thirst  is  present, 
there  is  a  lead  line  on  the  gums  in  some  cases,  though  less  than  in  chronic 
poisoning,  nausea  and  vomiting  sometimes  of  white-lead  chloride,  ab- 
dominal colic,  retraction  of  the  abdomen,  diarrhea  with  black  (lead 
sulphide)  or  bloody  movements  or  sometimes  constipation.  On  post- 
mortem examination,  the  catarrhal  gastro-enteritis  may  be  wrongly 
considered  a  postmortem  change;  Orfila's  white  spots  may  be  seen. 
{h)  Under  circulatory  symptoms,"  the  pulse  may  be  slow  (50  to  20)  and 
irregular;  anemia,  cyanosis  and  collapse  may  occur;  (c)  nervous  symp- 
toms embrace  vertigo,  stupor,  delirium,  neuralgia,  cramps,  convulsions 
and  even  cerebral  and  peripheral  paralyses;  {d)  nephritis  with  suppression 
of  urine  may  develop. 

Treatment. — Treatment  consists  of  full  doses  of  sodium  and  mag- 
nesium sulphate,  in  order  to  precipitate  an  insoluble  lead  sulphate, 
and  to  remove  it,  demulcent  drinks  (eggs  and  mucilages),  opium  for 
pain  and  cardiants. 

II.  Chronic  Poisoning.  —  Symptoms.  —  (a)  Colic,  the  most  common 
symptom,  occurred  in  88  per  cent,  of  Tanquerel's  1390  cases.  It  is  due 
to  local  deposit  of  lead  in  the  intestines,  spasm  of  the  bowel,  changes  in 
the  nerves  or  angiospasm.  It  may  develop  early  or  late;  it  may  be  pre- 
ceded by  malaise,  lumbago,  pain  in  the  legs  or  alcoholic  excesses.  It  is 
accompanied  by  constipation  (dry  colic),  rarely  by  diarrhea;  first  um- 
bilical, it  spreads  over  the  abdomen,  perhaps  to  the  legs  or  scrotum; 
it  is  relieved  by  pressure,  though  sometimes  the  abdominal  wall  is  hyper- 
esthetic;  vomiting  and  absolute  constipation  may  simulate  obstruction, 
and  the  author  observed  intussusception  as  a  result  of  lead  poisoning. 
There  is  no  fever,  the  pulse  is  small  and  hard  and  the  urine  is  scanty. 
Without  treatment  colic  is  protracted;  its  relief  is  usually  marked  by  a 
bowel  movement.  Relapses  are  very  frequent.  (6)  The  gingival  lead  line 
(Burton,  1834),  present  in  over  90  per  cent.,  is  a  gray-black  line,  2  to 
3  mm.  wide,  seen  most  clearly  on  the  lower  gums  and  due  to  deposition 
from  the  blood  of  lead  sulphide,  precipitated  by  the  sulphuretted  hydrogen 
of  the  tartar.  The  coincident  anemia  brings  it  out  very  clearly.  Similar 
deposits  may  occur  under  the  buccal  mucosa  opposite  the  molars.    It  is 


LEAD  POISONING  967 

very  frequently  mistaken  for  tartar,  which  occurs  on  the  teetli,  sometimes 
for  the  black  carbon  line  seen  in  miners,  or  rarely  for  the  dark  line  in 
argyria  or  bismuth  poisoning,  (c)  Other  digestive  symptoms  are  coated 
tongue,  fetid  breath,  parotitis,  saturnine  dyspepsia  and  rarely  icterus. 
Test  meals  show  lactic  acid  and  no  HCl.  (ri)  Anemia  is  very  frequent 
in  the  "lead  cachexia."  The  hemoglobin  and  erythrocytes  decrease 
moderately;  the  red  cells  show  basophile  granules  (Grawitz)  and  quite 
commonly  nucleation,  even  in  mild  cases  (Cadwalader,  1905).  The 
leukocytes  may  be  increased,  (e)  Heart  and  vessels.  The  heart  is  very 
often  hypertrophied,  as  evidenced  by  a  loud  second  aortic  tone  and  aortic 
regurgitation  of  atheromatous  origin;  the  arteries  are  often  sclerosed, 
occasionally  causing  angina  pectoris,  frequently  myocarditis,  irregular 
heart  action  and  perhaps  some  of  the  brain  symptoms  {v.  i.).  The 
asthma  saturninum  is  cardiac  or  uremic.  (/)  The  kidneys  are  often 
sclerotic,  as  a  result  of  the  elimination  of  the  metal;  the  change  does  not 
begin  around  the  vessels  but  in  the  tubules,  which  are  the  seat  of  a 
necrosing  deposit  of  carbonate  of  lime.  Nephritis,  gout  and  plumbism 
may  coexist,  {g)  Nervous  manifestations.  Peripheral  degenerative  neuritis 
occurs  in  7  per  cent.,  usually  as  a  late  symptom;  one-tenth  of  these 
cases  have  not  had  colic.  It  is  characterized  by  the  paralysis  of  muscles 
with  the  same  function,  by  muscular  atrophy  and  cramps,  tremor, 
cutaneous  hyperesthesia,  neuralgia,  arthralgia  (55  per  cent.),  myalgia 
and  by  varying  degrees  of  reaction  of  degeneration.  The  musculospiral 
type,  '' wrist-drop,"  is  the  most  common  and  is  bilateral;  the  supinator 
longus  (a  flexor)  and  the  small  extensor  of  the  thumb  escape  involvement; 
tenderness  and  anesthesia  are  rare.  Gubler's  tumors  are  swellings  of  the 
extensor  tendon  sheaths,  due  to  backward  dislocation  of  the  carpus  or 
perhaps  to  a  trophic  change;  they  are  hard,  ovoid,  indolent,  seldom 
painful  and  regress  with  the  paralysis.  A  second  but  rare  form  is  the 
brachial,  involving  the  deltoid,  biceps,  brachialis  anticus  and  supinator 
longus,  rarely  the  pectorals.  A  third  type  is  the  Aran-Duchenne,  which 
is  especially  observed  in  tailors  and  involves  the  small  muscles  of  the 
hand,  the  thenar  and  hypothenar  eminences;  it  resembles  that  of  chronic 
anterior  poliomyelitis  (which  indeed  has  been  found  in  a  few  cases  at 
autopsy).  A  fourth  type,  the  peroneal,  involves  the  peronei  and  toe 
extensors;  but  13  per  cent,  of  lead  palsies  affect  the  leg.  Lastly,  rare 
types  may  involve  the  larynx,  vagus  and  face;  generalized  paralyses, 
either  slow  or  rapid  like  Landry's  paralysis,  are  very  rare;  primary 
muscular  atrophy  may  occur,  most  often  of  the  Aran-Duchenne  type. 

Cerebral  forms  {encephalopathia  saturnina)  occur  in  5  per  cent.;  they 
are  often  preceded  by  headache,  colic  and  insomnia  and  are  attended  by 
amaurosis,  limitation  of  the  visual  field,  retinitis  albuminurica  or  satur- 
nina (with  inflammation,  engorgement  and  possibly  ultimate  atrophy) 
and  paralysis  of  the  eye  muscles.  The  most  frequent  type  is  the  delirious 
encephalopathy,  which  is  variable  or  mobile  in  character,  and  sometimes 
resembles  delirium  tremens;  the  next  type  is  the  convulsive  (epilepsia 
saturnina)  which  occurs  without  aurae,  is  usually  generalized,  often  fatal 
and  is  always  considered  when  epilepsy  develops  in  an  adult;  the  third 
t^^pe  is  the  comatose.    LTysteria  frequently  occurs  with  plumbic  encephal- 


968  IX  TOXIC  A  TIOXS—SUX  STROKE 

opathy.  Unrecognized  cases  may  become  dements  (pseudodementia 
paralytica  satm-nina).  Deposit  of  lead  in  the  brain  is  tlie  usual  cause; 
sometimes  the  cerebral  sjTnptoms  are  arteriosclerotic  (as  hemiplegia) 
or  uremic. 

Lead  poisonmg  is  usually  diagnosticated  by  the  etiology,  lead  line, 
lead  in  the  urine,  colic  and  wrist-drop.  In  a  case  of  long  coma  with 
choked  disk,  in  the  Cook  County  Hospital,  no  cause  was  found,  until 
after  a  second  examination,  the  lead  line  was  seen.  The  man  was  a 
barber,  who  dyed  the  hair  and  probably  absorbed  the  lead  through  his 
hands. 

Prognosis. — The  acute  forms  are  more  favorable.  Vascular  and  renal 
changes  are  largely  incurable.  Atrophic  paralyses  are  serious.  The 
■^Tist-drop  usually  regresses,  though  it  is  sometimes  permanent;  25  per 
cent,  of  cases  with  coma,  convulsions  and  other  cerebral  symptoms  die; 
after  apparent  recovery  mental  degeneration  ma}'  develop. 

Treatment." — (a)  Prophylaxis.  A  mask  should  be  worn  in  white-lead 
factories  to  avoid  inlialation  of  lead  dust;  workers  are  careless  and 
poisoning  is  frequent  despite  precautions.  Painters  and  others  may  often 
avoid  poisoning  by  carefully  cleaning  the  hands  and  nails  before  eating. 
(6)  Lead  colic  is  treated  by  h^-podermics  of  morphine,  nitroglycerin  and 
atropine  to  control  pain  and  spasm.  Spts.  of  chloroform  (TTLxx)  TAdth 
other  aromatics  may  be  given  by  mouth,  (c)  The  constipatio7i  and  re- 
moval of  any  lead  salts  unabsorbed  in,  or  excreted  by,  the  alimentary 
mucosa  necessitate  catharsis.  Full  doses  of  castor  oil  (3iv  or  more) 
with  paregoric  (3j)  CA'acuate  the  bowels  and  relieve  pain  and  spasm; 
sodium  and  magnesium  sulphates  purge  and  coincidently  precipitate  the 
lead  as  an  insoluble  sulphate,  (d)  To  eliminate  the  lead  from  the  tissues 
'potassium  iodide  should  be  given.  In  acute  or  severe  chronic  cases  it 
should  be  given  in  small  doses  (gr.  iij-v),  for  it  transforms  the  fixed  tissue 
metal  into  free  metal  in  the  circulation;  some  writers  obtain  better  effects 
from  potassium  bromide  (gr.  v-x) .  "Warm  baths  and  pilocarpine  (gr.  |) 
promote  excretion  by  diaphoresis  and  plenty  of  water  stimulates  the 
renal  elimination,  (e)  Iron  (not  arsenic)  should  be  given  for  anemia. 
(/)  For  treatment  of  neuritis,  see  Multiple  Neuritis. 

ARSENICAL  POISONING. 

Acute  poisoning  has  been  considered  under  Pernicious  Anemia. 

Chronic  Poisoning.- — (a)  Criminal  'poisoning  is  of  great  medicolegal 
importance,  as  in  the  unfortunate  Maybrick  case.  (6)  Poisoning  by 
reason  of  occupation  is  uncommon,  (c)  Therapeutic  poisoning  is  not 
common,  but  may  occur  in  chorea,  leukemia  and  pernicious  anemia. 
id)  Most  cases  are  accidental.  The  dyes  in  garments,  toys,  glazed  paper 
used  in  kindergartens,  ^Tappers,  artificial  flowers  and  wail  paper  are 
important  sources  of  intoxication.  The  action  of  moulds  (pencillium 
and  mucor)  may  liberate  volatile  arsenical  gases.  Contaminated  glucose, 
used  in  beer,  caused  the  Manchester  epidemic.  Arsenic  is  absorbed  by 
the  lungs  and  alimentary  tract  and  is  chiefly  eliminated  by  the  kidneys, 
which  may  degenerate.    Putnam  found  arsenic  in  the  urine  of  30  per  cent. 


FOOD  POISONING  969 

of  persons  who  showed  no  other  symptoms  of  arsenical  poisoning.  Arsenic 
is  widely  found  in  plants,  sea  water  and  springs.  Smaller  amounts  are 
eliminated  by  the  bowel,  milk  and  other  secretions. 

Symptoms. — ^The  symptoms  are  (a)  gastro-intestinal,  as  dry  throat, 
vomiting,  purging  or  colic;  the  "rice-water"  stools  contain  flecks  of 
mucus;  and  (b)  respiratory,  as  dry  cough  or  chronic  bronchitis,  (c) 
Emaciation,  weakness,  fever  and  anemia  may  occur,  {d)  Cutaneous 
symptoms,  as  erythema,  keratosis,  pemphigus,  herpes  and  brown  pig- 
mentation and  (e)  nervous  manifestations,  as  weak  memory,  vertigo, 
headache  and  multiple  neuritis  may  develop.  The  neuritis  has  the  same 
general  features  as  the  saturnine  form,  but  sensory  changes  are  more 
frequent  an,d  the  legs  are  more  often  affected  than  the  arms;  paralj^sis 
of  the  peronei  and  foot  extensors  causes  the  "  steppage"  gait.  The  small 
muscles  are  less  often  affected  than  in  plumbic  or  alcoholic  neuritis; 
paralysis,  ataxia,  trophic  disturbances  and  the  reaction  of  degeneration 
occur  as  in  other  neuritides. 

Treatment. — Treatment  is  that  of  lead  poisoning  or  neuritis. 

FOOD  POISONING. 

Bromatotoxismus  (Vaughan)  exists  in  several  forms: 

I.  Meat  Poisoning  (Kreatoxismu^) . — Sausages  and  head  cheese  are 
more  dangerous  than  beef  or  mutton.  Sausage  poisoning  (botulism 
or  allantiasis)  was  known  in  Germany  a  century  ago.  Van  Ermingem 
isolated  an  anaerobic  organism,  the  Bacillus  hotulinus;  it  contains  spores, 
is  flagellated  and  motile  and  grows  only  on  alkaline  media  at  a  low 
temperature  (18°  to  35°  C.) ;  it  is  a  saprophyte  and  causes  symptoms  by 
its  toxins,  which  are  not  destroyed  by  the  gastric  juice.  Paratyphoid 
organisms  were  found  by  Durham  (1900).  Meat  may  taste  and  smell 
normal  yet  contain  ptomaines;  their  nature  is  still  undetermined,  though 
Cobert  considers  them  promatropin.  Canned  meat  has  often  caused 
severe  symptoms.  In  instances  botulism  was  caused  by  eating  salad 
and  beans. 

Symptoms. — The  symptoms  of  botulism  appear  in  twelve  to  forty- 
eight  hours,  with  nausea,  vomiting  and  sometimes  diarrhea.  In  the 
Wellback  cases  Ballard  noted  as  early  symptoms  headache,  chilliness 
or  rigors  and  pains  in  the  chest  or  back.  Paralysis  of  the  soft  palate, 
larynx  and  esophagus  rapidly  develop  and  somewhat  later  paralysis  of 
the  bowel,  or  symptoms  like  atropine  poisoning,  mydriasis,  ptosis, 
disordered  vision,  adynamia  and  weak  heart  action;  the  sensorium  is 
clear  and  fever  is  unusual.  The  mortality  ranges  between  20  and  50  per 
cent.;  death  occurs  in  four  to  ten  days  and  the  autopsy  shows  parenchy- 
matous degenerations  and  ecchymoses,  but  especially  degeneration  of  the 
ganglionic  cells,  as  those  of  the  vagus  or  oculomotorius;  if  the  patient 
survives,  convalescence  is  established  only  after  months. 

The  symptoms  of  other  forms  of  meat  poisoning  are  either  toxemic 
(typhoid  type)  or  gastro-intestinal  (cholera  type) ;  the  typhoidal  symptoms, 
which  appear  after  an  incubation  of  four  to  six  days,  are  fever,  status 
typhosus  and  even  roseolse;  the  choleriform  symptoms,  which  develop 


970  IXTOXICA  TIONS— SUNSTROKE 

in  two  to  twelve  hours,  are  vomiting,  incessant  purging,  watery  stools, 
clammy  skin,  collapse  and  cyanosis.  Acute  meningitis  may  be  simulated 
exactly  (A.  D.  Dunn).    Mild  forms  occur  in  most  epidemics. 

Treatment. — Early  gastric  lavage,  colonic  flushings  and  purgation  are 
indicated;  calomel  followed  by  castor  oil  is  the  best  aperient.  Otherwise 
s\TQptomatic  medication,  as  in  cholera  or  tj^hoid,  is  indicated;  cham- 
pagne, strychnine,  h^^jodermocylsis  and  opium  may  be  given.  The 
resemblance  of  botulism  to  the  diphtheria  toxins  has  suggested  the 
use  of  antitoxme;  its  effects  in  animals  have  been  remarkable,  but  to 
the  author's  knowledge  it  has  not  been  used  in  man. 

n.  Poisoning  by  Milk. — Galactotoxismus  produces  symptoms  analog- 
ous to  those  of  the  infantile  affections  of  the  bowel,  as  vomiting,  bloody 
diarrhea,  fever  and  collapse.  In  cheese  poisoning  Vaughan  found  tyro- 
toxicon  and  other  more  frequent  toxins,  probably  albumoses.  Similar 
ptomaines  were  fomid  in  refrozen  ice-cream  and  custard.  In  Norway 
where  t\Totoxismus  is  most  prevalent,  the  colon  bacillus  has  been  re- 
peatedly found.  Home-made  cheese  is  more  dangerous  than  the  factory 
product.  Various  forms  of  toxemia  result;  some  are  cholera-like  and 
others  resemble  belladonna  poisoning.    Treatment  is  that  of  kreatoxismus. 

m.  Poisoning  by  Fish  {Ichthyotoxismus)  and  Shell-fish  (Mytilo- 
toxismus). — (a)  Ichthyotoxismus,  described  by  Comby  (1827),  may  be 
caused  by  poisonous  fish  or  poisonous  glands  in  certain  fish,  as  the  roe 
or  testicles,  the  muscular  parts  being  harmless;  the  barbel  in  Europe 
and  the  tetrodon,  diodon  and  fugu  in  Asia  are  poisonous  {d.  Beriberi). 
The  poisoning  due  to  putrefaction  is  more  common.  Parah1:ic  symptoms, 
like  curare  poisoning,  are  most  frequent,  (h)  Mussel  poisoning  (mAi:ilo- 
toxismus)  may  cause  dyspeptic  s\Tnptoms  in  mild  infections  and  cholera- 
like SATnptoms  or  symptoms  of  belladonna  poisoning  in  severe  forms. 
Rashes  are  common.  Brieger  isolated  a  mj-tilotoxin,  which  is  found 
largely  in  the  liver.  The  danger  lies  in  placing  mussel-  or  oyster-beds 
near  river  mouths,  so  that  they  feed  on  poisonous  excreta.  In  restaurants 
certain  glands  near  the  heads  of  lobsters,  considered  toxic,  are  carefully 
excised. 

IV.  Grain  Poisoning  (Sitotoxismus). — 1.  Ergotism. — Ergotism  (Thuil- 
lier,  1830,  and  Tiiczek,  lS79j  results  from  eating  grain  mixed  with  the  ergot 
fungus  fclaviceps  purpurea).  Ergotized  grain  is  found  largely  in  bad 
harvests,  resulting  from  wet  springs  and  hot  summers.  Epidemics  have 
occurred  in  Europe,  and  sporadic  cases  are  not  rare.  Acute  ergotism, 
with  digestive  SAHiptoms,  colic,  cyanosis,  weak  heart  and  generally 
lethal  outcome  is  less  common  than  chronic  ergotism,  of  which  two  forms 
exist;  the  first  is  the  convulsive  form,  attended  by  paresthesia,  lightning 
pains,  headache,  delirium,  melancholy,  dementia,  muscular  relaxation, 
generalized  epileptiform  attacks  or  local  muscular  contractures  (flexion 
of  the  arms  and  extension  of  the  toes  and  feet) ;  it  is  said  to  result  from 
the  alkaloid  cornutin.  The  second  jorm  is  the  gangrenous,  due  to  spha- 
celinic  acid  and  marked  by  locahzed  gangrene,  usually  in  the  phalanges 
and  less  often  in  the  tips  of  the  ears  and  nose.  Chronic  ergotism  is 
characterized  by  a  number  of  symptoms  which  suggest  tabes,  as  lightning 
pains,  ataxia  of  station  and  movements,  and  lost  knee-jerks;  and  in  five 


PELLAGRA  971 

autopsies  Tiiczek  and  Siemens  found  degeneration  with,  later,  sclerosis 
of  the  posterior  columns;  degeneration  in  the  anterior  cornua,  and  minute 
foci  of  softening  or  hemorrhage  also  occur.  The  clinical  course  is  chronic 
and  death  is  frequent  from  convulsions  or  cachexia. 

Treatment. — Treatment  includes  avoidance  of  diseased  grain  and 
opium  for  convulsions  and  nitroglycerin  for  gangrene. 

2.  Lathyrism  {Lupinosis). — Lathyrism  is  produced  by  meal  made 
from  vetches,  chiefly  the  lathyris  sativus  and  cicera.  Irving  described 
the  disease  in  India  and  it  has  been  seen  also  in  Algiers  and  Italy.  It 
probably  produces  a  lateral  and  possibly  some  posterior  sclerosis  of  the 
cord,  though  no  autopsies  are  reported.  Clinically  there  is  a  spastic 
paraplegia  with  increase  of  reflexes  and  some  paresthesia. 

V.  Potato  Poisoning. — Solanin  is  contained  in  potatoes  in  small 
amounts  (0.06  per  cent.)  but  larger  amounts  (0.4  per  cent.)  occur  in 
potatoes  which  lie  for  some  time  in  the  ground  or  sprout  in  cellars  (Bact. 
solaniferum).  Fever,  chills,  general  or  cardiac  weakness,  vomiting, 
diarrhea  and  jaundice  may  develop. 

PELLAGRA. 

A  disease  with  periodic  alimentary  disturbance,  skin  lesions  and 
changes  in  the  nervous  system. 

Etiology. — ^The  older  theory  ran  that  maidism  was  a  chronic  nutritional 
or  toxic  affection  due  to  the  use  of  corn  or  maize,  which  was  unripe, 
decayed  or  infected  with  the  aspergillus  or  other  moulds.  The  present 
tendency  is  to  regard  it  as  an  infection.  The  disposing  etiology  is  "  peasant 
life,  poverty  and  polenta"  (corn).  It  is  endemic  in  Italy,  Roumania, 
France,  Spain  and  Mexico  and  the  United  States  where  there  were 
30,000  to  50,000  cases  in  the  six  years  before  1913.  The  first  authentic 
description  dates  from  Casal,  of  Spain  (1735).  The  name  is  derived  from 
pelle  (skin)  and  agra   (rough). 

Prodromal  symptoms  develop  in  the  spring  and  include  lassitude, 
vertigo,  headache,  anorexia,  coated  tongue,  vomiting,  epigastric  pain  and 
diarrhea.  There  is  seldom  fever.  The  mrnal  erythema  appears  largely 
on  the  exposed  parts,  face,  hands  and  neck,  possibly  initiated  by  the 
sun's  rays.  The  circlet  of  eruption  on  the  neck  is  very  characteristic. 
The  hands  are  most  commonly  and  characteristically  involved,  the  palms 
generally  being  exempt.  The  eruption  is  a  dull  red,  like  sunburn,  fades 
on  pressure  and  may  become  macular.  The  color  then  deepens  to  a 
livid  blue,  ending  in  desquamation  and  pigmentation.  More  rarely 
vesiculation,  crustation,  fissuring  and  suppuration  develop.  Recurrence 
occurs  the  next  spring  (in  Italy)  or  the  same  fall  (in  the  United  States) 
and  leaves  the  skin  atrophic,  parchment-like,  perhaps  ulcerated  or 
ecchymotic. 

Nervous  Symptoms. — The  prodromal  symptoms  {v.  s.)  intensify  and 
the  skin  may  become  so  h^'peresthetic  as  to  induce  suicide.  The  patellars 
vary.  Babinski's  sign  may  be  observed.  Mental  depression  occurs  in 
most  cases;  stupor,  hallucinations,  etc.,  may  develop;  10  per  cent, 
become  insane.     There  are  severe  pains  in  the  back  but  the  most  char- 


972  INTOXICATIONS— SUNSTROKE 

acteristic  symptom  is  the  ataxic  paraplegia;  autopsies  reveal  a  postero- 
lateral sclerosis,  sometimes  with  atrophy  of  the  anterior  horns,  lepto- 
meningitis and  variable  brain  findings.  In  some  cases  mydriasis,  cataract, 
paralysis  of  the  eye  muscles,  optic  neuritis  and  choroiditis  develop. 

Digestive  symptoms  commence  in  the  prodromal  stage.  Stomatitis, 
the  stipple-tongue  (with  black  pigment),  vomiting,  pyrosis,  meteorism 
and  severe,  even  dysenteric,  diarrhea  increase  the  discomfort  and  lead  to 
prostration  and  emaciation.  There  is  slight  anemia,  with  some  increase 
of  the  large  mononuclears,  very  few  eosinophiles  and  no  leukocytosis. 
The  mortality  is  35  per  cent. 

The  rarer  acute  cases  may  resemble  typhoid  in  symptoms  and  pathology 
(status  typhosus  and  swelling  with  ulceration  of  the  intestinal  lymph 
structures),  or  meningitis  (foci  of  acute  meningomyelitis).  Other  findings 
at  autopsy  are  atrophy  of  the  digestive  mucosa,  parenchymatous  de- 
generation and  pigmentation,  the  latter  of  which  is  thought  to  occur 
from  adrenal  inflammation. 

Treatment. — Treatment  is  prophylactic  (proper  storage  of  the  grain); 
change  of  diet  or  of  locality  is  indicated  and  arsenic  should  be  given 
internally. 

BERIBERI. 

Definition. — Beriberi  or  polyneuritis  endemica  (Balz,  Scheube)  is  an 
endemic  and  epidemic  affection  of  the  tropics  and  subtropics,  of  un- 
known etiology,  characterized  anatomically  by  degenerative  inflammation 
of  the  peripheral  nerves,  and  clinically  by  motor  and  sensory  disturbances, 
anasarca  and  cardiac  disturbance.  Beri  signifies  a  sheep's  gait,  and 
kakke  means  disturbance  of  the  gait. 

History. — Beriberi  is  mentioned  in  the  oldest  Chinese  writings  and 
was  observed  in  the  Roman  legions,  24  B.C.,  by  Strabo  and  Cassius. 
In  the  seventeenth  century,  beriberi  was  noted  in  Brazil  and  the  Malay 
archipelago;  in  recent  times  it  has  been  described  in  India,  Japan,  the 
Dutch  Oriental  colonies  and  in  this  country. 

Distribution. — The  main  foci  of  beriberi  are  (1)  the  Malay  archipelago, 
Sumatra,  Borneo  and  Java;  also  China,  India,  the  Philippines,  Japan 
and  even  Australia.  The  mortality  was  very  high  among  the  Chinese 
coolies  in  the  Dutch  possessions.  (2)  Africa,  including  the  mainland 
and  adjacent  islands.  (3)  America  and  the  West  Indies,  Brazil,  Hon- 
duras and  Cuba.  Scheube  doubts  that  the  cases  in  the  epidemic  at 
Tuscaloosa,  Alabama,  were  beriberi,  but  they  apparently  were  Oriental 
beriberi.  Cases  appeared  in  Dublin  (1894-1898,  with  forty-two  deaths), 
in  England  and  in  Paris. 

Etiology. — ^There  are  two  distinct  views:  (1)  That  it  is  an  acute  in- 
fection (Balz,  Scheube);  the  same  telluric  conditions  promote  beriberi 
which  promote  malaria.  In  80,000  cases  among  the  Japanese  troops 
in  the  Russo-Japanese  War,  Kokubo  frequently  found  a  coccus.  (2)  The 
second  view  is  that  beriberi  results  from  food.  Polished  rice  loses  its 
pericarp,  in  which  there  is  some  vital  substance  the  loss  of  which  causes 
beriberi;  polished  or  milled  rice  causes  polyneuritis  in  fowl;  and  in  the 
disease,  the  feeding  of  the  pericarp  is  curative.    Natives  are  more  often 


BERIBERI  973 

affected  than  Europeans,  and  males  more  frequently  than  females. 
In  1879  there  were  8197  cases  in  Japan  and  in  1891,  only  1.  Poor  food, 
overcrowding  and  lack  of  hygiene  are  important  factors. 

Symptoms. — The  incubation  is  several  months.  The  symptoms  are 
threefold : 

1.  Neuritic  Symptoms. — A  more  detailed  description  of  these  s}'mp- 
toms  has  been  given  under  Multiple  Neuritis.  Anatomically,  there  is 
the  same  symmetrical  degeneration  or  inflammation  in  the  distal  parts 
of  the  peripheral  nerves,  but  also  often  in  the  phrenic  and  pneumogastric 
nerves  and  the  cardiac,  renal  and  solar  plexuses;  the  nuclei  of  the  sheath 
multiply;  the  axis-cylinders  degenerate;  there  is  a  lumpy  degeneration 
in  the  medullary  sheath  and  later,  a  connective-tissue  hypertrophy. 
In  8  cases  there  were  degenerative  changes  in  the  cord,  anterior  horns 
and  posterior  ganglia.  Clinically,  the  onset  is  gradual  and  the  course 
chronic. 

(a)  Motor  Symptoms. — The  muscles  of  the  calves,  the  knee  extensors 
and  the  abductors  and  flexors  of  the  thigh  are  weakened,  flaccid,  swollen 
and  atrophied.  The  muscles  are  more  frequently  tender  than  the  nerve 
trunks.  In  severe  cases  the  trunk,  arms  and  even  the  face  are  involved. 
Anatomically,  the  muscles  are  degenerated.  Phrenic  weakness  and  vagus 
symptoms,  such  as  rapid  heart,  vomiting,  epigastric  oppression  or 
digestive  disorder  are  not  infrequent;  the  lungs  are  sometimes  acutely 
emphysematous,  from  involvement  of  the  pulmonary  plexus.  Laryn- 
geal, glossopharyngeal,  hypoglossal  or  ocular  participation  is  more  rare. 
Cramps  and  fibrillary  contractions  are  frequent,  but  ataxia  is  uncommon, 
although  the  name  beriberi  refers  specifically  to  disturbed  locomotion. 
The  gait  is  described  as  like  that  of  one  walking  in  wet  clothes  or  wading 
in  water. 

(b)  Sensory  Syinptoms. — Paresthesia  is  common.  Hypesthesia  is 
most  marked  in  the  distal  parts,  though  the  soles  are  exempt;  it  is  more 
frequent  than  anesthesia,  which  is  rarely  complete.  Hyperesthesia  may 
occasionally  occur  over  the  spine  and  abdomen.  Pains  over  the  joints 
and  intercostal  spaces  are  quite  common. 

(c)  Trophic  Symptoms. — ^These  are  uncommon.  They  include  joint 
relaxation,  herpes  or  skin  atrophy. 

id)  Reflexes. — The  skin  refiexes  are  seldom  abolished.  Reduction 
of  the  tendon  reflexes  develops  equally  with  the  paralysis. 

ie)  Degeneration. — Slight  reaction  of  degeneration  is  common  and  may 
be  marked  in  severe  cases.    It  occurs  particularly  in  the  leg. 

2.  Dropsy. — Dropsy  occurs  in  97  per  cent,  of  cases  and  is  invariably 
in  fatal  cases;  it  may  be  marked  in  the  legs  and  face.  It  is  most  severe 
in  the  pericardium,  quite  severe  in  the  pleurae,  and  least  severe  in  the 
peritoneum.  It  is  caused  by  cardiac  and  perhaps  also  by  vasomotor 
involvement. 

3.  Cardiac  Insufficiency. — In  acute  cases,  death  may  result  in  a 
day,  and  65  per  cent,  of  acute  cases  terminate  fatally  within  two  weeks. 
There  is  palpitation,  cardiac  or  epigastric  oppression  or  pain;  tachy- 
cardia, dyspnea  and  cyanosis  develop;  the  right  ventricle  is  hypertrophied 
and  dilated;  the  first  apical  tone  is  weak;  there  is  splitting  of  the  heart 


974  INTOXICATIONS— SUNSTROKE 

tones,  gallop-rhythm,  and  systolic  or  even  diastolic  functional  bruits; 
the  urine  is  decreased  in  amount;  the  liver  is  turgid.  Anemia  is  marked 
and  the  leukocytes  may  be  increased.  Acute  pulmonary  edema  is  usually 
fatal.    The  heart  muscle  is  pale,  friable,  colloid  or  inflamed. 

The  types  of  beriberi  only  accentuate  the  above-named  symptoms: 
(1)  The  nidimentary  form  may  begin  with  fever  and  catarrh  of  the  air 
passages  and  alimentary  tract.  There  is  a  slight  edema  of  the  ankles, 
muscular  weakness,  especially  in  the  legs,  and  muscular  tenderness, 
paresthesia  and  palpitation.  (2)  The  atrophic  form  is  marked  by  atrophic 
paralysis.  If  edema  does  not  develop,  these  types  are  called  "dry  forms." 
(3)  The  dropsical  form  is  characterized  by  much  transudation  and  pro- 
nounced insufficiency  of  the  heart.  (4)  The  acute  cardiac  or  pernicious 
form  (i).  s.). 

Diagnosis. — The  leading  points  are  the  multiple  neuritis,  most  marked 
in  the  legs;  vagus  neuritis  and  cardiac  insufficiency;  and  dropsy. 

Prognosis. — In  Japan  and  the  Dutch  Indies  the  death-rate  is  3  or  4 
per  cent.;  in  Brazil  it  formerly  reached  50  to  75  per  cent.,  and  in  the 
Malay  archipelago,  40  to  50  per  cent.  Death  results  primarily  from  heart 
failure,  secondarily  from  paralysis  of  respiration,  less  frequently  from 
uremia,  pulmonary  embolism,  aspiration  pneumonia,  dysentery,  tuber- 
culosis or  marasmus.  Even  in  recovery,  permanent  residua  are  common, 
such  as  weakness,  or  obstinate  contractures  of  the  legs,  absence  of  knee- 
jerks  and  cardiac  instability  and  hypertrophy.  In  43  per  cent,  of  the 
fatalities  there  is  a  sudden  death.     Recurrences  are  common. 

Treatment. — In  the  early  stages,  purgation  and  salicylates  are  bene- 
ficial. In  the  later  stages,  electrotherapy  and  other  measm-es  employed 
in  multiple  neuritis  (q.  v.)  are  indicated.  Venesection  relieves  the  over- 
laden right  heart  and  dyspnea,  and  promotes  action  of  the  kidneys. 
Digitalis  frequently  fails  when  the  vagus  is  degenerated;  in  dropsical 
forms  it  is  helpful,  as  is  caffeine.  The  ice-bag  over  the  heart,  bromides 
and  belladonna  may  mitigate  cardiac  unrest  and  palpitation. 

ILLUMINATING-GAS  POISONING. 

Illuminating  gas  contains  H,  hydrocarbons  and  CO.  Steam  is  forced 
through  the  hot  coke  in  the  manufacture  of  the  gas  and  methane,  ethane, 
and  benzene  are  added.  Water-gas  contains  45  per  cent.  CO.  Alcoholism, 
the  increasing  difficulty  in  procuring  morphine  and  other  poisons,  igno- 
rance and  carelessness  cause  many  deaths  yearly. 

Symptoms  are  due  to  close  union  of  the  gas  and  the  hemoglobin, 
abolition  of  gaseous  interchange,  a  particular  action  of  the  poisons  on 
the  nervous  system,  and  absence  of  oxidation  of  the  waste  substances 
of  the  body.  Respiration:  The  breathing  is  rapid,  loud,  stertorous  and 
often  of  the  Cheyne-Stokes's  type.  W.  G.  Thompson  gives  the  average 
number  of  respirations  30;  they  were  62  in  one  non-fatal  and  80  in  a  fatal 
cases.  The  mouth  is  covered  with  froth  which  is  often  blood}'.  In 
fatal  cases,  there  is  found  pulmonary  congestion  and  edema;  sometimes 
bronchopneumonia,  atelectasis  and  emphysema.  Circulation:  The  pulse 
is  disproportionately  rapid  (120-140),  considering  the  fever  and  respi- 


SUNSTROKE  975 

ration,  feeble  and  often  irregular.  The  cherry-red  blood  is  notorious. 
W.  G.  Thompson  noted  leukocytosis,  even  50,000;  in  his  fatalities,  the 
white  cells  exceeded  18,000  but  patients  with  higher  counts  may  recover. 
The  hemoglobin  is  decreased  to  70  per  cent,  or  lower  (20  per  cent.). 
G.  J.  Jones  noted  reduction  of  the  reds  to  1,000,000,  often  wdth  poly- 
chromatophilia;  contrary  to  Thompson's  report,  he  finds  no  increase  of 
the  red  cells. 

Nervous  Symptoms. — Coma  ranks  first.  In  most  poisonings  it  is  pro- 
found; enduring  over  forty-eight  hours,  the  outlook  is  generally  unfavor- 
able, yet  Kinnicutt  reports  recovery  after  two  weeks  of  coma.  Of  Thomp- 
son's series,  80  per  cent,  of  comatose  cases  recovered.  The  pupils  are 
usually  small  and  immobile  but  may  vary  or  dilate.  Muscular  twitch- 
ings,  convulsions,  delirium,  opisthotonos,  rigidity,  increased  reflexes  and 
incontinence  are  common.  Postmortem  findings  include  intense  cerebral 
congestion,  cerebral  apoplexy,  serous  leptomeningitis,  disseminated 
encephalitis,  encephalomyelitis,  multiple  neuritis  and  cerebral  thrombosis 
with  softening  in  the  internal  capsule  and  lenticular  nucleus  (Kolisko). 
Acute  mania  and  paralyses  may  regress  after  days  or  months.  Gangrene 
of  the  legs  may  ensue. 

Vomiting  is  occasional  and  dryness  of  the  mouth  the  rule.  The  skin 
is  generally  cold,  dry,  cyanotic  but  may  be  clammy;  in  fatal  cases  Jones 
observed  serous  blebs.  The  temperature,  at  first  subnormal,  in  nearly 
all  cases  rises  after  twelve  to  eighteen  hours  to  99°  or  103°;  high  fever  is 
usually  fatal  in  one  to  three  days  but  W.  A.  Steele  records  recovery  with 
110°  and  a  pulse  of  215.  Glomerulonephritis  is  common.  The  urine  is 
high  in  specific  gravity  and  the  nitrogen  is  increased. 

Therapy. — Fresh  air  and  oxygen  inhalations  seem  rational  but  actually 
are  seldom  efficacious.  The  tongue  is  held  out  and  occasionally  gently 
pulled.  Artificial  respiration  is  indicated.  Robin  Advises  the  sitting 
posture  but  it  is  difficult  to  see  how  it  is  practicable.  The  skin  should  be 
kept  warm.  Atropine,  gr.  y^,  and  adrenalin,  TTlxxx,  are  indicated  but 
vasodilators,  as  nitroglycerin,  are  always  injurious.  Venesection  fol- 
lowed by  normal  salt  solution,  given  subcutaneously  and  repeated  in 
urgent  cases,  is  helpful. 

SUNSTROKE. 

The  difference  between  the  two  forms,  (1)  sunstroke,  and  (2)  heat 
exhaustion,  was  first  recognized  by  Dowler,  of  New  Orleans. 

Sunstroke,  also  known  as  siriasis,  insolation,  coup  de  soliel  and  thermic 
fever,  is  due  to  exposure  to  the  sun.  A  very  frequent  factor  is  alcoholism. 
There  is  thought  to  be  a  paralysis  of  the  bulbar  heat  centres,  leading  to 
excessive  production  of  heat  and  deficient  elimination  of  it.  The  theory 
of  infection  has  also  been  advanced. 

Symptoms. — Symptoms  may  develop  very  abruptly  and  cause  early 
or  even  immediate  death  from  asphyxia  and  paralysis  of  the  heart; 
this  type  was  long  confused  with  apoplexy.  In  most  cases  there  is  an 
interval  lasting  from  a  few  minutes  to  an  hour,  in  which  there  are 
headache,  vertigo,  visual  disturbances,  nausea,  and  perhaps  vomiting 
before  coma  intervenes. 


976  INTOXICATIONS— SUNSTROKE 

During  the  coma  which  develops  rapidly,  and  in  which  the  physician 
usually  sees  the  patient,  the  following  signs  are  observed:  the  face  is 
first  flushed,  later  rather  cyanotic,  and  sometimes  stained  with  petechiee. 
The  preliminary  pupillary  dilatation  passes  into  myosis  and  the  skin  has  a 
peculiar  odor.  The  pulse  usually  exceeds  100,  and  is  bounding.  The  rectal 
temperature  ranges  from  107°  to  112°  and  respiration  is  deep,  labored 
and  stertorous.  Save  for  the  laboring  chest,  the  patient  is  usually  quiet; 
about  25  per  cent,  of  the  author's  patients  struggled  during  treatment 
by  the  cold  bath  and  about  20  per  cent,  of  the  severe  cases  had  epilepti- 
form convulsions.  Lewis  and  Packard  (1901)  in  92  cases  found  con- 
vulsions and  unconsciousness  in  all  severe  cases;  immobile  pupils  and 
absent  knee-jerks  were  common.  Involuntary  evacuations  are  usual  and 
the  thin  feces  have  a  peculiar  odor.  There  is  a  leukocytosis  in  about 
75  per  cent,  of  the  cases.  Recovery  is  frequent;  consciousness  returns 
and  the  fever  falls.  Despite  treatment,  the  Cheyne-Stokes's  breathing 
may  develop,  the  pulse  may  grow  smaller  and  more  rapid,  and  death  may 
follow,  usually  in  a  little  more  than  a  day.  The  autopsy  shows  early 
rigor  mortis,  fluidity  of  the  blood,  great  venous  hyperemia,  particularly 
in  the  brain  and  lungs,  and  dilatation  of  the  right  and  contraction  of 
the  left  ventricle. 

After  sunstroke  the  patient  becomes  extremely  susceptible  to  hot 
weather.  Epilepsy,  multiple  neuritis  and  mental  symptoms  are  among 
its  after-effects.  The  author  saw  one  case  with  a  temperature  of  109° 
in  which  the  fever  fell  with  hydrotherapy  but  rose  to  104°;  in  a  few  days 
the  trouble  was  recognized  as  typhoid. 

Diagnosis. — ^The  diagnosis  is  easily  made.  Practically,  there  is  but 
one  possible  cause  of  confusion,  pontine  hemorrhage,  but  the  latter 
never  develops  nearly  as  high  a  temperatm-e  and  death  is  almost  in- 
stantaneous; should  the  patient  survive,  paralysis,  usually  of  the  crossed 
type,  is  obvious. 

Heat  exhaustion  may  result  from  exposure  to  the  sun  or  to  high  tem- 
perature with  humidity;  the  cases  seen  by  the  writer  came  largely  from 
laundries,  basement  stores  or  engine-rooms;  heat  exhaustion  occurs  also 
among  stokers  on  steamers.  The  symptoms  are  those  of  a  centric  vaso- 
motor paralysis.  The  skin  is  cool  and  livid,  rather  than  red,  and  the  rectal 
temperature  is  often  3°  or  4°  subnormal;  the  pulse  is  rapid  and  weak  and 
the  breathing  is  rapid  but  not  labored.  In  short,  the  symptoms  of  collapse 
are  present.  Restlessness,  anxiety  and  sometimes  delirium  are  noted, 
though  the  sensorium  is  practically  normal  in  most  cases. 

Treatment. — In  sunstroke  the  chief  indication  is  reduction  of  the 
retained  heat,  by  immersing  the  patient  in  a  hath  gradually  cooled  by  large 
pieces  of  ice.  Shock  is  averted  by  this  means;  cerebral  congestion  is 
lessened  by  placing  a  block  of  ice  under  the  neck,  an  ice-bag  on  the  vertex 
and  an  ice-bladder  over  the  anterior  neck;  active  friction  of  the  body 
and  limbs  with  the  open  hands  brings  to  the  surface  the  blood,  which  is 
cooled  by  the  bath  and  the  rubbing  with  pieces  of  ice.  With  this  treat- 
ment, few  more  than  one-third  of  the  cases  should  die.  The  patient 
should  be  taken  from  the  bath  when  his  rectal  temperature  is  102°, 
for  the  fall  usually  continues  after  cessation  of  treatment.    Laxatives 


SUNSTROKE  977 

are  generally  unnecessary,  for  the  bowels  move  freely.  Heart  stimulants 
should  be  given  pro  re  nata.  For  convulsions,  a  little  chloroform  by 
inhalation  and  a  hypodermic  of  morphine  are  indicated.  Asphj^xia  and 
distention  of  the  right  heart  are  relieved  by  phlebotomy. 

In  heat  prostration  the  treatment  is  diametrically  the  opposite;  a 
warm  bath  or  hot  bricks  for  subnormal  registration,  diffusive  cardiants, 
as  ammonia,  camphor  and  strychnine,  saline  solutions  under  the  skin 
and  applications  of  mustard  are  indicated;  cold  and  venesection  are 
obvioush'  contra-indicated. 


62 


INDEX. 


Abdominal  pain,  causes  of,  547,  563 
in  pneumonia,  73 
in  typhoid  fever,  36 
Abortion  in  diabetes,  732 

in  syphilis,  221 

in  typhoid  fever,  40 
AbouKa,  hysterical,  907 
Abscess  of  brain.     See  Brain,  abscess  of 
cold,  148 

extradural,  differentiation  of,  802 

of  liver.     See  Liver,  abscess  of. 

of  lung.     See  Lung,  abscess  of. 

perinephric,  654 

subphrenic,  611 

differentiation  of,  465,  472 
Acetanilide,  599,  943 
Acetonuria,  diabetic,  728,  730,  735 
Acetphenetidin,  50,  57,  106,  412,  741 
Achlorhydria,  502,  503 
Achondroplasia,  956 
Achylia  gastrica,  503 

etiology  of,  503 
pathology  of,  503 
prognosis  of,  503 
symptoms  of,  503 
treatment  of,  503 
"Acid-fast"  bacilli,  165,  411 
Acidosis,  diabetic,  728,  730,  735 
Aconite,  268,  412 
Acoria,  533 
Acrodynia,  290 
Acromegaly,  720 

course  of,  721 

diagnosis  of,  721 

differentiation  of,  721 

etiology  of,  720 

prognosis  of,  721 

symptoms  of,  720 

treatment  of,  721 
Acroparesthesia,  944 
Actinomycosis,  193 

diagnosis  of,  195 

digestive  tract,  194 

etiology  of,  193 

forms  of,  193 

head  and  neck,  193 

incubation  in,  193 

parapleuritis,  195,  462 

respiratory  tract,  195 

treatment  of,  195 
Acupuncture,  905,  950 
Adams-Stokes's  syndrome,  342 
Addison's  anemia,  672 


Addison's  disease,  701 
course  of,  703 
diagnosis  of,  703 
differentiation  of,  704 
etiology  of,  701 
symptoms  of,  702 
treatment  of,  704 
Adenia,  687 
Adenitis,  bronchial,  169 

cervical,  169 
Adenoids,  488 

Adhesions  in  gastric  ulcer,  514 
Adhesive  plaster,  466 
Adiamorrhysis,  764 
Adipose  ascites,  617 
Adiposis  dolorosa,  747 

pathology  of,  747 
symptoms  of,  747 
treatment  of,  748 
Adiposity,  746 
Adrenal  glands,  diseases  of,  701 

insufficiency  in  typhoid,  41 
Adrenalin,  77,  88,  89,  110,  189,  704,  411, 

430,  702,  704 
Aerophagia,  531 
African  lethargy,  246 
Agar-agar,  560 
Agaricin,  188 
Ageusia,  881 
Agraphia,  755,  756 
Ague-cake  in  malaria,  236 
Ainhum,  947 

Air,  fresh,  in  tuberculosis,  184 
Albumin  in  urine,  644 
Albuminuria,  644 

albumose,  646 

Bence-Jones,  646 

diabetic,  729 

diagnosis  of,  646 

diphtheritic,  83 

etiology  of,  645 

genuine,  644 

globulin,  644 

in  malaria,  237 

mucin,  646 

in  nephritis,  620,  625,  628 

nucleo-albumin,  646 

peptone,  646 

in  pneumonia,  70 

prognosis  of,  646 

renal,  644 

rheumatic,  285 

scarlatinal,  264 

spurious,  644 

syphilitic,  207 


980 


INDEX 


Albuminuria,  tests  for,  645 
boiling,  645 
ferrocyanide,  646 
JoUes's,  646 
nitric  acid,  645 
■  Spiegler's,  646 
in  tuberculosis,  168 
in  typhoid  fever,  40 
in  yellow  fever,  293 
Albumose,  tests  for,  646 
Alcohol,  coma  from,  959,  772 
injections,  943 
therapeutics  of,  56,  76,  943 
Alcoholism,  acute,  diagnosis  of,  959 
symptoms  of,  959 
treatment  of,  959 
chronic,  prognosis  of,  960 
symptoms  of,  960 
treatment  of,  961,  962 
delirium  tremens,  961 
differentiation  of,  772,  807,  959 
Alexia,  753,  956 

Alkalies.     See  Sod.  bicarbonate. 
Alkaptonuria,  651 
Allantiasis,  969 
Allergy,  88 

Allocheiria,  tabetic,  852 
Aloes,  562 
Alum,  416 
Amaurosis,  875 

with  idiocy,  866 
Amblyopia,  874,  ^75 
Ameba  dysenteriae,  120 
Amebiasis,  120 

Amebic  dysentery.     See  Dysentery. 
Ammonia,  aromatic  spirits,  336,  535 
Ammoniemia,  653 
Ammonium  acetate,  268 
carbonate,  76,  377,  422 
chloride,  415,  422 
in  urine,  569,  728 
Amyl  nitrite,  189,  399,  400,  452 
Amyloid  degeneration  of  kidneys,  q.  v. 
of  liver,  q.  v. 
of  spleen,  q.  v. 
in  tuberculosis,  168 
Amyotonia,  951 

congenita,  951 
Anaphylaxis,  88 
Anartliria,  754 
Anemia,  aplastic,  676 
classification  of,  667 
in  family  jaundice,  590 
in  heart  disease,  366 
in  ictero-anemia,  590 
infantum  pseudoleukemica,  690 
lienalis,  687 
lymphatica,  687 
pernicious,  672 
course  of,  675 
diagnosis  of,  676 
differentiation  of,  523,  676,  677 
etiology  of,  672 
prognosis  of,  675 
symptoms  of,  blood,  672 
circulation,  674 
digestion,  674 
hemolymph  glands,  674 


Anemia,  pernicious,  symptoms  of,  metab- 
olism, 673 
nervous,  675 
skin,  673 
subjective,  673 
treatment  of,  677 
pseudopernicious,  of  children,  690 
secondary,  parasitic,  311 

posthemorrhagic,  acute,  678 
etiology  of,  678 
prognosis  of,  679 
symptoms  of,  678 
treatment  of,  679 
chronic,  etiology  of,  679 
differentiation  of,  677 
symptoms  of,  680 
treatment  of,  680 
splenic,  690 
splenica  infettiva  dei  bambini,  690 
Anesthesia,  dissociated,  831,  836,  847,  848 

dolorosa,  831 
Aneurysm,  abdominal,  408 
diagnosis  of,  409 
prognosis  of,  409 
signs  of,  408 
symptoms  of,  408 
treatment  of,  408 
of  aorta,  400 
of  brain,  211,  782 
celiac,  409 
gastric,  409 
of  heart,  330 
hepatic,  409 
intracranial,  211,  782 
diagnosis  of,  783- 
etiology  of,  782 
pathology  of,  783 
symptoms  of,  783 
treatment  of,  783 
of  lung",  424 
mesenteric,  409 

miliary,  in  cerebral  hemorrhage,  765 
renal,  409 
splenic,  409 
syphilitic,  208,  211 
thoracic,  400 

death,  mechanism  of,  407 
diagnosis  of,  406 
differentiation  of,  407,  460 
etiology  of,  208,  211,  400 
pathology  of,  401 
physical  signs  of,  402 

heart  changes,  403 
respiratory  changes,  404 
sympathetic,  406 
vascular  changes,  404 
prognosis  of,  407 
symptoms  of,  401 
treatment  of,  408 
Angina  abdominalis,  335,  398 
cruris,  335,  397 
erysipelatous,  59 
Ludovici,  84,  482 
pectoris,  333 

diagnosis  of,  335 
differentiation  of,  335 
etiology  of,  333 
pathology  of,  333 


INDEX 


981 


Angina  pectoris,  prognosis  of,  335 
symptoms  of,  333 
treatment  of,  335 
phlegmonosa,  484 
Angina,  scarlatinal,  263 
syphilitic,  203 
in  typhoid  fever,  34 
ulceromembranosa,  484 
Vincent's,  484 
Angioneurotic  crisis,  693 

edema,  945 
Angiosclerosis,  392 
Anguillula  intestinalis,  316 
Ankylostoma  duodenale,  311 
Anopheles,  232 
Anorexia,  533 
Anosmia,  873 
Anthracosis  of  lungs,  440 
Anthrax,  127 

bacteriology  of,  127 
etiology  of,  127 
external,  128 

diagnosis  of,  128 
differentiation  of,  45,  60,  128 
prognosis  of,  129 
symptoms  of,  128 
treatment  of,  129 
mternal,  129 
intestinal,  129 

diagnosis  of,  45,  129 
symptoms  of,  129 
respiratory,  130 

symptoms  of,  130 
treatment  of,  130 
septicemia,  130 
Antiformin,  140 
Antimony,  420,  422 
Antitoxin  in  diphtheria,  87 

in  tetanus,  136 
Anuria,  renal  coLic  causing,  659 
Aorta,  aneurysm  of,  400 

arteriosclerosis  of,  394,  397 
atheroma  of,  394,  397 
dilatation  of,  intermittent,  409 
embolism  of,  410 
inflammation  of,  410 
rupture  of,  410 
syphilis  of,  208 
thrombosis  of,  410 
tuberculosis  of,  181 
Aortic  insufficiency,  351 

diagnosis  of,  355,  361 
etiology  of,  351 
mechanism  of,  352 
physical  signs  of,  352 

auscultation,  354 
inspection,  352 
palpation,  353 
percussion,  354 
prognosis  of,  370 
treatment  of,  371 
stenosis,  356 

diagnosis  of,  357 
differentiation  of,  357,  361 
etiology  of,  356,  380 
mechanism  of,  356 
physical  signs  of,  356 

auscultation,  356 


Aortic  stenosis,  physical  signs  of,  inspec- 
tion, 356 
palpation,  356 
percussion,  356 
prognosis  of,  370 
treatment  of,  370 
Aortitis,  acute,  208,  410 
chronic,  394,  401 
syphilitic,  208,  351 
Aphasia,  amnestic,  755 
auditory,  755 
conduction,  755 
localization,  754 
motor,  754 
optic,  753 
sensory,  755 
visual,  756 
Aphthse  epizooticse,  301 
Aphthous  fever,  301 
Apneumatosis  of  lungs,  441 
Apocynum,  377 
Apomorphine,  422,  959 
Apoplectiform  attacks  in  paretic  demen- 
tia, 805 
bulbar  paralysis,  780,  811 
seizures  in  multiple  sclerosis,  844,  848 
Apoplexy,  765.    See  Cerebral  Hemorrhage, 
cardiac,  332,  772 
habitus,  765 
Appendicitis,  544 

actinomycotic,  194 
in  aged,  547 

bacteriology  of,  544,  547 
in  children,  547 
complications  of,  abscess,  546 
chronic  changes,  547 
necrosis,  546 
peritonitis,  546 
ulceration,  546 
diagnosis  of,  547 

differentiation  of,  73,  172,  194,  515 
etiology  of,  544 
pathology  of,  544 
prognosis  of,  547 
symptoms  of,  544 
early,  544 
late,  546 
remote,  547 
treatment  of,  548 
tuberculous,  172,  176 
typhoid,  73 
Appendix  vermiformis,  cancer  of,  554 
foreign  bodies  in,  544 
inflammation  of,  544 
typhoid  ulcers  of,  35,  36 
Appetite,  disturbance  of  sense  of,  533 
Aprosexia,  488 

Argyll-Robertson  pupil,  853,  855,  877 
in  paretic  dementia,  805 
Argyria,  704 
Arrhythmia,  339 

Arsenic,  188,  228,  229,  377,  430,  687,  691, 
932 
action  and  administration,  677,  678 
Arsenical  poisoning,  968 
Arterial  tension,  395,  396,  399 
Arteries,  diseases  of,  392 

syphilitic  endarteritis  of,  208,  211 


982 


INDEX 


Arteritis,  392,  410 
pneumococcic,  71 
syphilitic,  208,  211 
in  typhoid  fever,  32 
Arteriocapillary  fibrosis,  392 
Arteriosclerosis,  392 

diagnosis  of,  395,  398 
differentiation     of,     from     syphilitic 

endarteritis,  211 
etiology  of,  392 
pathogenesis  of,  393 
pathology  of,  393 
prognosis  of,  398 
symptoms  of,  395 
syphilitic,  208,  211 
treatment  of,  399 
Artery  of  hemorrhage,  765 
Arthritis  deformans,  951 
diagnosis  of,  954 
differentiation  of,  954 
etiology  of,  951 
pathology  of,  951 
symptoms  of,  951 
treatment  of,  955 
types  of,  952 

diifuse,  acute,  952 

chronic,  952 
Heberden's  nodes,  953 
juvenile,  953 
monarticular,  953 
vertebral,  953 
divitum,  738 
gonorrheal,  137 
pauperum,  738 
pneimiococcic,  71 
rheumatic,  282 
in  scarlatina,  265 
in  syphilis,  218 
in  tuberculosis,  182 
in  typhoid  fever,  41 
Arthropathies,  syringomyelic,  847 

tabetic,  854 
Asafetida,  55,  502,  564 
Ascaris  lumbricoides,  307 
Ascites,  adipose,  617 

in  cancer  of  liver,  579 
chyliform,  617 
chylous,  617 
in  cirrhosis  of  liver,  568 
diagnosis  of,  614 

differentiation  of,  173,  614,  615,  616 
etiology  of,  613 
in  heart  disease,  369 
in  pericarditis  adhesiva,'  389,  586 
symptoms  of,  613 
treatment  of,  618 
Aspergillosis,  165,  197 
Aspidium,  303 
Aspiration,  abdominal,  616 
thoracic,  388,  458,  467 
Aspirin,  288 
Assam  fever,  245 

Associated  movements  in  apoplexy,  771 
Association,  centres  for,  754 
Astasia-abasia,  hysterical,  909 
Asthenic  bulbar  paralysis,  810 
Asthma,  bronchial,  427 

diagnosis  of,  429 


Asthma,  bronchial,  differentiation  of,  429, 
368 
etiology  of,  427 
pathogenesis  of,  428 
prognosis  of,  429 
symptoms  of,  427 
treatment  of,  429 
cardiac,  368 
Millar's,  718 
thymic,  718 
Ataxia,  cerebellar,  762,  856,  866 
cortical,  753 
crus  lesion  causing,  760 
Friedreich's,  865 
hereditary,  865 
cerebellar,  866 
diagnosis,  of  865 
etiology  of,  865 
pathology  of,  865 
prognosis  of,  865 
symptoms  of,  865 
locomotor,  849 
poliomyelitic,  100 
pons  lesions  causing,  760 
in  tabes,  851 
Atelectasis  of  lungs,  acquired,  441 

congenital,  441 
Ateliosis,  723 
Atheroma,  392 

of  aorta,  394,  397 
Athetosis,  in  cerebral  infantile  paralysis, 
789 
posthemiplegic,  772 
Athyrea,  709,  712 
Atophan,  741 

Atrophia  hepatis  fusca,  565 
Atrophy,  hemifacial,  882 

progressive  spinal,  882 
Atropine,  therapeutics  of,  77,  88,  188,  269, 

342 
Aura,  epileptic,  920 
Autoserotherapy,  468 
Autumnal  fever,  24 


B 


Babinski's  sign,  630,  770,  858,  859 
Baccelli's  sign  in  pleurisy,  458 

in  pneumonia,  69 
Bacilluria,  treatment  of,  57 

in  typhoid  fever,  40 
Bacillus,  acid-fast,  165,  411 

aerogenes  encapsulatus,  391 
in  pneumothorax,  469 

anthracis,  127 

botulinus,  496,  969 

coh,  21 

comma,  141 

diphtheriae,  78 

dysenterise,  119 

enteritidis,  496 

fusiformis,  485 

influenza,  102 

Klebs-Loeffler,  78 

lepraj,  140,  190 

mallei,  130 

Oppler-Boas,  523 


INDEX 


983 


Bacillus,  pertussis,  107 

plague,  115 

pseudotuberculosis,  165 

smegma,  140 

tetani,  133 

tuberculosis,  139 

typhosus,  25 
Bacterial  latency,  20 
Bacteriemia,  septic  infections,  17,  19,  32 
Balantidium  coli,  247 
Balne's  cough,  488 
Balsam  of  Peru,  422 
Bamberger's  sign  in  pericarditis,  385 
Banting's  cure,  746 
Banti's  disease,  571,  690 
Barlow's  disease,  697 

diagnosis  of,  697 
etiology  of,  697 
prognosis  of,  697 
symptoms  of,  697 
treatment  of,  697 
Basedow's  disease,  709 
Basham's  mixture,  635 
Baths  in  typhoid  fever,  50 
Baume's  law,  221 
Becker's  sign,  710 
Bednar's  plaques,  478 
Bed-sores  in  typhoid  fever,  57 
causes  of,  57,  840 
treatment  of,  57,. 840 
Beef-tea  52 

Belladonna'^  110,  124,  188,  268,  269,  338, 
378,  412,  430,  502,  518,  535,  538,  558, 
562,  711 
Bence-Jones's  albumose,  646,  691 
Benzene,  311 
Benzoic  acid,  422 
Benzoin,  188 
Benzol,  687 
Beriberi,  972 

diagnosis  of,  974 

etiology  of,  972 

prognosis  of,  974 

symptoms  of,  973 

treatment  of,  974 
Beta-naphtol,  535 
Beta-oxybutyric  acid,  728 
Bichloride.     See  Hydrargyrum. 
Biernacki's  sign,  852 
Bile  ducts.     See  Gall  ducts. 
Bile,  flow  of,  536 
Bilharzia  disease,  316 
Bilirubin,  test  for,  in  stools,  537 
Biot's  breathing,  92,  151 
Bismuth,  55,  124,  497,  518,  535 
Black  death,  115,  117 

smallpox,  252 

vomit,  292,  293 

water  fever,  240 
Bladder,  tuberculosis  of,  179 
Blastomycosis,  165,  196 
"Bleeders,"  698 
Blindness,  mind-,  753 

color-,  753 
Blood,  bacilli  in,  17,  19,  32 

cultures  in  pneumonia,  69 
in  sepsis,  19 
in  typhoid,  32 


Blood,  diseases  of,  667 
Blood-pressure,  395,  396,  399 
Bloodvessels,  syphilis  of,  208,  211 

tuberculosis  of,  184 
Blue  mass,  225,  376 
Bones,  diseases  of,  956 
syphilis  of,  217 
tuberculosis  of,  181,  182 
Boric  acid,  therapeutics  of,  268 
Bothriocephalus  latus,  304 
Botulism,  969 
Boulimia,  533 
Bowels.     See  Intestines. 
Brachycardia,  341 
Bradycardia,  341 
etiology  of,  342 
prognosis  of,  343 
symptoms,  342 
treatment  of,  343 
Brain,  abscess  of,  799 

diagnosis  of,  801 
differentiation  of,  796,  801,  802 
etiology  of,  799 
pathology  of,  799 
prognosis  of,  802 
symptoms  of,  800 
treatment  of,  802 
actinomycosis  of,  195 
anemia  of,  763 
aneurysms  of,  211,  782 
arteriosclerosis  of,  211,  397,  779 
atrophy  of,  780 
cancer  of,  212,  789 
circulatory  diseases  of,  763 
congestion  of,  763 
cysts  of,  790 
degeneration  of,  788 

lacunar,  782 
diseases  of,  749 
edema  of,  764 

embolism.  See  Cerebral  embolism,  775 
glioma  of,  790 
gumma  of,  212,  213,  790 
hemorrhage  of.     See  Cerebral  hemor- 
rhage, 765 
in  syphilis,  211 
hyperemia  of,  763 
inflammation    of.      See  Encephalitis 

also,  782 
lesions  of,  in  diphtheria,  83,  84 
localization  of.     See  Cerebral  locali- 
zation, 749 
sarcoma  of,  212,  790 
sclerosis  of,  788,  804 
"softening"  of,  779,  782,  802 
syphilis  of,  211 

arterial  disease,  211 
differentiation  of,  211,  212,  213, 

790,  796,  803,  846 
gumma,  212,  213,  790 
meningitis,  212 
softening,  211 
thrombosis,  211 
thrombosis.  See  Cerebral  thrombosis. 
See  Brain,  syphilis  of. 
See  Sinus  thrombosis, 
tuberculosis  of,  175,  789 
tumors  of,  789 


r 


984 


INDEX 


Brain,  tumors  of,  classification  of,  789 
course  of,  796 
diagnosis  of,  795 
differentiation  of,  781,  795,  796, 

807,  811 
etiology  of,  789 
localization  of,  792,  796 
pathology  of,  789 
prognosis  of,  796 
symptoms  of,  791 
treatment  of,  797 
Brand  bath  in  typhoid  fever,  51,  52 
Breasts,  syphilis  of,  218 
tuberculosis  of,  180 
Breathing,  Biot's,  92,  151 

Cheyne-Stokes's,  92,  151,  631,  772 
metamorphosing,  159 
Bright's  disease.     See  Nephritis. 
Brill's  disease,  278 
Briquet's  sjTidrome,  910 
Broadbent's  sign,  389 
Broca's  convolution,  755 
Brodie's  joints,  906,  909 
Bromatotoxismus,  969 
Bromides,  57,  110,  338,  924.     See  Potass. 

bromide. 
Bromism,  differentiation  of,  807 
Bromoform,  110 
Bronchi,  dilatation  of,  423 
diseases  of,  418 
foreign  bodies  in,  426 
inflammation  of,  418 
stenosis  of,  426 
stones  in,  427 
syphilis  of,  210 
Bronchial  adenitis,  108,  168 
asthma,  427 
breathing  in  pleurisy,  458 

in  pneumonia,  68,  69,  73,  74 
in  tuberculosis,  158 
casts,  66,  423 
glands,  anthracosis  of,  440 

tuberculosis  of,  108,  168 
stenosis,  426 

diagnosis  of,  427 
etiology  of,  426 
symptoms  of,  426 
treatment  of,  427 
ulcers,  syphilitic,  210 
Bronchiectasis,  423 

complications  of,  425 
diagnosis  of,  425 
differentiation  of,  425 
etiology  of,  423 
pathology  of,  423 
physical  signs  of,  424 
symptoms  of,  424 
treatment  of,  425 
Bronchitis,  acute,  418 

etiology  of,  419 
symptoms  of,  419 
treatment  of,  420 
capillary,  434 
chronic,  421 

diagnosis  of,  195,  422 
etiology  of,  421 
pathology  of,  421 
l)rognosis  of,  422 


Bronchitis,  chronic,  symptoms  of,  421 
treatment  of,  422 
fibrinous,  423 

diagnosis  of,  423 
etiology  of,  423 
prognosis  of,  423 
symptoms  of,  423 
treatment  of,  423 
in  heart  disease,  368        -* 
in  influenza,  104,  105 
in  measles,  272 
mucinosa,  423 
pseudomembranacea,  423 
putrid,  421 

differentiation  of,  425 
syphilitic,  210 
tuberculous,  153,  165 
in  typhoid  fever,  39 
in  whooping-cough,  108 
Bronchophony,  69,  73,  74,  159,  458 
Bronchopneumonia,  434 
bacteriology  of,  435 
capillary,  436 
diagnosis  of,  437 
differentiation  of,  148,  161,  437 
diphtheritic,  84,  85 
disseminated,  436 
etiology  of,  434 
generalized,  436 
in  influenza,  104 
issues  of,  437 
measles  as  cause  of,  272 
pathology  of,  435 
physical  findings  of,  436 
prognosis  of,  437 
symptoms  of,  435 
treatment  of,  prophylactic,  437 

symptomatic,  437 
types  of,  special,  436 
in  typhoid,  39 
in  whooping-cough,  108 
Bronchorrhea,  421 
Brown  mixture,  422 
Brown-Sequard's  paralysis,  835 
Bryson's  sign,  710 
Brudzinski's  sign,  91 
Bruit  d'  arain  in  pneumothorax,  471 
de  diable,  668 
de  pot  fele,  159 
Bubonic  plague,  115 

Bulbar  paralysis,  apoplectiform,  811,  780 
asthenic,  810 
chronic,  808 

diagnosis  of,  809 
etiology  of,  808 
pathology  of,  808 
prognosis  of,  810 
s3Tiiptoms  of,  808 
treatment  of,  810 
syringomyelia,  848 
Bundle  of  His,  320,  342 
Burr  bath,  in  typhoid  fever,  51 
Bursitis,  syphilitic,  218 


Cachexia  lienalis,  687 
lymphatica,  687 


INDEX- 


985 


Cachexia,  scorbutic,  695 
strumipriva,  714 
thATeopriva,  714 
Cacodj'lates,  671,  67S 
Caffeine,  76,  376 
Caisson  paralysis,  834 
Calcium  lactate  in  hemorrhages,  189,  452 

salicylate,  537 
Calculus.'    See    Gall-stones    and    Kidney 

calculus,  etc. 
Calmette  tuberculin  test,  164 
Calomel,  225,  562,  637 
Caloric  feeding,  53,  54 
Camphor,  77,  110,  412 
Camphor-chloral,  943 
Camphoric  acid,  188 
Cancrum  oris,  479 
Cannabis  indica,  939 
Capsule,  internal,  localizing  signs,  756 
Caput  ^ledusse,  569 
Carbohj'drates,  physiology  of,  725 
Carbolic  acid.     See  Phenol. 
Carbuncle,  differentiation  of ,  116,  117,  128 
Cardiac  insufficiency  of  stomach,  531 

spasm,  492,  531 
Cardialgia,  532 
Cardiogmus,  337 
Cardiolysis,  390 
Cardiopalmus,  337 
Cardiospasm,  esophagus,  492,  531 
Carlsbad  water,  517 
Carphologia  in  typhoid  fever,  33 
Cascara,  562 
Castor  oil,  562 

Casts  in  pneumonia,  bronchial,  66 
fibrin,  66,  423 
urmary,  620,  625,  629 
Cat's  tongue,  scarlatinal,  264 
Catarrhus  sestivus,  412 
Catechu,  535 
Cathartics,  561 
Catheter,  nasal,  52 
Cauda  equina,  lesions  of,  825 
Cavit}^,  signs  of,  159 
Cecum,  actinomj^cosis  of,  194 

tuberculosis  of,  176 
Cellulitis,  differentiation  of,  60 
Centrum  ovale,  locaUzing  s\Tnptoms,  756 
Cercomonas,  247 
Cerebellar  ataxia,  762 
Cerebellum,  localizing  symptoms  of,  761 
Cerebral  embolism,  775 

diagnosis  of,  778 
differentiation  of,  781 
etidlog}'  of,  775 
localization  of,  777 
basilar,  778,  811 
cerebral,  anterior,  778 

posterior,  778 
internal  carotid,  778 
Sylvian  artery,  777 
vertebral,  778 
pathology  of,  775 
prognosis  of,  778 
symptoms  of,  776 
treatment  of,  779 
hemorrhage,  765 
cerebellar,  733 


Cerebral  hemorrhage,  cortical,  733 
crus,  733 
diagnosis  of,  772 
of  coma,  722 
of  hemiplegia,  773 
of  location,  773 
differentiation,  633,  781,  783,  908 
etiology  of,  765 
localizations  of,  766 
medulla,  773,  811 
pathology  of,  765 
pons,  773 
prognosis  of,  773 
s\anptoms  of  chronic,  770 
hemiplegia,  769 
individual,  769 
insult,  768 
permanent,  768 
prodromes,  768 
reflexes,  770 
sensation,  770 
stroke,  768 
treatment  of  clxronic  stage,  775 
of  insult,  774 
of  reaction,  775 
ventricular,  773 
localization,  749 

centrum  ovale,  756 
cerebellum,  761 
cerebral  peduncle,  759 
corpora  quadrigemina,  758 
corpus  striatum  758 
crus,  759 

frontal  cortex,  754 
internal  capsule,  756 
motor  cortex,  749 
occipital  cortex,  753 
optic  thalamus,  758 
parietal  cortex,  753 
pons,  760 

temporal  cortex,  753 
thrombosis,  779 

diagnosis  of,  781 
differentiation  of,  781,  811 
etiologj'  of,  779 
localization  of,  basilar,  780 
cerebral  anterior,  780 

posterior,  780 
Syhaan  artery,  780 
vertebral,  780 
pathologj"  of,  779 
prognosis  of,  782 
s\Tiiptoms  of,  779 
treatment  of,  782 
Cerebrasthenia,  913 
Cerebrospinal  fever,  89 

meningitis,  epidemic,  89 
Cerium  oxalate,  497 
Cervical  adenitis,  169 

rib,  900 
Cervix,  syphilis  of,  217 
Cestodes,  diseases  caused  by,  302 
Chalicosis  of  lungs,  440 
Chalk,  502,  535 
Chancre,  199 
Chancroid,  200 
Charcot-Leyden  crystals,  429 
Charcot's  disease,  854,  858 


me> 


INDEX 


Cheese  poisoning,  970 

Cheyne-Stokes's  breathing,  92,   151,    631, 

772 
Chiasm,  optic,  873 
Chicken-breast,  489 

rhachitic,  743 
Chicken-pox,  259 

complications  of,  260 
diagnosis  of,  260 
differentiation  of,  254,  260 
etiology  of,  259 
sequels  of,  260 
symptoms  of,  259 
Chills,  treatment  of,  242 
Chloral,  110,  136,  400,  638,  917,  932 
Chlorides,     absence     of,     in     pneumonic 

urine,  70 
Chloroform,  55,  62,  110,  188,  336,  422 
Chloroma,  686 
Chlorosis,  667 

complications  of,  669 
course  of,  669 
diagnosis  of,  670 
differentiation  of,  156,  670,  677 
etiology  of,  667 
prognosis  of,  669 
symptoms  of,  667 
treatment  of,  670 
Choked  disk  in  brain  tumor,  791,  796 
Cholangitis,  catarrhal,  598 

differentiation  of,  594,  595 
suppurative,  598 
Cholecystitis,  597 

differentiation  of,  594,  595 
etiology  of,  597 
following  typhoid  fever,  38 
prognosis  of,  598 
symptoms  of,  598 
treatment  of,  598 
Cholecystotomy,  597 
Cholelithiasis.     See  Gall-stones,  591 
Cholemia,  566,  570,  589 
Cholera,  Asiatic,  111 

bacteriology  of.  111 
complications  of,  112 
diagnosis  of,  112 
dissemination  of.  111 
prognosis  of,  114 
symptoms  of,  112 
treatment  of,  114 
infantum,  541 
nostras,  113 
Cholorine,  113 

Chondrodystrophia  fetalis,  956 
Chorea,  acute,  926 

course  of,  929 
diagnosis  of,  929 
etiology  of,  927 
pathology  of,  927 
prognosis  of,  929 
S3Tnptoms  of,  927 
treatment  of,  931 
types  of,  929 
in  cerebral  infantile  paralysis,  789 
chronic,  930 
electric,  930 

endocarditis  from,  348,  929 
habit,  930 


Chorea,  Huntingdon's,  930 

posthemiplegic,  771,  789 

rheumatic,  285 
Choreiform  affections,  926 
Choroidal  tubercles,  150,  152 
Choroiditis,  syphilitic,  215 
Chromaffin  cells,  702 
Chvostek's  sign,  717 
Chyle  in  urine,  314,  649 

vessels,  disease  of,  564,  649 
Chyliform  ascites,  617 

pleurisy,  473 
Chylothorax,  473 
Chylous  ascites,  617 
Chyluria,  649 

parasitic,  314 
Circulation,  diseases  of,  319 
Cirsomphalos,  569 
Claudication  intermittente,  334,  397 
Climate  in  tuberculosis,  185 
Cocaine,  106,  411,  558 
Coccidia,  247 
Coccidioides,  196 
Coccygodynia,  942 
Codeine,  110,  420,  736 
Cod-liver  oil,  188 
Colchicum,  741,  742 
Colectasia,  556 
Colic,  biliary,  592 

renal,  659 
Colica  mucosa,  538 

etiology  of,  538 
symptoms  of,  538 
treatment  of,  538 

pictonum,  965,  966 
Colitis,  membranacea,  538 

mucosa,  538 
Collapse  in  diphtheria,  82 

in  pneumonia,  69 

in  typhoid  fever,  28,.  31,  38,  48 
Collar  of  brawn  in  scarlatina,  265 
CoUargol,  23 
CoUes's  law,  221 
Colon  bacillus.     See  Septic  infections. 

dilatation  of,  556 

prolapse  of,  556 
Coloptosis,  556 
Coma,  alcoholic,  772,  959 

apoplectic,   632,   772,   773,   776,   780, 
781 

diabetic,  729,  730 

epileptic,  921 

gas-poisoning,  975 

influenzal,  103 

opium,  772 

in  pernicious  malaria,  240 

uremic,  630,  631,  632,  772 

vigil  in  typhoid  fever,  33 
Comma  bacillus.  111 

Common  bile  duct,  gall-stones  in,  593,  606 
Concato's  disease,  612 
Concretio  pericardii,  389 
Conjugate  deviation,  761,  769,  878 
Constipation,  558 

in  colica  mucosa,  treatment  of,  538 

etiology  of,  558 

spastic,  561 

symptoms  of,  559 


INDEX 


987 


Constipation,    treatment    of,    cathartics, 
561 
diet,  560- 
enemata,  561 
exercise,  561 
massage,  561 
Constitutio  lymphatica,  719 
Constitutional  diseases,  725 
Consumption,  152 
Contractures  in  apoplexy,  771 

hysterical,  909 
Conus  medullaris,  lesions  of,  825 

stenosis,  207,  330 
Convulsions  in  brain  tumor,  791,  795 
in  cerebral  embolism,  777,  781 
hemorrhage,  769,  781 
thrombosis,  781 
epileptic,  920,  923 
hysterical,  907,  923 
infantile,  926 

etiology  of,  926 
symptoms  of,  926 
treatment  of,  926 
Jacksonian,  751,  752,  792,  795,  923 
in  syphilis,  212 
in  typhoid  fever,  33 
in  uremia,  630 
in  whooping-cough,  108,  109 
Coproliths,  569 
Cor  bovinum,  325,  352 

villosum,  382 
Cornea,  syphilis  of,  214 
Coronary  disease,  arteritis,  207,  330 
Corpora  oryzoidea,  182 

quadrigemina,    localizing   symptoms, 
758 
Corpulence,  746,  747 
Corpus    striatum,    localizing    symptoms, 

758 
Corrigan's  disease,  351 
Corset  liver,  584 

Cortex,  cerebral,  localization,  749 
Coryza,  411 

in  diphtheria,  81 
in  influenza,  104 
syphilitic,  222 
in  typhoid  fever,  39 
Cough,  therapy  of,  187 
Courvoisier's  law,  593 
Cracked-pot    resonance,    in    tuberculous 

cavities,  159 
Craniotabes,  rhachitic,  743 
Cranium  progenium,  721 
Crede's  coUargol,  23 

silver,  23 
Creolin,  61 
Creosote,  187,  425 
Crepitant  rale,  68 

diseases  where  present,  68 
in  pneumonia,  68 
Cretinism,  712 

diagnosis  of,  713 
etiology  of,  712 
symptoms  of,  713 
Crie  hydrencephalique,  91,  151 
Crises,  tabetic,  854 
Croton  oil,  270,  774 
Croton-chloral,  943 


Croup,  differentiation  of,  85 

diphtheritic,  81 

false   415 

differentiation  of,  85,  108,  415 
Crus,  localizing  symptoms,  759 
Cryptococcus,  196 
Crystals,  Charcot-Leyden,  429 
Culex,  232,  289 
Cyanosis  in  heart  disease,  368,  380 

with  polycythemia,  691 

with  splenomegaly,  691 
Cyclaster  scarlatinalis,  261 
Cycloplegia,  877 
Cynanche  gangrceneuse,  482 
Cysticercus,  of  brain,  302,  790,  796 

cellulosse,  304 
Cystitis  differentiation  of,  178,  653 

in  typhoid  fever,  40 
Cytodiagnosis,  460 

in  lumbar  puncture,  94 
Cytorrhyctes  vaccinise,  256 

variolge,  248 


Damoiseau's  curve  in  pleurisy,  456 
Dandy-fever,  289 
Deafness,  888 

cortical,  753,  754 
Death,  sudden,  207,  371,  449,  464,  468, 

708,  718,  719 
Degeneratio  renum  polycystica,  664 
De  la  Camp's  sign,  170 
Delhi  boil,  245 
Delirium  cordis,  340,  367 

in  fevers,  treatment  of,  57 
in  pneumonia,  71 
tremens,  diagnosis  of,  961 
etiology  of,  961 
prognosis  of,  961 
symptoms  of,  961 
treatment  of,  962 
Dementia  paralytica,  802 
diagnosis  of,  806 
differentiation  of,  807 
etiology  of,  802 
pathogenesis  of,  802 
pathology  of,  802 
prognosis  of,  807 
symptoms  of,  804 
treatment  of,  808 
paretic,  802 
senile,  807 
Dengue,  289 

complications  of,  290 
diagnosis  of,  290 
differentiation  of,  290 
etiology  of,  289 
prognosis  of,  290 
sequels  of,  290 
symptoms  of,  290 
treatment  of,  290 
Dercum's  disease,  747 
Dermatitis,  differentiation  of,  60,  266 
Dermatomyositis,  949 
D'Espine's  sign,  170 
Dextrocardia,  380 
Diabete  bronze,  572,  732 


988 


INDEX 


Diabetes,  bronzed,  572,  732 
coma  from.  730 
decipiens,  728 
insipidus,  737 

cerebral  s}"philis,  212,  737 
diagnosis  of,  737 
etiologj'  of,  737 
prognosis  of,  738 
symptoms  of,  737 
treatment  of,  738 
mellitus,  725 

cerebral  s\-philis,  212 
complications  of,  730 
amam-osis.  731 
arteries,  731 
blood,  731 
coma,  730 
cystitLs,  732 
dj'spnea,  730 
heart,  731 
gangrene,  733 

of  lungs,  731 
genital,  732 
infectious,  732 
iatestines,  732 
liver,  732 
mental,  730 
neuralgia,  730 
neuritis,  730 
pregnancy,  732 
renal,  732 
retinitis,  731 
skin,  732 
stomach,  731 
tuberculosis  of  lungs,  731 
cour,se  of,  733 
diagnosis  of,  733 
etiolog^'  of,  725 
physiolog}-  of,  725 
prognosis  of,  733 
sj-mptoms  of,  glycosuria,  727 
tests  for,  727 
polydipsia,  729 
polyphagia,  729 
mine,  acetone,  728 
albuminuria,  729 
ammonium,  729 
/3-ox^•but^Tic  acid,  729 
diacetic  acid,  729 
pneumatui'ia,  729 
quantity,  728 
sugar,  727 
treatment,  complications,  735 
diet,  733 
general,  735 
tjT)es,  736 
phosphatic,  650 
Diacetone,  diabetic,  729 
Diaphragmatic  hernia,  472,  550 
Diarrhea,  558 

in  cholera  Asiatica,  112 
in  dysentery,  119,  121,  123 
etiologj'  of,  540,  558 
infantile,  540 

cholera  infantum,  541 
chronic  dj'spepsia,  542 
ferment  af,  540 
ileocohtis,  541 


Diarrhea,   infantile,    treatment    of   acute 
colitis,  543 
dyspepsia,  542 
enteritis,  543 
of  cholera  infantum,  543 
of  chronic  dyspepsia,  543 
dietetic,  542 
nervous,  558 
in  pneumonia,  69 
treatment  of,  114,  123 
in  t}i)hoid  fever,  treatment  of,  55 
Diazo  reaction,  in  malaria,  237 
in  measles,  273 
in  pneumonia,  70 
in  tuberculosis,  168 
in  tj-phoid  fever,  40 
Dibothi-iocephalus,  304 
Dicrotic  pulse  in  tj-phoid  fever,  30 
Diet  in  constipation,  560 
in  diabetes,  733 
in  gastric  catarrh,  501 
in  gastric  dilatation,  508 
in  gastric  ulcer,  518 
in  gout,  741 
Karell's,  372 
in  obesity,  746 
in  nephritis,  633 
in  tuberculosis,  186 
in  t}-phoid,  52 
Dietl's  CTisis,  644 
Dietrich's  heart  stenosis,  207,  330 
Digestive  tract,  diseases  of,  477 
Digitalis,  physiological  action.  373 
preparations,  375 
therapeutics  of,  76,  189,  269,  336,  375, 

376,  377 
toxicity,  374 
Diphtheria,  78 

bacteriolog}'  of,  78 
complications  of,  82 
alimentarj',  84 
glands,  84 
heart,  82 
nephritis,  83 
paralysis,  83 
respiratorv,  84 
skin,  84,  82 
course  of,  85 
diagnosis  of,  85 

differentiation  of,  85,  263,  415,  486 
dissemination  of,  79 
etiology-  of,  78 

bacillus  diphtheriae,  78 
Klebs-Loeffler  bacillus,  78 
larjTigeal,  81 

localization  of,  special,  SO 
ear,  82 
eye,  82 
genitalia,  82 
larjTix,  81 
nose,  81 
skin,  82 
nasal,  81 
patholog3^  79,  80 
pharyngeal,  80 
prognosis  of,  85 
sequela  of,  82 
symptoms  of,  80 


INDEX 


989 


Diphtheria,    symptoms  of,   classifications 
of,  80 
treatment  of,  86 
general,  88 
local,  86 
prophylactic,  86 
serotherapy,  87 
symptomatic,  88 
types  of,  78,  80 
catarrhal,  80 
chronic,  80 
general  infection,  81 
latent,  80 
pharyngitic,  80 
septic,  81 
simple,  80 
tonsillitic,  80 
Diphtheritic  croup,  81 
enteritis,  539 
ophthalmia,  82 
otitis,  82 

vulvovaginitis,  82 
Diphtheroid,  78 
Diplegia,   in  cerebral  infantile  paralysis, 

787  .     . 

Diplococcus    intracellularis    menmgitidis, 

89 
Diplopia,  878 
Dipsomania,  959 
Disinfection,  49 

by  formaldehyde,  258 
Distoma  of  kidney,  316 
of  lung,  316 
pulmonale,  316,  317 
Distomiasis,  316 

Dittrich's  mycotic  plugs,  421,  424 
Diuretin,  377,  635 
Diver's  paralysis,  834 
Dobell's  solution,  411 
Doehle's  bodies,  264 
Dover's  powder.     See  Opium. 
Drachontiasis,  315 
Dracunculus  medinensis,  315 
Dropsy.     See  Edema. 
Drug  eruptions,  266,  272 
Drlisenfieber,  298 
Dubini's  disease,  930 
Duct.     See  Gall  ducts. 
Ductless  glands,  diseases  of,  701 
Ductus  Botalli,  patency,  379 
Duke's  disease,  275 
Dumdum  fever,  245 
Dunbar's  serum,  413 

Duodenal  ulcer.       See  Stomach  ulcer,  509 
Dm-oziez's  murmur,  355 
Dysacusis,  888 
Dysarthria,  754,  761 
Dysbasia  intermittens,  397 
Dyschesia,  561 
Dysentery,  118 

classification  of,  119 
amebic,  120 

complications  of,  122 
etiology  of,  120 
issues  of,  122 
pathology  of,  122 
symptoms  of,  121 
treatment  of,  123 


Dysentery,  classification  of,  indeterminate 
types,  123 
catarrhal,  123 
croupous,  123 
gangrenous,  123 
parasitic,  123 
liver  abscess  in,  122,  576 
Shiga's  bacillary,  119,  541 
diagnosis  of,  120 
pathology  of,  120 
prognosis  of,  120 
symptoms  of,  119 
treatment  of,  123 
Dyspepsia,  acute,  496 

in  children,  acute,  540 
chronic,  498 
intestmal,  534,  536 
nervosa,  527,  533 
Dysphagia,  491,  761,  890 
Dyspnea  in  heart  disease,  368 

Kussmaul's,  in  diabetes,  730 
Dystrophy,  muscular,  862 


E 


Ear,  diphtheria  of,  82 
syphilis  of,  216 
tuberculosis  of,  180 
Ebstein's  cure,  746 
Echinococcus  disease,  305 
of  brain,  790 
of  heart,  336 

of  liver.     See  Liver,  cysts  of. 
of  lungs,  306 
of  pleura,  466 
renal,  666 
Eclampsia  in  contracted  kidney,  630 

in  kidney  of  pregnancy,  622 
Eczema,  differentiation  of,  60 
Edema,  angioneurotic,  945 
cardiac,  370 
of  glottis,  417 
in  heart  disease,  370 
hereditary,  946 
^f  larynx,  417 
of  lungs,  450 
renal,  620,  626,  632,  636 
in  scarlatina,  265 
in  trichiniasis,  310 
Egophony,  69,  159,  458 
Ehrlich's  diazo  reaction,  40,  70,  168,  273 

side-chain  theory,  87,  134 
Eiselsberg's  sign,  509 
i  Elastic  fibers,  154 
I  Elaterin,  636 
i  Elephantiasis,  315 
Embolism.     See  Aorta,  etc. 

in  sepsis,  20 
Emetin,  124 

Emphysema  of  lungs,  430 
Empyema,  460,  468 
necessitatis,  461 
pneumococcic,  70,  460 
pulsans,  460 
streptococcic,  460 
Encephalitis,  797 

acute  hemorrhagic,  798 


990 


INDEX 


Encephalitis,  acute,  ophthalmoplegic,  798 
in  aged,  782 
etiology  of,  797 
in  influenza,  103 
pathology  of,  797,  798 
poliencephalitis,  798 
inferior,  798 
superior,  798 
poliencephalomyelitis,  798 
prognosis  of,  798 
suppurative,  799 
symptoms,  798 
syphilitic,  211 
treatment  of,  799 
Encephalomalacia,  atheromatous,  779 
embolic,  775 
syphilitic,  211,  840 
Encephalomyelitis,  disseminated,  841 
Encephalopathia,  saturnina,  967 
Endarteritis  deformans,  392 

syphilitic,  208 
Endocarditis,  343 
acute,  344 

benign,  348 

diagnosis  of,  46,  47,  349 
etiology  of,  263,  283,  348 
localization  of,  349 
pathology  of,  348 
prognosis  of,  349 
symptoms  of,  349 
treatment  of,  349 
malignant,  344 

bacteriology,  347 
diagnosis  of,  21,  46,  47,  347 
etiology  of,  344 
pathology  of,  344 
prognosis  of,  348 

septic,  346 
symptoms  of,  345 
treatment  of,  349 
types  of,  345 
typhoidal,  345 
verrucose,  348 

chorea,  relations  of,  248,  927,  928,  929 
chronic,     350.      See    Aortic    insuffi- 
ciency, etc. 
etiology  of,  350 
pathology  of,  350 
prognosis  of,  370 
symptoms  of,  351,  366 
treatment  of,  371 
differentiation  of,  46,  47,  283,  286,  386 
pneumococcic,  70 
rheumatic,  283,  286 
scarlatinal,  263 
syphilitic,  207 
tuberculous,  166,  181 
Endocardium," diseases  of,  343 
Enemata,  nutrient,  516 

oil,  561 
English  sweats,  299 
Enstrongylus,  316 
Entameba  dysenteria;,  120,  121 
Enteralgia,  563 
Enteritis,  actinomycotic,  194 
acute,  534 

diagnosis  of,  45,  535 


Enteritis,  acute,  etiology  of,  534 
pathology  of,  534 
symptoms  of,  534 
treatment  of,  535 
clironic,  536 

pathology  of,  536 
prognosis  of,  537 
symptoms  of,  536 
treatment  of,  537 
croupous,  539 
diphtheritic,  539 
mucous,  538 
phlegmonous,  539 
Enterocolitis,  535 
Enterodynia,  563 
Enterokinase,  536 
EnteroUths,  552 
Enteroptosis,  555 
etiology  of,  555 
symptoms  of,  656 
treatment  of,  557 
Enterospasm,  563 
Enterostenosis,  551 
Eosinophilia,  310,  313,  581 
Ephemeral  fever,  298 
Epididymitis  in  mumps,  280 

in  tuberculosis,  179 
Epilepsy,  919 

in   cerebral   infantile  paralysis,    787, 

789 
convulsions  in  cerebral  syphilis,  211, 

213 
course  of,  923 
diagnosis  of,  922 
differentiation  of,  923,  630,  795 
etiology  of,  919 

Jacksonian,  751,  752,  792,  795,  923 
pathology  of,  919 
prognosis  of,  923 
symptoms  of,  919 
syphilitic,  211,  213 
treatment  of,  924 
tjrpes  of,  921 
Epileptiform  attacks  in  paretic  dementia, 

805 
Epinephrin,  702 
Epistaxis,  etiology  of,  414 
treatment  of,  414 
in  typhoid  fever,  39,  57 
Erb-Goldflam  syndrome,  810 
Erb's  sign,  716 
Ergot,  therapeutics  of,  57 
Ergotism,  970 
Eructations,  gastric,  531 
Erysipelas,  58 

bacteriology  of,  58 
complications  of,  59 
circulatory,  59 
genito-urinary,  60 
nervous,  59 
respiratory,  59 
septic,  60 
course  of,  59 
as  curative  agent,  62 
diagnosis  of,  60 
differentiation  of,  60,  61 
etiology  of,  58 

streptococcus  erysipelatis,  58 


INDEX 


991 


Erysipelas  of  larynx,  60 
of  lungs,  60 
of  pharynx,  59,  61 
prognosis  of,  61 
recurrence  of,  61 
sequels,  59 
stages,  59 
symptoms  of,  58 
eruption,  58 
fever,  59 
incubation,  58 
treatment  of,  61 
local,  61 
medicinal,  62 
prophylaxis,  61 
serotherapy,  62 
varieties  of,  59,  60,  61 
Erysipeloid,  61 

differentiation  of,  61 
Erythema,  differentiation  of,  60,  266, 
290 
visceral  crises  in,  693 
Erythremia,  691 

Erythrol  tetranitrate,  336,  399,-  400 
Erythromelalgia,  944 
Eserine,  504 

Esophagitis,  etiology  of,  489 
symptoms  of,  490 
treatment  of,  490 
Esophagomalacia,  490 
Esophagus,  abscess  of,  489 

cancer  of,  complications,  494 
diagnosis,  495 
etiology  of,  494 
pathology,  494 
symptoms,  494 
treatment,  495 
dilatation  of,  etiology  of,  492 
symptoms  of,  492 
treatment  of,  493 
diseases  of,  489 
diverticulum,  493 
hemorrhage  of,  495 
inflammation  of,  489 
measurements  of,  491 
necrosis  of,  490 
neuroses  of,  495 
perforation  of,  495 
pulsion-diverticulum,  493 
rupture  of,  495 
sounding  of,  491 
spasm  of,  492 
stenosis  of,  490 
stricture  of,  diagnosis,  491 
etiology  of,  490 
])hysical  signs  of,  491 
prognosis  of,  490 
symptoms,  491 
treatment  of,  492 
syphilis  of,  204 
traction-diverticulum,  494 
tuberculosis  of,  175 
tumors  of,  benign,  495 
typhoid  ulceration  of,  34,  35 
ulceration  of,  175,  490 
varices  of,  495,  570 
Ether,  336,  375 
Exophthalmos,  goitrous,  709 


276, 


Extra-systole,  339 

Exudates,  character  of  fluid,  615 

Eye,  diphtheria  of,  82 

syphilis  of,  214 

tuberculosis  of,  175 


Facial  hemiatrophy,  882 

hemihypertrophy,  882 
Fallopian  tubes,  syphilis  of,  217 

tuberculosis  of,  180 
Farcy,  130 

Fasciola  hepatica,  317 
Fat  necrosis,  pancreatic,  601 

in  urine,  650 
Febricula,  298 

Feces,  functional  examination  of,  537 
Felix  mas,  303 
Felons,  syringomyelic,  847 
Fever,  ephemeral,  298 

gastric,  298 

glandular,  298 

hepatic,  571,  593 

herpetic,  298 

miliary,  299 
'     mountain,  300 

spotted,  93 

syphilitic,  201,  206 

therapy  of,  50,  268 
Fibrillation,  auricular,  339 
Fibrin  casts  in  pneumonia,  66 
Fibrositis,  949 
Filaria  medinensis,  315 

nocturna,  314 
Fish  poisoning,  970 
Fissures  of  lungs,  interlobar,  463 
Fistula  in  ano,  177 
Flexner's  serum,  95 
Flint's  murmur,  354 
Food  poisoning,  969 

values,  54 
Foot,  tabetic,  854 
Foot-and-mouth  disease,  301 
Forced  movements,  762 

postures,  762 
Forchheimer's  spots,  275 
Formaldehyde  as  disinfectant,  258 
Fourth  disease.     Duke's,  275 
Fragilitas  ossium,  957 
Frambesia,  247 
Freud's  theory,  911 
Friction-rub,  pericarditic,  384,  386 

pleuritic,  386,  457,  464 
Friedreich's  ataxia,  865 

change  of  note,  159 

tones,  355 
Fumigation,  formaldehyde,  258 
Funnel-breast,  489 
Furuncles,  diabetic,  732 


G 


Galactotoxismus,  970 
Gall-bladder,  cancer  of,  complications  of, 
600 


992 


INDEX 


Gall-bladder,   cancer  of,   complication  of, 
differentiation  of,  594,  595 
etiology  of,  599 
pathology  of,  600 
symptoms  of,  600 
diseases  of,  588 

dilTerential  table,  594,  595 
in  gall-stones,  593,  594 
inflammation  of,  597 
tumors  of,  599 
Gall  ducts,  diseases  of,  588 
inflammation,  598 
occlusion  of,  588,  598,  606 
stones  in,  593,  594 
tumors  of,  594,  595,  600 
Gallop-rhythm,  321 
Gall-stones,  591 

chemistry  of,  591 

compUcations  of,  ampulla  Vateri,  596 
common  duct,  593,  606 
cystic  duct,  593 
diabetes,  596 
fistulse,  596 
gall-bladder,  593 
intestinal  obstruction,  551,  552, 
596 
diagnosis  of,  596 
differentiation  of,  206,  515,  594,  595, 

602,  606 
etiology  of,  591 
following  typhoid  fever,  38 
frequency  of,  592 
intestinal  obstruction  from,  551,  552, 

596 
prognosis  of,  596 
properties  of,  591 
symptoms  of,  592 
treatment  of,  colic,  597 
medicinal,  597 
prevention,  597 
sm-gical,  597 
varieties  of,  591 
Gambir,  535 
Gangrene,  diabetic,  733 

spontaneous  sj'mmetrical,  945 
in  typhoid  fever,  30 
Gas  poisoning,  974 
Gastralgia,  532 

differentiation  of,' 517 
Gastrectasia,  504 
Gastric  fever,  298 
Gastrin,  501 

Gastritis,  acute  diphtheritic,  496,  498 
parasitic,  498 
phlegmonous,  497 
simple,  diagnosis  of,  45,  497 
etiology  of,  496 
symptoms  of,  496 
treatment  of,  497 
toxic,  497 
atrophic,  503 

chi-onic,  diagnosis  of,  498,  517 
etiology  of,  498 
pathology  of,  498 
symptoms  of,  498 
treatment  of,  diet,  501 
lavage,  501 
medicinal,  502 


Gastritis,  dift'erentiation  of,  45,  517 

stenosing,  504,  509 
Gastrodynia,  532 

Gastro-enter ostomy,  508,  519,  526 
Gastroptosis.     See  Enteroptosis,  555 
Gastrorrhagia,  526 
Gastrostomy,  495,  526 
Gastrosuccorrhea,  diagnosis  of,  530 
etiology  of,  529 
prognosis  of,  530 
symptoms  of,  529 
treatment  of,  530 
Gelatin  injections,  tetanus  from,  56 

in  aneurysm,  408 
Genitaha,  sj^hihs  of,  216 

tuberculosis  of,  179 
Gerhardt's  change  of  note,  159 
German  measles,  275 

diagnosis  of,  275 
differentiation  of,  273 
etiology  of,  275 
prognosis  of,  276 
symptoms  of,  275 

constitutional,  275 
eruption,  275 
incubation,  275 
prodromes,  275 
stages,  275 
treatment  of,  275 
Gersuny's  sign,  559 
Gifford's  sign,  710 
Gigantism,  722 
Ginger,  535 

Gingivitis,  scorbutic,  695 
Glanders,  130 

course  of,  131 
diagnosis  of,  132 
differentiation  of,  132,  255,  273 
etiology  of,  130 
pathology  of,  131 
symptoms  of,  131 
farcy,  131 
glanders,  132 
treatment  of,  133 
Glandular  fever,  298 
Globuhn,  tests  for,  94,  646 
Globus,  hj-stericus,  910 
Glomerulonephritis,  scarlatinal,  264 
Glossitis,  acute,  480 
Glottis,  edema  of,  417 

ia  typhoid  fever,  39 
spasm  of,  diagnosis  of,  109,  429 
Glycosuria,  727.     See  Diabetes. 
sjTjhilitic,  212 
tests  for,  727 
GlycjTrhiza,  422,  562 
Goitre,  707 

exophthalmic,  709 
acute,  711 
com'se  of,  711 
diagnosis  of,  711 
etiology  of,  709 
forme  fruste,  711 
pathology,  710 
prognosis,  711 
sj'mptoms  of,  709 
accessor}^,  710 
cardinal,  709 


i 


INDEX 


993 


Goitre,      exophthalmic,      symptoms     of, 
constitutional,  711 
exophthalmos,  709 
goitre,  710 
tachycardia,  709 
tremor,  710 
treatment  of,  711 
general,  711 
medicinal,  711 
organotherapy,  712 
thyroidectomy,  712 
Gonococcus.     See  Septic  infections,  21 

localizations,  137,  347 
Gonorrheal  infection,  137 
arthritis,  137  _ 

classification,  138 
course,  138 
pathology,  138 
symptoms,  138 
treatment,  138 
regional,  137 
septicopyemia,  137 
Gout,  738 

acute,  symptoms  of,  739 

treatment  of,  741 
chronic,  742 

symptoms  of,  739 
complications  of,  740 
diagnosis  of,  740 
etiology  of,  738 
pathology  of,  739 
prognosis  of,  741 
Grafe's,  von,  sign,  710 
Grain  poisoning,  970 
Grancher's  sign,  170 
Grape-sugar  for  hemorrhage,  56 
Graphospasmus,  932 
Graves's  disease,  709 
Greene's  sign  in  pleurisy,  455 
Grindelia,  430 
Grippe.     See  Influenza,  102 
Grocco's  sign  in  pleurisy,  456 
Ground-itch,  311,  312 
Guaiac,  484,  487 
Guaiacol,  188,  955 
Guinea-worm  disease,  315 
Gumma.     See  Syphilis. 
Gums,  tuberculosis  of,  175 
Gutta  cadens,  471 


H 


Habitus  enteroptoticus,  556 

"Half-moon"  space,  456,  470 

Hanford's  tender  toes  in  typhoid  fever, 

32,  34 
Hanot's  disease,  573 
Hay  fever,  412 

etiology  of,  412 
symptoms  of,  412 
treatment  of,  412 
Haygarth's  nodosities,  952 
Head,  actinomycosis  of,  193 
Headache,  in  brain  tumor,  791,  795 
differentiation  of,  938 
in  fevers,  treatment  of,  57 
in  meningitis,  90,  91,  95 
63 


Headache,  migraine,  937 
sick,  937 

in  typhoid  fever,  33 
Head's  maximal  points,  942,  940 
Hearing,  centre  for,  753 
Heart.     See  also  Myocardium,   endocar- 
dium, 
aneurysm  of,  330 
arrhythmia,  339 

arteriosclerosis  of,  207,  208,  330,  333 
atrophy  of,  327 
block,  320,  342 
bovine,  325,  352 
bundle  of  His,  320,  342 
dilatation  of,  320 

diagnosis  of,  322,  668 
differentiation  of,  322,  387,  389 
etiology  of,  320 
pathology  of,  321 
prognosis  of,  323 
signs  of  aixricular  dilatation,  322 
of  left  ventricle  dilatation, 

321,  396 
of  right  ventricle  dilatation, 

322,  432 
symptoms  of,  322 
treatment  of,  323 
in  typhoid  fever,  30 

disease  cells,  368 
congenital,  378 

aortic  atresia,  380 
dextrocardia,  380 
interauricular  defects,  379 
interventricular  defects,  379 
patent  ductus  Botalli,  379 
persistent     isthmus     aortse, 

379 
prognosis  of,  381 
pulmonary  stenosis,  378 
symptoms  of,  general,  380 
transposition  of  vessels,  380 
treatment  of,  381 
tricuspid  stenosis,  380 
valvular  anomalies,  380 
valvular,  combined  lesions,  365 
diagnosis  of,  365 
prognosis  of,  370 
course  of,  370 
prognosis  of,  370 
signs     of.     See     Individual 

lesions, 
symptoms  of,  366 
cardiac,  367 
constitutional,  366 
edema,  370 
embolism,  370 
gastro-intestinal,  369 
joints,  370 
kidney,  369,  639 
liver,  369,  585 
nervous,  367 
respiratory,  368 
spleen,  369 
treatment  of,  371 

cardiants,  373,  375 
compensated     lesions, 

371 
digitalis,  373 


994 


INDEX 


Heart     disease,    valvular,    treatment    of, 
exercise,  372 
hygiene,  372 
Oertel  method,  323 
purgative,  372 
rest,  372 

Schott  method,  323 
symptomatic,  376 
uncompensated  lesions, 

372 
venesection,  372 
dulness,  322 
embolism,  345 
failure,  diphtheritic,  82 
fatty,  327 

diagnosis  of,  328 
etiology  of,  327 
pathology  of,  327 
prognosis  of,  328 
signs  of,  328 
symptoms  of,  328 
treatment  of,  328 
fragmentation  of,  82 
functional  tests,  323 
gallop-rhythm,  321 
hypertrophy  of,  324 
diagnosis  of,  326 
etiology  of,  324 

in  interstitial  nephi-itis,  396,  629 
pathology  of,  325 
prognosis  of,  326 
signs    of    left    ventricle    hyper- 
trophy, 325,  396 
of    right    ventricle    hyper- 
trophy, 326,  358,  432 
symptoms  of,  325 
treatment  of,  327 
intermittence  of,  339 
irritable,  337 

murmiu-s,  anemic  diastolic,  347,  355, 
668,  674 
Flint's,  354 

functional    diastolic,    347,    355, 
668,  674 
systohc,  347,  357,  359,  363, 
668,  674 
neuroses  of,  337 
palpitation  of,  337 
diagnosis  of,  338 
etiology  of,  337 
signs  of,  338 
symptoms  of,  337 
treatment  of,  338 
pang,  333 
parasites  of,  336 
physiology,  319 

retraction  of  apex  of,  389 
rupture  of,  330,  332 
diagnosis  of,  333 
etiology  of,  332 
pathology  of,  332 
symptoms  of,  332 
treatment  of,  333 
sino-auricular  node,  319 
size  of,  322 
syphilis  of,  207 
thrombosis  of,  337 
tuberculosis  of,  181 


Heart,  tumors  of,  336 
Heat  exhaustion,  976;  977 
Heberden's  nodes,  953 
Hematemesis,  diagnosis  of,  527 

differentiation  of,  hemoptysis,  452 

etiology  of,  526 

in  gastric  cancer,  517,  521 
ulcer,  512,  515,  517 

in  pneumonia,  71 

in  portal  cirrhosis,  570 

symptoms  of,  527 

treatment  of,  518 
Hematomyelia,  829,  833 
Hematoporphyrinuria,  651 
Hematorrhachis,  829 
Hematuria,  647 

angioneurotic,  647 

diagnosis  of,  647 

endemic,  316 

etiology  of,  647 

renal  stone  causing,  659,  660 
tumor  causing,  662 

syniptoms  of,  647 

treatment  of,  648 

tuberculosis  causing,  178 
Hemianesthesia,  hysterical,  906 

lesions  in,  crus,  760,  778 

internal  capsule,  757,  770,  771 
optic  thalamus,  758 
pons,  760 
spine,  835,  836 
Hemianopsia,    753,    757,    758,    760,    770, 

778,  874,  875 
Hemiathetosis,  758,  772,  789 
Hemiatrophy,  facial,  882 
Hemichorea,  758,  771,  789 
Hemichromatopsia,  753,  874 
Hemicrania,  937 
Hemifacial  atrophy,  882 

hypertrophy,  882 
Hemihypertrophy,  facial,  882 
Hemiopia.     See  Hemianopsia. 
Hemiplegia  in  aged,  782 

alternating,  759,  760,  811 

in  apoplexy,  768,  769,  770,  773,  781 

cerebral,  757,  793 

collateral,  770 

cortical,  750 

in  crus,  759 

in  diphtheria,  84 

double,  760,  761,  787,  811 

embolism,  777,  781 

etiology  of,  773,  781 

hysterical,  908 

infantile  paralysis,  786 

internal  capsule  lesion  in,  757,  758 

in  meningitis,  92 

in  pachymeningitis,  815 

in  pleurisy,  468 

in  pons,  760 

spinal,  831,  835 

thrombosis,  780,  781 

in  typhoid,  34 

uremic,  630-633,  772 
Hemochromatosis,  572,  732,  704 
Hemoglobinm'ia,  648 

epidemic,  648,  694 

etiology  of,  648 


INDEX 


995 


Hemoglobinuria  in  malaria,  240 

in  nephritis,  619,  622,  648 

paroxysmal,  648 

symptoms  of,  648 

syphilitic,  207 

treatment  of,  649 
Hemopericardium,  392 

differentiation  of,  387 
HemophiHa,  698 

diagnosis  of,  699 

etiology  of,  698 

prognosis  of,  699 

renal,  647,  698 

symptoms  of,  698 

treatment  of,  699 
Hemoptoe.     See  Hemoptysis. 
Hemoptysis,  154,  450 

aneurysm  causing,  406 

bronchiectasis  causing,  423 

cause  of  tuberculosis,  154 

differentiation  of,  452 

endemic,  317 

etiology,  423,  451 

forms  of,  154,  155 

frequency  of,  154,  451 

in  heart  disease,  368 

prognosis,  452 

symptoms  of,  154,  451 

treatment  of,  188,  452 

in  tuberculosis,  154 
Hemorrhagic  diseases,  692 

classification  of,  692 
hemophilia,  698 
infantile  scurvy,  697 
of  newborn,  694 
purpura,  692 
scurvy,  695 
Hemorrhoids,  557 
Hemothorax,  473 
Henoch's  purpura,  694 
Hepar  adiposum,  582 

migrans,  584 

mobile,  584 
Hepatargia,  566,  570,  589 
Hepatic  fever,  intermittent,  571,  593 

insufficiency,  566,  570,  589 

vein  cirrhosis  of  liver,  567 

vessels,  diseases  of,  586,  588 
Hernia,  diaphragmatic,  472,  550 
differentiation  of,  472 

external,  550 

internal,  550 

of  linea  alba,  515 
Herome,  377,  415,  420,  422 
Herpes  in  malaria,  47,  236 

in  meningitis,  47,  93 

in  pneumonia,  69 

in  tuberculosis,  47 

in  typhoid  fever,  30 

zoster,  881,  901,  942 
Herpetic  fever,  298 
Herxheimer  reaction,  201 
Hexamethylenamina,  57,  101,  102 
Hiccough,  897 
Hippocratic  facies,  38,  608 

fingers,  168,  425,  574 

ligatiu-e,  452 

succussion,  471 


Hirschsprung's  disease,  556 
His's  bundle,  320,  342 
Hodgkin's  disease,  687 
Hormones,  701 
Hormonol,  563 
Horseshoe  kidney,  643 
Hoiu'-glass  stomach,  508 
Hunger,  disturbance  of  sense  of,  533 
Huntingdon's  chorea,  930 
Hutchinson's  facies,  879 
mask,  852 
teeth,  223 
triad,  214,  222,  223 
Hydatid  cysts.     See  Liver,  cysts  of. 

thrill,  580 
Hydatids,  305 

Hydrargyri  chloridum  mite,  224,  225 
corrosivi,  225,  226 
iodidum,  225,  487 
massa,  225,  376 
tannicum,  225 
unguentum,  225,  226 
Hydrarthrosis,  intermittens,  946 
Hydrencephalic  state,  541,  763 
Hydrencephaloid,  541,  763 
Hydrobilirubin,  test  for,  in  stools,  537 
Hydrocephalus,  acute,  811 
chronic,  acquired,  813 

diagnosis  of,  813 
etiology  of,  813 
symptoms  of,  813 
treatment  of,  813 
congenital,  812 
course  of,  813 
etiology  of,  812 
pathology  of,  812 
symptoms  of,  812 
Hydrochinon  in  urine,  651 
Hydrochloric  acid,  action  of,  502 

tests  for,  in  stomach,  499 
Hydrocyanic  acid,  497 
Hydrogen  peroxide,  80,  125,  538 
Hydromyelus,  846 
Hydronephrosis,  655 
diagnosis  of,  656 

differentiation  of,  656,  657,  663,  665 
etiology  of,  655 
pathology  of,  655 
prognosis  of,  657 
symptoms  of,  656 
treatment  of,  657 
Hydropericardium,  391 

differentiation  of,  387 
Hydroperitoneum,  613 
Hydrophobia,  294 
course  of,  296 
diagnosis  of,  296 
differentiation  of,  296 
etiology  of,  295 
incubation  in,  295 
pathology  of,  296 
prognosis  of,  296 
stages  of,  295 
symptoms  of,  295 
treatment  of,  296 
inoculation,  296 
late,  297 
primary  wound,  297 


996 


INDEX 


Hydrophobia,  treatment  of,  prophylactic, 

296 
Hydrops  articulorum  interraittens,  946 

pericardii,  391 

renum  cysticus,  664 
Hydrotherapy  in  typhoid  fever,  51 
Hydrqthorax,  472  I 

diagnosis  of,  473 

differentiation  of,  from  pleurisy,  465 

etiology  of,  472 

symptoms  of,  473 
Hymenolepis,  305 
Hyoscine,  57 

Hyoscyamus,  377,  430,  562 
Hyperaciditas  hydrochlorica,  528 
Hyperacusis,  885,  888 
Hyperchlorhydria,  diagnosis  of,  528 

differentiation  of,  517,  528 

etiology  of,  528 

in  gastric  ulcer,  513 

prognosis  of,  528 

symptoms  of,  528 

treatment  of,  516,  529 
Hyperesthesia  of  stomach,  532 
Hyperdiamorrhysis,  764 
Hyperglycemia,  725,  727 
Hyperkinesis  cordis,  337 

gastric,  531 
Hypernephroma,  663 
Hyperorexia,  533 
Hyperosmia,  873 
Hyperostosis  cranii,  722 
Hyperpituitarism,  720 
Hypersecretion,  gastric,  529 
Hypersusceptibility,  88 
Hyperthyroidism,  709 
Hypertrophy,  hemifacial,  882 
Hypnotism,  911 
Hypochlorhydria,  530 
Hypochondriasis,  807,  916 
Hypodermatoclysis,  77,  637 
Hypophysis,  diseases  of,  719 
Hypopituitarism,  720 
Hyposecretion,  gastric,  530 
Hysteria,  905 

course  of,  910 

diagnosis  of,  911 

differentiation  of,  109,  296,  840,  846, 
908 

etiology  of,  905 

prognosis  of,  910 

symptoms  of,  905 

treatment  of,  911 


Icing  liver,  369,  612,  616 
Icterus,  588 

acute  catarrhal,  etiology  of,  598 
prognosis  of,  598 
symptoms  of,  598 
treatment  of,  598 
febrile,  299 
in  cancer  of  liver,  579 
in  cirrhosis  of  liver,  571,  573,  587 
diagnosis  of,  587,  590 
differentiation  of,  587,  590 


Icterus,  epidemic,  299 
etiology  of,  588 
family  icterus,  590 
gravis,  566 
in  heart  disease,  369 
hematogenous,  588 
ictero-anemia,  590 
malarial,  240 
neonatorum,  589 
pneumonic,  71 
prognosis  of,  591 
symptoms  of,  589 
syphihtic,  205,  207 
treatment  of,  591 
in  typhoid  fever,  38 
urobilin,  369,  588,  590 
in  yellow  fever,  293 
Ichthyotoxismus,  970 
Idiocy,  amaurotic  family,  866 
Ileocolitis  in  children,  acute,  541 

dysenteric,  541 
Ileus,  dynamic,  552 
hysterical,  552 
Illuminating-gas  poisoning,  974 
Incoordination.     See  Ataxia. 
Indicanuria,  651 
Infantile  convulsions,  926 
diarrhea,  540 
paralysis,  cerebral,  786 

diplegic  form,  787 
hemiplegic  form,  786 
Infantilism,  722 
Infarcts.     See  Kidney,  etc. 
Influenza,  102 

bacteriology  of,  102 
diagnosis  of,  105 
'    differentiation  of,  105 
etiology  of,  102 
prognosis  of,  106 
symptoms  of,  103 
alimentary,  105 
circulatory,  105 
classification  of,  103 
duration  of,  103 
fever,  103 
geni  to-urinary,  105 
joint,  105 
muscle,  105 
nervous,  103 
respiratory,  104 
skin,  105 

types  of,  102,  103      • 
treatment  of,  106 
varieties  of,  102,  103 
Infusions,  saline,  77 
Insane,  paralysis  of,  802 
Insolation,  975 

Intermittent  limping,  334,  397 
Internal  capsule,  localizing  symptoms,  756 
Intestinal  dyspepsia,  534,  536 

obstruction,  548 
"Intestines,  actinomycosis  of,  194 
amyloidosis  of,  168,  204 
anthrax  of,  129 
arteriosclerosis  of,  398 
cancer  of,  553 

complications  of,  554 
diagnosis  of,  554 


INDEX 


997 


Intestines,    cancer    of,    differentiation  of, 
555 
etiology  of,  553 
pathology  of,  553 
symptoms  of,  554 
treatment  of,  555 
congestion  of,  369 
diseases  of,  534 
diverticula,  563 
foreign  bodies  in,  forms  of,  551,  552, 

559 
hemorrhage  of,  557  ^ 
diagnosis  of,  557 
etiology  of,  657 
symptoms  of,  557 
treatment  of,  557 
in  typhoid,  36,  55 
inflammation     of,     534,     536,     538, 

539 
neuroses  of,  563 

obstruction  of,  diagnosis  of,  552 
differentiation  of,  552,  602 
dynamic,  552 
foreign  bodies,  551 
gall-stones     causing,    551,    552, 

596 
intussusception,  548 
invagination,  548 
knots,  560 
strangulation,  549 
stricture,  651 
treatment  of,  653 
tumors,  553 
twists,  550 
volvulus,  560 
perforation  of,  typhoid,  37,  66 
syphihs  of,  204 
typhoid  fever,  hemorrhage,  36 

perforation,  37,  66 
tuberculosis  of,  167,  176 
tumors  of,  benign,  556 
cancer  of,  653 
sarcoma  of,  656 
ulceration  of,  539 

dysenteric,  120,  122,  123 
syphilitic,  204 
in  tuberculosis,  167,  176 
in  typhoid,  35 
m-emic,  631 
Intoxications,  17,  959 
Intubation  in  diphtheria,  89 
Intussusception  of  bowel,  648 
etiology  of,  548 
issues  of,  649 
pathology  of,  548 
symptoms,  549 
varieties  of,  548 
•Iodides.     See  Potas.  iodide. 
Iodine,  54,  484 
Iodoform,  61 
Ipecac,  124,  420 
Iridoplegia,  877 
Iritis,  syphiUtic,  214 
Iron,  therapeutics  of,  62,  86,   338,   377, 

635,  670,  671 
Ischialgia,  903 

Isthmus  aortse,  persistent,  379 
Itching,  treatment  of,  699 


Jaboulay's   sign  in  hour-glass   stomach, 

509 
Jacksonian  convulsions.     See  Epilepsy. 
Jalap,  636 

Jaundice.     See  Icterus. 
Jelhnek's  sign,  710 
Joffroy's  sign,  710 
Joints,  diseases  of,  951 

rheumatic,  281 

syphilis  of,  217,  218 

tuberculosis  of,  181,  182 
Jungle  fever,  240 
Justus's  test  in  syphilis,  209 


Kahler's  disease,  646 
Kakke,  972 
Kala  azar,  246 
KareU's  diet,  372 
Keratitis,  syphilitic,  214,  223 
Kernig's  sign,  91 
Ketonuria,  728 
Kidneys,  absent,  642 

amyloid  degeneration  of,  639 

differentiation  of,  640,  641 
etiology  of,  639 
pathology  of,  639 
symptoms  of,  642 
syphilitic,  207 
tuberculous,  168 
anomalies  of  secretion,  644 

of  structm-e,  642 
arteriosclerosis  of,  397,  627 
ascending  infection  of,  652 
calculus  of,  657 

chemistry  of,  658 
complications  of,  660 
diagnosis  of,  660 
differentiation  of,  660 
etiology  of,  667 
pathology  of,  658 
prognosis  of,  660 
symptoms  of,  668 
treatment  of,  660 
cancer,  complications  of,  662 
diagnosis  of,  662 
differentiation  of,  663 
etiology  of,  661 
pathology  of,  661 
prognosis  of,  662 
symptoms  of,  661 
treatment  of,  664 
congestion  of,  passive,  369,  638 
diagnosis  of,  639 
differentiation  of,  640,  641 
etiology  of,  638 
pathology  of,  638 
symptoms  of,  639 
contracted,  arteriosclerotic,  627 
ascending,  653 
embolic,  639 
primary,  627,  640,  641 
secondary,  625,  640,  641,  653 
cystic,  664 


998 


INDEX 


Kidneys,  cystic,  diagnosis  of,  665 
etiology  of,  664 
pathologj'  of,  664 
sj^mptoms  of,  664 
treatment  of,  665 
degeneration  of,  cj'stic,  664 
diseases  of,  619 
dislocation  of,  acquired,  643 

congenital,  643 
distoma  of,  316 

echinococcus  of,  complications  of,  666 
sjonptoms  of,  665 
treatment  of,  666 
embolism  of,  370,  639 
enstrongjdus  of,  316 
floating,  643 
functional  tests,  635 
horseshoe,  643 
hj'pernephroma,  663 
infarction  of,  370,  639 
large,  red,  624 

variegated,  624 
white,  624 
maKormations  of,  642 
movable,  643 

compUcations  of,  644 
diagnosis  of,  644 
etiologj^  of,  643 
prognosis  of,  644 
symptoms  of,  643 
treatment  of,  644 
of  pregnane}',  eclampsia  in,  622 
rudiment  arj-,  642 
sarcoma  of,  663 
stone  of,  657 
supernumerarj',  643 
"surgical,"  654 
sj-philis  of,  207 
tuberculosis  of,  177 
tumors  of,  661 
Klebs-Loeffler  bacillus,  78 
Kopftetanus,  135 
Ivoplik's  spots,  271 
Korsakow's  psychosis,  871 
Ivreatotoxismus,  969 
Kussmaul's  breathing,  730 
Kj-phosis,  rhachitic,  743 


L.\EiOGL0550PH.VRYXGEAL  paralysis,  808 
LabATinth,  inflammation  of,  95 
Lachr\Tiial    glands,    symmetrical    hyper- 
trophy of,  482,  691  " 
Lactic  acid  in  gastric  cancer,  522 
Lactosuria,  726 

La  Grippe.     See  Influenza,  102 
Landry's  parah^sis,  842 
Lane's  kink,  559 
Langerhans's  islands,  725 
insufficiency,  725 
Larjmgismus  stridulus,  108,  415,  716,  892 
Laryngitis,  acute  catarrhal,  414 

diagnosis  of,  415 

etiologj'  of,  414 

sjinptoms  of,  415 

treatment  of,  415 


Larj^ngitis,  acute,  in  children,  415 
fibrinous,  416 
nodose,  416 
submucous,  416 
suppurative,  416 
chronic  catan-hal,  416 

etiologj'  of,  416 
sjTuptoms  of,  416 
treatment  of,  416 
hj'pertrophic,  417 
pachj'dermia,  416 
tuberosa,  416 
diphtheritic,  81 
rheumatic,  484 
stridulous,  108,  415,  716,  892 
syphilitic,  209,  180 
LarjTix,  diseases  of,  414 
edema  of,  417 
erysipelas  of,  60 
paralysis  of,  404,  891-893 
perichondritis  of,  39,  417 
sjanptoms  of,  417 
treatment  of,  418 
spasm  of,  716,  892 
stenosis  of,  415,  416,  418 
syphilis  of,  180,  209 
tuberculosis  of,  180 
tumors  of,  418 
typhoid,  39 
idcerations  of,  418 
Lasegue's  sign,  282,  903 
LathjTism,  971 
Lead,  acetate,  55,  416,  741 

cohc,  differentiation  of,  966,  807 
poisoning,  acute,  965,  966 
chronic,  965,  966,  871 
Leishmaniasis,  245 
Leontiasis  ossea,  722 
Leprosy,  190 

bacteriology  of,  190 
course  of,  192 
diagnosis  of,  192 
differentiation  of,  849 
distribution  of,  190 
pathologj'  of,  191 
prognosis  of,  192 
symptoms  of,  191 
treatment  of,  192 
Leptomeningitis.     See  Meningitis. 
Leukanemia,  686 
Leukemia,  680 

classification  of,  680 
h-mphatic,  acute,  680 

diagnosis  of,  681 
s\Tiiptoms  of,  681 
chronic,  682 

com'se  of,  683 
diagnosis  of,  683 
.symptoms,  682 
mj^eloid,  683 

complications  of,  685 
diagnosis  of,  685 
difl'erentiation  of,  686 
prognosis  of,  686 
symptoms  of,  683 
treatment  of,  687 
Leukocythemia,  680 
Leukocj'tosis  in  pneumonia,  69 


INDEX 


990 


Leukocytosis,  v.  s.  Leukemia. 

in  sepsis,  19 
Leukoderma,  202 
Leukopenia  in  typhoid  fever,  32 
Leukoplakia,  sypliilitic,  203 

of  tongue,  480 
Levulose,  736 

Leyden-Curschmann  spirals,  429 
Licorice.     See  Glycyrrhiza. 
Lien  mobile,  706 
Lientery,  535,  606 
Life  assurance,  syphilis  and,  221 
Linitis  plastica,  509 
Lips,  tuberculosis  of,  175 
Lipuria,  650 
Liquor  antisepticus,  52 
Lithuria,  650 
Litten's  sign  in  pneumonia,  68 

in  pleurisy,  455 
Little's  disease,  788,  789 
Liver,  abscess  of,  575 
amebic,  576 

diagnosis  of,  577 
differentiation  of,  46,  47,  208, 

547,  578,  587 
pathology  of,  576 
symptoms  of,  hepatic,  576 
icterus,  577 
rupture,  577 
septic,  576 
treatment  of,  578 
cholangitic,  576 
differentiation  of,  206,  465,  577, 

578,  580,  587 
dysenteric,  122,  575 
etiology  of,  575 
pylephlebitic,  575 
septic,  575 
solitary,  575,  576 
tropical,  575,  576 
in  typhoid  fever,  38 
varieties  of,  575 
actinomycosis  of,  195 
amyloid,  168,  204,  583 
diagnosis  of,  583 
differentiation  of,  587 
etiology  of,  168,  583 
pathology  of,  583 
symptoms  of,  583 
anomalies  of,  584 
atrophy  of,  acute  yellow,  565 
course  of,  566 
diagnosis  of,  566 
differentiation   of,    566, 

587 
etiology  of,  565 
pathology  of,  565 
symptoms  of,  565 
treatment  of,  567 
cancer  of,  578 

diagnosis  of,  580 
differentiation  of,  206,  580,  587 
primary,  578,  580 
secondary,  578,  580 
symptoms  of,  ascites,  579 
cachexia,  579 
icterus,  579 
liver,  578 


Liver,  cancer  of,  treatment,  578 
cirrhosis  of,  567 
alcoholic,  567 
atrophic,  567 
biliary,  573 

diagnosis  of,  574 
differentiation  of,  574,  587 
etiology  of,  573 
symptoms  of,  573 
digestive,  573 
icterus,  573 
liver,  573 
nutrition,  574 
spleen,  573 
urine,  574 
treatment  of,  575 
capsular,  567 

cardio  tuberculosa,  167,  177 
classification  of,  567 
Glissonian,  567 
Hanot's,  573,  567 
hepatic  vein,  567 
in  heart  disease,  367 
Laennec's,  567 
malarial,  237 
mixed,  567 
Pick's  pseudocirrhosis,  571,    611, 

616 
pigmentary,  572 
portal,  567 

classification  of,  567 
complications  of,  570 
cardiac,  570 
febrile,  571 
hematemesis,  570 
hemorrhages,  570 
icterus,  571 
nephritis,  570 
peritonitis,  570 
pulmonary,  570 
course  of,  571 
diagnosis  of,  571 
differentiation  of,  571,  572, 

574,  587,  616,  637 
etiology  of,  567 
pathology  of,  567,  574 
prognosis  of,  571 
symptoms  of,  568 
general,  568 
liver,  568 
treatment  of,  medical,  572 
surgical,  573 
tuberculous,  167,  177 
congestion  of,  arterial,  585 
passive,  367,  585 

differentiation  of,  585,  587 
etiology  of,  585 
pathology  of,  585 
symptoms  of,  367,  585 
corset,  584 
cysts  of,  echinococcus,  580 

complications  of,  581 
diagnosis  of,  581 
differentiation  of,  581,  587 
multilocular,  307 
prognosis  of,  581 
rupture  of,  581 
symptoms  of,  580 


1000 


INDEX 


Liver,   cysts  of,   echinococcus,   treatment 
of,  582 
unilocular,  580 
hydatid,  differentiation  of,  581, 

587 
non-parasitic,  581 
diseases  of,  565 

differential  table  of,  587 
echinococcus,  580 
enlargement    of,    differentiation     of, 

from  pleurisy,  581 
fatty,  582 

differentiation  of,  587 
etiology  of,  582 
pathology  of,  582 
symptoms  of,  582 
floating,  584 
flukes,  317 
gumma  of,  206 
icing  liver,  612,  616,  571 
instJfficiency,  566,  570 
large,  causes  of,  571 
lobulated,  206 

nut-meg,  in  heart  disease,  367 
perihepatitis,  369 
sarcoma  of,  578 
smaU,  causes  of,  572 
syphilis  of,  205 

differentiation  of,  206,  587 
gummatous,  206 
interstitial,  205 
tuberculosis  of,  167,  177 
tumors  of,  578 
wandering,  584 
zuckerguss,  612,  616,  571 
Lobeha,  430 
Lock-jaw,  133 
Locomotor  ataxia,  849 

system,  diseases  of,  949 
Loeffler's  solution,  86 
Ludwig's  angina,  84,  482 
Lues  venerea,  197 
Luetin,  219 
Lumbago,  950 
Lumbar  punctiu-e,  57,  93,  94,  637 

and  injections,  95 
Lmnpy-jaw,  194 
Lungs,  abscess  of,  442 

bacteriology  of,  442 
diagnosis  of,  443 
differentiation  of,  443 
etiology  of,  442 
patholog\'  of,  442 
pneumonic,  71 
prognosis  of,  443 
symptoms  of,  443 
treatment  of,  443 
in  typhoid  fever,  39 
actinomycosis  of,  195 
anthi'acosis  of,  440 
anthrax  of,  130 
arteriosclerosis  of,  398 
atelectasis  of,  441 
acquired,  441 

etiology  of,  441 
pathology  of,  441 
symptoms  of,  441 
treatment  of,  441 


Lungs,  atelectasis  of,  congenital,  441 
etiology  of,  441 
pathologj^  of,  441 
symptoms  of,  441 
treatment  of,  441 
calculi  of,  427 
cavities  of,  differentiation  of,  472 

signs  of,  159 
chalicosis  of,  440 
circulatory  affections  of,  448 
cirrhosis  of,  438,  464 
congestion  of,  active,  448 
passive,  368,  448 

treatment  of,  449 
in  typhoid  fever,  39 
diseases  of,  430 
echinococcus  of,  306 
edema  of,  450 

etiology  of,  450 
in  heart  disease,  368 
pathology  of,  450 
symptoms  of,  450 
treatment  of,  450 
embolism  of.     See  Infarct  of. 
emphysema  of,  430 
diagnosis  of,  433 
differentiation  of,  433 
etiology  of,  431 
interstitial,  433 
pathogenesis  of,  431 
pathology  of,  431 
prognosis  of,  433 
S3'mptoms  of,  431 
treatment  of,  433 
erysipelas  of,  60 
fever,  62 
flukes,  317 

gangrene  of,  bacteriology  of,  444 
complications  of,  445 
course  of,  446 
diagnosis  of,  446 
differentiation  of,  446 
etiology  of,  444 
pathology"  of,  444 
physical  signs  of,  445 
pneumonic,  71 
prognosis  of,  446 
sjTnptoms  of,  445 
treatment  of,  446 
in  typhoid  fever,  39 
hemoptysis,  450 
hemorrhage  of,  154,  450 
hj-pertrophy  of,  433 
hypostasis  of,  39,  57,  448,  449 
indm-ation  of,  162,  438,  464 
brown,  368,  448 
pneumonic,  71 
infarct  of,  449 

diagnosis  of,  73,  449 
etiology  of,  449 
pathology  of,  449 
s^TQptoms  of,  449 
in  typhoid,  39 
interlobar  fissures  of,  463 
parasites  of,  316 

distoma,  316,  317 
echinococcus,  306 
pneumokoniosis,  440 


INDEX 


1001 


Lungs,  senile,  433 
siderosis  of,  440 
stoneSj  427 
syphilis  of,  q.  v. 
tuberculosis  of,  q.  v. 
tumors  of,  446 
cancer,  446 

etiology  of,  446 
physical  signs  of,  447 
symptoms  of,  447 
differentiation  of,  407,  465 
lymphosarcoma,  448 
sarcoma,  448 
Lupus,  183 
Lymphadenitis,  anthracosis,  440 

glands,  tuberculosis  of,  169,  109,    689 
Pfeiffer's,  298 
Lymphangitis,  differentiation  of,  60 
Lymphatism,  719 
Lymphemia,  acute,  680 

chronic,  682 
Lymphoma,  malignant,  687 
Lymphosarcomatosis,  690 
Lyssa,  298 

M 

Magnesium  carbonate,  502,  518 
oxide,  501 
sulphate,  137,  636 
Maidism,  971 
Maladie  de  Roger,  379 

de  Woillez,  448 
Malaria,  229 

cachexia  of,  238 

chronic,  238 

diagnosis  of,  240 

differentiation   of,    46,    47,  239,   240, 

241 
etiology  of,  230 

Plasmodium,  230 

forms    of,    estivo-autumnal, 
231 
half-moons,  232 
quartan,  230 
tertian,  231 
latency,  238 
pernicious,  239 

etiology  of,  239 
forms  of,  239 
algid,  240 
alimentary,  240 
biliary,  240 
cerebral,  240 
comatose,  240 
convulsive,  240 
hemoglobinuric,  240 
hemorrhagic,  240 
meningeal,  240 
typhoid,  239 
prognosis  of,  241 
relapses  of,  238 

relation  of,  to  other  diseases,  238 
spontaneous  recovery  from,  241 
sjrmptoms  of,  233 
blood,  235 
circulatory,  236 
digestive,  237 


Malaria,  symptoms  of,  fever,  233 
estivo-autumnal,  235 
quartan,  234 
tertian,  235 
genito-urinary,  237 
nervous,  238 
respiratory,  237 
skin,  236 
spleen,  236 
treatment  of,  241 

prophylactic,  241 
specific,  242 
symptomatic,  242 
Mai  perforant  de  pied,  192,  730,  806,  854 
Male  fern,  303 
Mallein,  131 
Malta  fever,  125 

complications  of,  126 
course  of,  126 
diagnosis  of,  126 
etiology  of,  125 
prognosis  of,  126 
symptoms  of,  125 
treatment  of,  126 
types  of,  126 
Mammae,  syphilis  of,  218 

tuberculosis  of,  180 
Mania,  807 
Mania  a  potu,  961 
Marriage  after  syphilis,  224 
Mastitis,  syphihtic,  218 
Measles,  270 

clinical  course  of,  270 

diagnosis  of,  274 

differentiation  of,  106,  249,  254,  255, 

273 
etiology  of,  270 

German.     See  German  measles, 
prognosis  of,  274 
stages  of,  270 
symptoms  of,  271 
digestive,  273 
eruption,  271 
fever,  272 
general  course,  270 
genito-urinary,  273 
nervous,  273 
respiratory,  272 
treatment  of,  274 

of  complications,  274 
Meat  poisoning,  969 
Meat-juice,  52  - 
Meckel's  diverticulum,  549 
Mediastinal  hemorrhage,  476 
pleurisy,  462 
tumors,  474 
Mediastinitis,  acute,  475 

chronic,  389 
Mediastinopericarditis,  389 
Mediastinum,  diseases  of,  474 
Medulla,  diseases  of,  761 
Megalogastria,  507 
Megalomania,  804 
Melanemia  in  malaria,  236 
Melanoderma,  701,  702 
Melanoglossia,  481 
Melanotrichia  linguse,  481 
Melanuria,  579 


1002 


INDEX 


Melasma  suprarenale,  702 
Meniere's  disease,  diagnosis  of,  889 
etiology  of,  888 
symptoms  of,  889 
treatment  of,  889 
Meninges,  carcinoma  of,  212 
cerebral,  diseases  of,  814 
hemoi'rhage  into,  816 
inflammation  of,  89 
spinal,  diseases  of,  829 

hemorrhage,  829 
pachymeningitis,  829 
tumors  of,  830 

differentiation   of,    213, 
832 
tuberculosis  of,  175 
tumors  of,  830 
sarcoma  of,  212 
Meningismus,  34,  95 
Meningitis,  carcinomatous,  212 
chronic,  818 

epidemic  cerebrospinal,  89 
bacteriology  of,  89 
clinical  forms  of,  93 
complications  of,  93 
diagnosis,  93 
differentiation,  46,  47,  93,  94, 

95,  101 
etiology  of,  89 
pathology  of,  89 
prognosis  of,  93 
sequelae  of,  93 
symptoms  of,  89 
treatment  of,  95 
in  influenza,  103 
pachymeningitis,  814 
pneumococcic,  71,  94 
sarcomatous,  212 
serous,  818 

differentiation  of,  93,  94 
symptoms  of,  818 
suppurative,  846 

differentiation  of,  46,  47,  94,  95, 

240 
pathology  of,  817 
symptoms  of,  818 
syphilitic,  212 
tuberculous,  150 

differentiation  of,  14,  46,  47,  94, 

95,  148,  149 
etiology  of,  150 
pathology  of,  150 
symptoms  of,  151 
in  typhoid  fever,  33 
Meningococcus  intracellularis,  89 
Meningomyelitis,  837 
Menthol,  86,  412,  538     ' 
Meralgia  paresthetica,  901 
Mercury,  223,  224,  225,  226,  227,  228,  229 
intoxication  by,  478.     See  Hydrargy- 
rum. 
Merycismus,  532 

Mesenteric    glands,    suppuration    of,    in 
typhoid  fever,  38 
tuberculosis  of,  170 
vessels,  dilatation  of,  564 
embolism  of,  564 
periarteritis  of,  410 


Mesenteritis,  173,  564,  610,  616 
Mesentery,  diseases  of,  564 
embolism  of,  564 
hemorrhage  of,  564 
inflammation  of,  564 
suppuration  of,  564 
tumors  of,  564 
Metabolism,  diseases  of,  725 
Metastasis,  20 
Metatarsalgia,  942 
Metazoan  diseases,  302 
Meteorism  in  typhoid  fever,  35,  55 
Methyl  blue,  653 
Micrococcus  catarrhalis,  419 

melitensis,  125 
Microgastria,  509 
Micromania,  805 
Micromelia,  713,  721 
Migraine,  937 

diagnosis  of,  938 
etiology  of,  937 
ophthalmoplegic,  877 
prognosis  of,  938 
synaptoms  of,  937 
treatment  of,  939 
Mikulicz's  di.sease,  482,  691 
Miliaria,  differentiation  of,  260 
in  pneumonia,  69 
in  typhoid  fever,  30 
Miliary  fever,  299 

tuberculosis,  46,  47,  146 
Milk  diet,  52,  634 
poisoning,  970 
sickness,  300 
Millar's  asthma,  718 
Mimetic       movements      of      expression, 

758 
"Mind-blindness,"  753,  754 
Mitral  insufficiency,  357 

diagnosis  of,  358,  361 
etiology  of,  357 
mechanism  of,  357 
physical  signs  of,  357 
prognosis  of,  370 
treatment  of,  371 
stenosis,  359 

diagnosis  of,  361 
differentiation,  332,  361 
etiology  of,  359 
mechanism  of,  359 
physical  signs  of,  359 
prognosis  of,  370 
treatment  of,  371 
Mobius's  sign,  710 
Mogigraphia,  932 
MoUer's  disease,  697 

Monoplegia,      m     cerebral      thrombosis, 
780 
cortical,  750 

internal  capsule,  lesion  in,  759 
MorbiUi,  270 
Morbus  coeruleus,  380 
coxae  senilis,  953 
maculosus  neonatorum,  694 
Werlhofii,  693 
Moro's  test,  164 

Morphine,  56,  57,  77,  110,  377,  429 
Morphinism,  963 


INDEX 


1003 


Morphinomania,  963 
Morvan's  disease,  848 
Mosquito,  conveyance  of  malaria  by,  230, 
232,  241 
yellow  fever,  289 
Motor  cortex,  749 
tracts,  819 

degeneration  of,  822 
Mountain  fever,  300 
Mouth,  diseases  of,  477 
syphilis  of,  203 
washes,  52,  477,  478 
Movements,  associated,  771 
forced,  762 
mimetic,  758 

resisted,  in  heart  disease,  323 
Muguet,  479 
Multiple  neuritis,  869 

sclerosis,  843 
Mumps,  279 

complications  of,  280 
diagnosis  of,  280 
etiology  of,  279 
prognosis  of,  281 
sequels  of,  280 
symptoms  of,  279 
treatment  of,  281 
Muscles,  diseases  of,  949 

motor     cortex,    v.    cerebral    localiza- 
tion tracts,  819 
syphilis  of,  218 
tuberculosis  of,  167,  183 
Muscular  atrophy,  arthritic,  861 
neuritic,  862 
progressive  spinal  860 

diagnosis  of,  861 
differentiation   of,    100, 

841,  861,  864 
etiology  of,  860 
pathology  of,  860 
prognosis  of,  861 
symptoms  of,  860 
treatment  of,  861 
dystrophy,  862 

diagnosis  of,  864 
differentiation  of,  100,  864 
infantile  atrophic,  863 
juvenile,  864 
pseudohypertrophic,  862 
treatment  of,  864 
Musset's  sign,  352 
Myalgia,  950 

capitis,  950 
Myasthenia,  gravis,  810 

differentiation  of,  810 
pseudoparalytica,  810 
Myasthenic  reaction,  810 
Mycosis  intestinalis,  129 
Mycotic  plugs,  421 
Mydriasis,  syphilitic,  215 
Myelasthenia,  913 
Myelemia,  683 
Myelitis,  acute,  836,  837 
course  of,  838 
diagnosis  of,  840 
differentiation  of,  101,  840,  872 
disseminated,  841 
etiology  of,  837 


Myelitis,  acute,  localization  of,  839 
pathology  of,  837 
prognosis  of,  838 
symptoms  of,  838 
transverse,  837 
treatment  of,  840 
annular,  837 
chronic,  841 
cortical,  837 
Myeloma,  multiple,  690 
Myelomalacia,  214,  833 
Myocarditis,  acute,  328 
diagnosis  of,  329 
etiology  of,  328 
pathology  of,  328 
symptoms  of,  329 
treatment  of,  329 
chronic  fibrous,  329 

diagnosis  of,  331 
differentiation  of,  331 
etiology  of,  329 
pathogenesis  of,  330 
pathology  of,  329 
prognosis  of,  332 
symptoms  of,  331 
treatment  of,  333 
in  diphtheria,  82 
rheumatic,  283 
segmentary,  82,  329 
syphilitic,  207 
in  typhoid  fever,  31 
Myocardium,     diseases     of,     319. 
Heart, 
fragmentation,  82,  329 
myofibrosis,  329 
myolysis,  82,  329 
myomalacia  cordis,  330 
parasites  of,  336 
segmentation,  82,  329 
syphilis,  207 
tuberculosis,  181 
tmnors  of,  336 
Myoclonia,  930 
Myofibrosis,  myocarditis,  329 
Myoidema,  167 
Myolysis  in  diphtheria,  82 

myocardial,  329 
Myomalacia,  cordis,  330 
Myopathies,  862 
Myositis,  949 

fibrositic,  949 
ossificans,  950 
rheimiatic,  284 
syphilitic,  218 
trichinae,  310 
Myotonia,  933 

etiology  of,  933 
symptoms  of,  933 
treatment  of,  934 
MyiTh,  268,  477 
Myrtol,  188 
Mytilotoxismus,  970 
Myxedema,  712 
of  adults,  713 
of  children,  712 
differentiated,  709,  713 
operative,  714 
treatment  of,  714 


See 


1004 


INDEX 


N 


Xasal  feeding  in  tj'phoid  fever,  52 
Xasopbaiynx,  tuberculosis  of,  180 
Xauheim  baths  in  heart  disease,  323,  324 
X'eck,  actinomycosis  of,  193 
rigidity,  meningitic,  90 
Xeck  sign,  91 

Xegri  bodies  in  hydrophobia,  296 
Xematodes,  diseases  caused  by,  307 
Xephrectomy,  657,  661,  664 
Xephritis,  acute,  619 
cholera,  622 
course  of,  622 
diagnosis  of,  622 
,      differentiation  of,  622,  640,  641 
etiologj'  of,  619 
hemoglobinuric,  622 

kidney  of  pregnane}^,  622 
patholog}'  of,  619 
prognosis  of,  622 

recurrent,  622 
s\Tnptoms  of,  albuminuria,  620 
anasarca,  620 
anemia,  621 
casts,  620 
heart,  620 
xn-iue,  620 
treatment,  623 
tjTDes  of,  622 
clu-onic,  624 

interstitial,  627 

complications  of,  630,  632 
diagnosis  of,  632 

of    cardiac    symptoms, 

632 
of  m'emia,  632 
of  urinary  findings,  632 
differentiation  of,  632,  640, 

641 
etiology  of,  393,  627 
pathology  of,  627 
prognosis  of,  633 
symptoms  of,  628 

cardiovascular,  396,  629 
digestive,  631 
hemorrhages,  632 
inflammations,  632 
retinitis,  629 
uremia,  630 
urinary,  628 
treatment  of,  633 
parenchymatous,  624 

compHcations  of,  626 
death  in,  causes  of,  626 
diagnosis  of,  626 
differentiation  of,  640,  641 
etiology  of,  624 
pathology  of,  624 
prognosis  of,  627 
symptoms  of,  625 
anemia,  626 
cardiovascular,  626 
edema,  626 
urinar}',  625 
treatment  of,  633 
treatment  of,  climate,  633 
diet,  633 


Xephritis,  chronic,  treatment  of,  diuretics, 
635 

edema,  636 

heart  stimulants,  637 

incisions,  637 

rest,  633 

sweating,  636 

vasodilators,  637 

venesection,  637 

water,  635 
in  cirrhosis  of  liver,  570 
diphtheritic,  83 
gouty,  740 
in  malaria,  237 
in  pneumonia,  70 
scarlatinal,  264 
suppurative,  652,  654 
syphihtic,  207 
tuberculous,  168 
tjTDhoid,  40 
Xephrohthiasis,  657 
Xephi-ohthotomy,  661 
Xephrorrhaphy,  644 
Xephi'otomj',  654,  657,  661 
Xerves.     See  also  Paralysis, 
anterior  crural,  901 
auditoiy,  paralysis  of,  887 
brachial  plexus,  900 
circumflex,  898 
cranial,  diseases  of,  873 
diseases  of,  867 
eighth,  disease  of,  887 
eleventh,  disease  of,  894 
facial,  paralysis  of,  central,  885 

peripheral,  883 
spasm  of,  887 
fifth,  paralysis  of,  880,  881 

spasm  of,  882 
fourth,  disease  of,  875 
glossopharyngeal,  890 
hjT^oglossal,  disease  of,  896 
lumbar  plexus,  901 
median,  899 
musculospiral,  898 
rdnth,  890 
obturator,  901 
olfactory,  873 
optic,  873 
peroneal,  902 
phrenic,  897 
popliteal,  902 
posterior  thoracic,  898 
recurrent  larjmgeal,  paralysis  of,  890, 
893 

spasm  of,  891,  892 
sacral  plexus,  902 
sciatic,  902 

seventh,  disease  of,  885 
sixth,  disease  of,  875 
spinal  accessory,  paralysis  of,  895 

spasm  of,  895 
superior  gluteal,  902 
suprascapular,  898 
syphiHs  of,  214 
tenth,  890 

thu'd,  disease  of,  875 
tweh'th,  disease  of,  896 
uhiar,  899 


INDEX 


1005 


Nerves,  vagus,  890 
Nervous  fever,  24 
diseases,  749 
Neuralgia,  939 

cervicobrachial,  941 
cervico-occipital,  940 
diabetic,  730 
etiology  of,  939 
in  influenza,  104 
intercostal,  942 
lumbar,  942 
in  malaria,  238 
phrenic,  941 
sacral,  942 
symptoms  of,  940 
treatment  of,  943 
trifacial,  940 
visceral,  942 
Neurasthenia,  912 
course  of,  916 
diagnosis  of,  916 
differentiation  of,  807,  916 
etiology  of,  913 
prognosis  of,  916 
symptoms  of,  913 
treatment  of,  916 
types  of,  913 
Neuritis,  867 

brachial,  900 

diabetic,  730 

diagnosis  of,  869 

in  diphtheria,  83 

etiology  of,  867 

facial,  883 

hypertrophic,  868 

in  influenza,  104 

lead  poisoning  causing,  967 

in  leprosy,  191 

multiple,  869 

diagnosis  of,  871 
differentiation  of,  100,  101, 

871,  872 
etiology  of,  869 
pathology  of,  870 
prognosis'of,  871 
symptoms  of,  870 
treatment  of,  872 
optic,  92,  873 
pathology  of,  867 
rheumatic,  285 
sciatic,  903 
symptoms  of,  867 
treatment  of,  869,  872 
in  typhoid  fever,  32,  34 
Neuroma",  872 
Neurones,  819 

motor,  752,  819 
sensory,  823 
Neuroses,  905 
fatigue,  932 
occupation,  932 
traumatic,  918 
trophic,  944 
vasomotor,  944 
Nigrities  linguae,  481 
Nitroglycerin,  therapeutics  of,    269, 

399,  400,  429,  939 
Nitromuriatic  acid,  58 


Nocardiosis,  196 

Nodes,  rheumatic,  284,  286 

Noma  oris,  479 

Nose,  diphtheria  of,  81 

diseases  of,  411 

saddle-back,  209 

syphilis  of,  209 

tuberculosis  of,  180 
Nucleo-albumin,  tests  for,  646 
Nystagmus,  880 

in  multiple  sclerosis,  844 


Oatmeal  diet,  736 
Obermeir's  spirillum,  243 
Obesity,  746 

etiology  of,  746 
Frohch's  type,  720,  722 
symptoms  of,  746 
treatment  of,  746 
Ochronosis,  651 
Oertel's  cure,  747 

treatment  of  heart  disease,  323 
Oidiomycosis,  196 
Oidium  albicans,  479 
Oleum  olivse,  518 
ricini,  562,  943 
tiglii,  270,  774 
Oligocardia,  341 
Oligochromemia,  668 
Ophthalmia,  diphtheritic,  82 

neuroparalytic,  881 
Ophthalmoplegia,  progressive  nuclear,  879 

syphilitic,  215 
Ophthalmo-reaction,  164 
Opisthotonos,  91,  134 
Opium,  coma  from,  772 
poisoning,  acute,  963 

chronic,  963 
therapeutics  of,  55,  77,  124,  188,  225, 
268,  415, 420,  422,  429,  558,  736.  See 
also  Morphine,  Codeine,  Heroine. 
Oppler-Boas  bacillus,  423 
Optic  atrophy,  multiple  sclerosis,  845 
syphilitic,  215 
tabetic,  853 
typhoid,  41 
centre,  753,  874 
chiasm,  873 
nerve,  873,  874 
neuritis,  873 

in  brain  abscess,  800 
in  meningitis,  92 
syphilitic,  215 
in  typhoid  fever,  41 
thalamus,  localizing  symptoms,  758, 

794 
tract,  874,  875 
Orchitis,  in  mumps,  280 
syphilitic,  216 
in  typhoid  fever,  41 
Oriental  sore,  245 
Osmic  acid  injection,  943 
336,    Osteitis  deformans,  722 

Osteo-arthropathie    hypertrophiante    pneu- 
i      monique,  168,  425,  722 


1006 


INDEX 


Osteo-arthropathy,  hypertrophic,  168,  425, 

722 
Osteochondritis,  syphilitic,  223 
Osteomalacia,  956 
Osteomyelitis.    See  Septic  infections,  22 

in  typhoid  fever,  41 
Otitis,  diphtheritic,  82 

media,  brain  abscess  from,  799 
sinus  thrombosis  from,  784 

measles,  274 

scarlatinal,  265 
Ovary,  syphilis  of,  217 
Oxaluria,  651 
Oxycephaly,  957 
Oxygen,  therapeutics  of,  77 
Oxyuris  vermicularis,  308 
Ozena,  413 


Pachydermia,  203,  713 
Pachymeningitis,    cervical    hypertrophic, 
829 
external,  814 

hemorrhagic,  diagnosis  of,  815 
differentiation  of,  807,  815 
etiology  of,  803,  814 
pathology  of,  803,  814 
prognosis  of,  815 
symptoms  of,  815 
treatment  of,  815 
internal,  814 
Paget 's  disease,  722 
Pain,  abdominal,  36,  547,  563 

centre  for,  754 
Palate,  tuberculosis  of,  175 
Palpitation  of  heart,  337 
Palsy,  shaking,  934 
Pancreas,  calculi  of,  604 

cancer  of,  differentiation  of,  606 

symptoms,  605 
cysts  of,  604 

diagnosis  of,  604 
etiology  of,  604 
pathology  of,  604 
symptoms  of,  604 
treatment  of,  605 
diseases  of,  601 
hemorrhage  from  603 
inflammation  of,  acute,  601 

chronic,  603 
necrosis,  601 
syphilis  of,  205 
tumors  of,  605 

differentiation  of,  606 
symptoms  of,  605 
treatment  of,  606 
Pancreatitis,  acute,  diagnosis  of,  601,  602 
differentiation,  602 
etiology  of,  601 
prognosis  of,  602 
symptoms,  601 
treatment  of,  603 
chronic,  etiology  of,  603 
pathology  of,  603 
prognosis  of,  603 
symptoms  of,  603 
treatment  of,  603 


Paracentesis,  abdomen,  616 

chest,  388,  458,  467 
Paradysentery,  119 
Paragonimus  Westermanni,  317 
Paralysis.     See  Monoplegia,  Hemiplegia, 
Paraplegia,  and  Nerves, 
agitans,  934 

diagnosis  of,  936 
differentiation  of,  845,  936 
etiology  of,  934 
pathology  of,  934 
prognosis  of,  936 
symptoms  of,  934 
treatment  of,  936 
alternating,  759,  760 
anterior  crural,  901 
of  auditory  nerve,  887 
Bell's,  883 
brachial  plexus,  900 
Brown-Sequard's,  835 
bulbar,  apoplectiform,  100,  780,  811 
asthenic,  810 
chronic,  808 
caisson,  834 
circumflex,  898 
combined,  of  arm  nerves,  900 
compression,  spinal,  831 
conjugate,  760 
cortical,  750,  793 
crossed,  759,  760 
diphtheritic,  83 
diver's,  834 
facial,  883 

diagnosis  of,  885 
etiology  of,  883 
localization  of,  760,  885 
pathology  of,  883 
prognosis  of,  886 
symptoms  of,  883 
in  tetanus,  135 
treatment  of,  886 
of  fifth  nerve,  880 
of  fom'th  nerve,  877 
Gublers's,  760 
hemiplegia,  q.  v. 
hypoglossal,  808,  896 
hysterical,  908 
infantile  cerebral,  96,  786 
diplegic,  787 

diagnosis  of,  789 
etiology  of,  787 
pathology  of,  787 
symptoms  of,  788 
treatment  of,  789 
hemiplegic,  786 

diagnosis  of,  787 
etiology  of,  786 
symptoms  of,  786 
treatment  of,  789 
of  insane,  802 
labioglossopharyngeal,  808 
Landry's,  100,  842 
laryngeal,  891 

recm-rent,  404,  891,  893 
lead,  967 

lumbar  plexus,  901 
in  malaria,  240 
median,  899 


INDEX 


1007 


Paralysis  in  meningitis,  92 

monoplegia,  q.  v. 

musculospiral,  898 

ninth,  890 

obturator,  901 

ocular,  759,  760,  798,  853,  875,  879 

oculomotor,  759,  760,  798,  853,  875, 
876,  877,  878 

paraplegia,  q.  v. 

periodic  family,  213,  858,  936 

peroneal,  902 

phrenic,  897 

pophteal,  902 

posterior  thoracic,  898 

progressive,  of  insane,  802 

pseudo-,  697 

pseudobulbar,  810 

pupil,  877 

recurrent,  877 

sacral,  902 

sciatic,  902 

seventh,  883 

sixth  nerve,  877 

spinal  accessory,  894 

superior  gluteal,  902 

suprascapular,  898 

of  sympathetic  nerves,  879,  944 

third  nerve,  876 

ulnar,  899 

uremic,  630,  631,  632,  633,  772 

vagus,  809,  890 

of  vocal  cords,  891,  893 

Weber's,  759 
Paramyoclonus  multiplex,  930 
Paramyotonia,  ataxic,  934 

congenital,  934 
Paranephritis,  654 
Paraplegia,  ataxic,  866 

in   cerebral   infantile   paralysis,    787, 
788 

cerebral,  749 

dolorosa,  826,  831 
hysterical,  840,  908 

spastic  spinal,  857 
Paraplegic  state,  841 
Parapleuritis,  462 

Parasites,  diseases  due  to  animal,  302 
Parathyroid  glands,  715 
Paratyphoid  fever,  26,  45,  46 
differentiation  of,  46 
microorganisms  of,  46 
symptoms  of,  46 
Paregoric.     See  Opium. 
Paresis  analgesique  avec  panaris,  848 
Parkinson's  disease,  934 
Parorexia,  533 
Parosmia,  873 
Parotitis,  acute,  481 
chronic,  482 
epidemic,  279 
postoperative,  281 
secondary,  281 
in  typhoid  fever,  34 
Parrot's  disease,  697 

ulcers,  478 
Pasteur  treatment,  296 
Pastia's  sign,  262 
Favor  nocturnus,  488 


Peliosis  rheumatica,  692 
Pellagra,  971 

differentiation  of,  971 
Pelletierine,  303 
Pelvis,  rhachitic,  744 
Penis,  syphilis  of,  216 
Pentosuria,  733 
Pepsin,  test  for,  in  stomach,  500 

therapy  of,  502 
Periarteritis  nodosa,  410 
Pericarditis,  381 
adhesive,  389 

diagnosis  of,  390 
prognosis  of,  390 
symptoms  of,  389 

cardiac  insufficiency,  389 
diastolic   collapse   of   veins, 
389 
recoil,  389 
inspiratory  swelling  of  veins, 

389 
paradoxical  pulse,  389 
retraction  of  apex,  389 
of  chest  wall,  389 
treatment  of,  390 
differentiation  of,  from  pleurisy,  386, 

465 
effusive,  382 

course  of,  388 
diagnosis  of,  386 

character  of  exudate,  387 
dulness,  386 
friction-rub,  386 
pathology  of,  382 
physical  signs  of,  383,  385 
prognosis  of,  388 
symptoms  of,  383 
treatment  of,  388 
etiology  of,  381 
externa,  386 
fibrinous,  382 
^  physical  findings  of,  382 

>  symptoms  of,  382 

pneumococcic,  71 

pseudoch-rhosis  of  liver  in,  571,  616 
rheumatic,  283,  286 
syphilitic,  208 
tuberculous,  171,  387 
Pericardium,  diseases  of,  381 
tuberculosis  of,  171,  387 
Perichondritis,  laryngeal,  in  typhoid  fever, 
39 
of  larynx,  209,  417 
Perihepatitis,  369,  612,  616 
differentiation  of,  616 
Perinephric  abscess,  654    - 
diagnosis  of,  655 
etiology  of,  654 
symptoms  of,  654 
Perinephritis,  195,  654 
Periostitis,  rheumatic,  284 
syphilitic,  217 
in  typhoid  fever,  41 
Peripleuritis,  195,  462 
Perisplenitis,  612,  706 
Peristaltic  unrest,  531 
Peritoneum,  cancer  of,  613 

differentiation  of,  616 


1008 


INDEX 


Peritoneum,  diseases  of,  607 

tuberculosis  of,  172 
Peritoiiitis  in  cirrhosis  of  liver,  570 
diffuse,  acute,  607 

course  of,  607 
diagnosis  of,  609 
differentiation  of,  610 
etiology  of,  607 
perforative,  609 
pneiunococcic,  609 
puerperal,  22,  609 
symptoms     of,     abdominal, 
607 
general,  608 
local,  607 
treatment  of,  610 
types  of,  609 
chronic,  610 

differentiation  of,  615,  616 
deforming,  610 
hemorrhagic,  chronic,  612 
localized,  611 

adhesive,  612 

perihepatitis,  612 
suppurative,  611 

pyopneumothorax,  sub- 

phrenicus,  611 
subphrenic  abscess,  611 
tuberculous,  172,  173,  174,  616 
typhoid  perforation  causing,  37 
Peritonsillar  abscess,  487 
Perityphhtis,  194,  544 
Perles,  asthma,  429 

Pernicious    anemia.       See    Anemia,    per- 
nicious. 
Pertussis.     See  Whooping  cough. 
Peru,  balsam  of,  422 
Pest.     See  Plague. 
Pesticemia  in  plague,  q.  v. 
Petechiae  in  tjqjhus  fever,  277 
Petit  mal,  922 
PharjTigitis,  acute,  485 
chronic,  485 
diphtheritic,  80 
phlegmonous,  485 
ulcerative,  485 
PharjTxx,  disease  of,  483 
erysipelas  of,  59,  61 
paralysis  of,  890 
spasm  of,  891 
syphihs  of,  203 
tuberculosis  of,  175 
typhoid  ulcers  of,  35 
lilceration  of,  485 
Pfeiffer's  fever,  298 
Phenacetin.     See  Acetphenetidin. 
Phenol,  55,  137,  268,  412,  484,  497 
Phenylhydrazin  test,  728 
Phenylis  salicylas,  50,  57,  288,  535,  538 
Phlebitis,  pneumococcic,  71 
portal  vein,  586 
septic,  20 
syphilitic,  208 
typhoid,  31 
Phlebosclerosis,  395 
Phlebotomy,  77,  372,  637,  774 
Phlegmon,  differentiation  of,  60 
Phosphates  in  urine,  650 


Phosphaturia,  650 
Phosphorus  poisoning,  745 

therapy  of,  745 
Phrenocardia,  337 
Phthisis,  152 

aneurysmal,  405 
fibroid,  162,  438 
ventricuh,  503 
Pick's  pseudocirrhosis,  571,  616 
Pigeon-breast,  489,  743 
Pigmentation  in  Addison's  disease,  701 
Piles,  557 
Pilocarpine,  637 
Pirquet's  test,  164 
Placenta,  syphilis  of,  222 
Plague,  115 

diagnosis  of,  118 
etiology  of,  115 
prognosis  of,  118 
symptoms  of,  116 
treatment  of,  118 
Plasmodium  malarise,  229,  240 
Pleura,  diseases  of,  453 

tuberculosis  of,   162,    171,   454,   460, 

461 
tumors  of,  474 
Pleurisy,  453 

bacteriology  of,  454 
in  children,  462 
chyliform,  461 
com-se  of,  466 
cytodiagnosis  in,  460 
diagnosis  of,  464 

diaphragmatic,  461 
differentiation  of,   73,   74,   464,   465, 

581,  611 
empyema,  454,  460 
necessitatis,  460 
pneumococcic,  70,  460 
pulsans,  460 
streptococcic,  460 
treatment  of,  468 
etiology  of,  453 
fibrinous,  460 
forms  of,  459 
hemorrhagic,  461 
in  influenza,  104 
interlobar,  462 
issues  of,  462 
mediastinal,  462 
parapleuritis,  462 
peripleuritis,  462 
physical  signs  of,  454 

auscultation,  457 
diagnostic  puncture,  458 
inspection,  454 
palpation,  455 
percussion,  455 
pneumococcic,  70,  460 
polymorphous,  458 
prognosis  of,  466 
purulent,  454,  460 
putrid,  461 
rheumatic,  284 
serous,  454,  459 
streptococcic,  460 
suppurative,  454,  460 
symptoms  of,  454,  459 


INDEX 


1009 


Pleui'isy,  treatment  of,  466 
aspiration,  467 
in  tuberculosis,    162,    171,   453,   454, 

460,  461 
in  typhoid  fever,  40 
.r-ray  findings,  458 
Pleuritic  friction,  386,  457,  464 
Pleurodynia,  950 
Pleuropericardial    friction,    diagnosis    of, 

386 
Pleuropneumonia,  62 
Plumbism,  965 
Pneumatosis  peritonei,  609 
Pneumaturia,  649,  729 
Pneumobacillus,  63 
Pneumococcemia,  62,  69 
Pneumococcic  pharyngitis,  483,  486 
Pneumococcus.        See    Septic    infections 
and  Pneumonia,  21. 
endocarditis,  347 
meningitis,  94 
peritonitis,  609 
Pneumokoniosis,  440 
etiology  of,  440 
pathology  of,  440 
symptoms  of,  440 
treatment  of,  441 
Pneumomalacia,  444 
Pneumonia,  62 

aspiration,  434 
bacteriology  of,  62 

pneumobacillus,  63 
pneumococcus,  62 
bronchopneumonia,  434 
central,  67,  73 
cerebral,  73,  74 

clinical  types  and  variations  of,  72 
complications  of,  70 
abscess  of  lung,  71 
alimentary,  71 
arteritis,  71 
arthritis,  71 
delirium  tremens,  71 
empyema,  70 
endocarditis,  70 
gangrene  of  lung,  71 
icterus,  71 

indiu-ation  of  lung,  71 
joint,  71 
lung,  71 
meningitis,  71 
nervous,  71 
pericarditis,  71 
peritonitis,  609 
pleurisy,  70 
thrombophlebitis,  71 
course,  63 
crossed,  67 

death,  mechanism  in,  70 
diagnosis  of,  73 
differentiation  of,  44,  73,  74,  148,  160, 

161 
erysipelatous,  60 
etiology  of,  62 
frequency  of,  62 
hepatization  in,  gray,  67 
red,  67 
'"  immunity  from,  63 
64 


Pneumonia,  indurative,  438 
diagnosis  of,  439 
etiology  of,  438 
pathology  of,  439 
physical  findings  of,  439 
prognosis  of,  439 
symptoms  of,  439 
treatment  of,  440 
interstitial,  438 
Litten's  sign  in,  68 
lobar,  in  influenza,  104 

in  typhoid  fever,  39,  44 
lobular.     See  Bronchopneumonia, 
massive,  67,  73,  74 
migratory,  72 
pathology  of,  67 
physical  signs  of,  67 
plague  pneumonia,  117 
pleurogenous,  439 
prognosis  of,  74 
rheumatic,  284 
"schluck, "  434 
secondary,  72 
symptoms  of,  64 
chill,  64 
circulatory,  69 
digestive,  69 
fever,  64 
nervous,  70 
prodromes,  64 
respiratory,  65 
skin,  69 
sputum,  66 
urine,  70 
syphilitic,  210 
total,  67 
treatment  of,  75 
hygienic,  75 
prophylactic,  75 
symptomatic,  75 
white,  syphilitic,  210 
Pneumonitis,  62 
Pneumopericardium,  391 
Pneumoperitoneum,  609 
Pneumorrhagia,  450 
Pneumothorax,  468 
artificial,  189,  452 
diagnosis  of  type  of,  471 
differentiation  of,  472,  611 
etiology  of,  469 
pathology  of,  469 
physical  signs  of,  470 
prognosis  of,  472 
symptoms  of,  469 
treatment  of,  472 
in  tuberculosis,  166,  189 
Podagra.     See  Gout. 
Pododynia,  942 
Podophyllin,  562 
Poisoning.     See  Arsenical,  etc. 
Poliencephalitis,  inferior,  798 

superior,  798 
Poliencephalomyelitis,  798 
Poliomyelitis,  acute,  96 

diagnosis  of,  100 
differentiation  of,   100,   101,  787 

871 
etiology  of,  96 


1010 


IXDEX 


PoliomA'elitis,  acute,  pathology  of,  96 
prognosis  of,  101 
symptoms  of,  acute  stage,  98 
chronic  stage,  99 
degenerative  stage,  99 
localization,  99 
treatment  of,  101 
t>-pes,  98,  100 
chronic,  841 
subacute,  841 
Pollakiuria,  178,  628,  728 
PoUantin,  413 

Polyarthritis,  rheumatic,  281 
Polycardia,  340 
Polycj'themia  with  splenic  tumor,  691 

in  heart  disease,  367,  380 
Polydipsia,  729,  737 
Polyesthesia,  tabetic,  852 
Polvglobulism,  691 
Polymyositis,  949 
Pohiieuritis  endemica,  972 
Polvorrhomenitis,  612,  616 
Poh-phagia,  533,  729,  737 
Polvuria  in  cerebral  s\'philis,  212 
"  diabetic,  728,  737 
in  nephritis,  628 
in  pj-elitis,  652 
in  renal  tuberculosis,  178 
Pomegranate,  303 
Pons,  localizing  symptoms,  760 
Porencephalia,  788 
Portal  vein  phlebitis,  205,  586 
thrombosis,  205,  586 
Postmortem  tubercles,  183 
Postures,  forced,  762 
Potassium  acetate,  269 
bromide,  924,  925 
chlorate,  477,  478 

iodide,  164,  188,  195,  220,  227,  228, 
332,  335,  377,  399,  413,  422,  430, 
484,  708 
permanganate,  413 
Potato  poisoning,  971 
Pregnancy,  effect  of  sj-philis  on,  221 
in  heart  disease,  371 
tuberculosis  and,  168,  190 
tjTDhoid  and,  40 
Prison  fever,  276 
Proctitis,  535 
Profeta's  law,  221 
Progeria,  723 
Prosopalgia,  940 
Prosoplegia,  883 
Prostitution,  regulation  of,  224 
Pseudoangina,  335 
Pseudocii-rhosis.     Pick's  pericarditic,  521, 

612,  616 
Pseudodiphtheria,  78,  79 
Pseudoleukemia,  687 

aUied  affections,  689 
coxu-se  of,  689 
diagnosis  of,  689 
differentiation  of,  171,  689 
etiology  of,  687 
pathologj'  of,  688 
sj^mptoms  of,  688 
blood,  688 
bone,  688 


Pseudoleukemia,  symptoms  of,  fever,  689 
Ivmph  glands,  688 
skin,  688 
j  spleen,  688 

treatment  of,  691 
Pseudomeningitis,  34,  95 
Pseudoparalvsis,  697 
Pseudorheurnatism,  182,  282,  287 
Pseudosclerosis  ('multiple),  843,  846 
Pseudotabes,  871 
Pseudotetanus,  135 
Pseudotuberculosis,  141,  165 
aspergillus,  141,  165 
protozoan,  141 
streptothrLx,  141,  165 
Psittacosis,  302 
Psychasthenia,  916 
Psychoses,  influenzal,  103 
Korsakow's,  871 
in  t\'phoid  fever,  33 
Ptosis,  876 
Ptyalism,  481 

.Puerperal  fever.     See  Septic  infections,  1  / 
erysipelatous,  22 
lymphangitis,  22 
peritonitis,  22 
sapremia,  22 
thrombophlebitis,  22 
Pulmonary  artery,  sj-philis  of,  208 
insufficiency,  362 
etiology  of,  362 
mechanism  of,  362 
svmptoms  of,  362 
stenosis,  362,  378 

congenital,  362,  3/8 
diagnosis  of,  362 
etiolog}-  of,  362,  378 
mechanism  of,  362 
signs  of,  362,  378 
Pulse,  alternating,  340 
bigeminus,  339,  367 
celer,  353 
collapsing,  353 
dicrotic,  q.  v. 
differens,  395,  404 
durus,  395 

hver,  positive,  363,  364 
paradoxical,  389,  390 
''pistol,  ■'  353 
Quincke's  capillary,  352 
retarded,  404 
tardus,  341 
venous,  negative,  363 

positive,  340,  363,  364 
"water-hammer,"  353 
Pulsus  paradox-US,  389,  390 
Pupil,  .\Tg3-ll-Robertson,    805,    853,    855, 
877" 
reflexes  of,  826 

Wernicke's  hemianopsic  reaction,  875 
Purpm-a,  fulminans,  694 
hemorrhagica,  693 
diagnosis  of,  693 
etiology  of,  693 
prognosis  of,  693 
symptoms  of,  693 
treatment  of,  693 
Henoch's,  694 


INDEX 


1011 


Purpui'a,  renal,  647,  G9S 

rheumatica,  692 

diagnosis  of,  692 
prognosis  of,  692 
symptoms  of,  692 
treatment  of,  692 

simplex,  692 

symptomatic,  692 

variolous,  252 

visceral  crises  in,  693 
Pus  in  urine,  649 

Pustule,  malignant.     See  Anthrax. 
Pyelitis,  6.52 

complications  of,  653 

diagnosis  of,  653 

etiologj'  of,  652 

pathologA'  of,  652 

prognosis  of,  653 

S3*mptoms  of,  652 

treatment  of,  653 

in  typhoid  fever,  40 
Pyelonephi'itis,  652 
Pyemia,  17 
Pvknocardia,  340 
Pylephlebitis,  205,  586 

diagnosis  of,  586 

etiology  of,  575,  586 

suppurative,  575,  586 

sj-mptoms  of,  586 

treatment  of,  586 
P^'lethrombosis,  205,  586 
Pylorectom}',  508,  526 
Pylorus,  hypertrophy  of,  504,  507 

insufficiency  of,  532 

spasm  of,  504,  507,  515,  531 

stenosis  of,  504,  507 
Pyocj'aneus.     See  Septic  infections. 
Pyonephrosis,  656 
Pyopneumothorax      subphi'enicus,      465, 

472,  611 
Pvothorax  subphrenicus,  611 
Pyramidal  tracts,  749,  766,  819-823,  827 
Pyuria,  649 

diagnosis  of,  649 

etiologj'  of,  649 

renal  calculus  causing,  659 

symptoms  of,  649,  652 

treatment  of,  649 

tuberculosis  causing,  178 


Quincke's  lumbar  puncture,  93 

pulse,  352 
Quinine  in  malaria,  242 

administration  of,  62,   109,   110, 
124,  188 
Quinquad's  sign,  960 


Rabic  tubercles  in  hydrophobia,  296 
Rabies,  294 

Rag-sorters'  disease,  130 
Rat-bite  fever,  301 
Ray  fungus,  193 


Raynaud's  disease,  945 
Reaction  of  degeneration,  8oS 
Rectal  feeding,  516 
Rectum,  cancer  of,  555 

syphilis  of,  204 
Recurrent  fever,  243 

convalescence  in,  245 
diagnosis  of,  245 
etiology  of,  243 
prognosis  of,  245 
symptoms  of,  243 
treatment  of,  245 
Reflexes  in  spinal  cord,  824,  826 
Relapsing  fever,  243,  689 
Ren  arcuatus,  643 

Renal  calculus.    See  Kidney,  calculus  of. 
Rennet,  test  for,  500 
Resorcinol,  479,  502 
Respirator}^  tract,  diseases  of,  411 
Rest  cure,  917 

Retina,  arteriosclerosis  of,  398 
Retinitis,  873 

albuminuric,  629 
diabetic,  731 
leukemic,  685 
syphilitic,  215 
Retropharj'ngeal  abscess,  484 
Rhachitis.     See  Rickets. 

acute.     See  Barlow's  disease,  697 
Rhatany,  479 
Rhubarb,  562 
Rheumatic  fever,  281 
Rheumatism,  acute  articular,  281 
course,  281 
diagnosis  of,  286 

anomalous  forms,  283 
in  childhood,  286 
gonorrheal,  287 
pseudoi'heumatism,  287 
scarlatinal,  287 
differentiation  of,  287 
etiology  of,  281 
f requeue}-  of,  281 
prognosis  of,  286 
symptoms  of,  281 
arthritis,  282 
blood,  285 
bone,  284 
circulatory,  283 
digestive,  285 
eye,  285 
fever,  282 
general,  281 
genito-urinary,  2S5 
muscle,  284 
nervous,  285 
prodromal,  282 
pseudorheumatism, 

187,  282,  287 
respiratory,  284 
skin,  284 
treatment  of,  287 
atypical,  283 
cerebral,  282,  28'5 
chronic,  951 

endocarditis  from,  283,  263,  348 
masked,  283 
muscular,  950 


1012 


INDEX 


Rheumatism,  relations  of  chorea  to,  285, 
927-929 

pericarditis,  381,  283 

scarlatinal,  265 

spinal,  285 

sj-pliilitic,  217,  218 

tonsilhtis,  485 

tuberculous,  182 

^-isceral,  287 
Rheumatoides,  287 
Rhinitis,  acute,  411 

etiologj-  of,  411 
sjinptoms  of,  411 
treatment  of,  411 

chronic,  413 

atrophic,  413 
hypertrophic,  413 
treatment  of,  413 

diphtheritic,  81 

fibrinous,  81,  413 

s\-philitic,  222 
Rickets,  742 

acute,  697 

complications  of,  745 

coiu'se  of,  745 

diagnosis  of,  745 

differentiation  of,  745,  811 

etiology-  of,  742 

pathologj-  of,  744 

prognosis  of,  745 

svmptoms  of,  743 

tardy,  742 

treatment  of,  745 
Riga's  disease,  478 
Risus  sardonicus,  134 
Rocky  INIomitain  fever,  300 
Romberg's  sign,  851 
Rosarv.  rhachitic,  743 
Rose  cold,  412 

spots.     See  Roseola. 
Roseola,  in  measles,  271 

in  tj-phoid  fever,  29 

in  tn^hus  fever,  277 
Rosin's  sign,  710 
Rbtheln,  275 
RubeUa,  275 
Rubeola,  270 

notha,  275 
Rumination,  532 
Rumpel-Leede  sign,  262 


S 


St.  A^-THOXT's  fire,  58 
St.  Vitus' s  dance,  926 
Sahcj-lates,  action  of,  28/ 

administration,  288,  289,  741,  932 
Sahne  infusions,  77,  637 
Sahvary  calculi,  482 

glands,  diseases  of,  481 

inflammation  of.     See  Parotitis, 
symmetrical  h\'pertrophv  of,  482, 

691  " 

tuberculosis  of,  175 
Salivation,  etiologj'  of,  481 
sj^mptoms  of,  481 
treatment  of,  481 


Salol.     See  Phenylis  saUcvlas. 

Salt,  635 

Salt-free  diet,  635 

Salvarsan,  228,  229 

Sanatoria  in  tuberculosis,  185 

Santal  oU,  422 

Santonin,  308 

Sapremia,  17 

Saturnism,  965 

Scarlatina.     See  Scarlet  fever,  260 

Scarlet  fever,  260 

diagnosis  of,  265 

differentiation  of,  249,  263,  266, 

273,  796,  807,  845,  846,  856 
endocarditis  from,  263,  348 
etiolog\'  of,  260 
prognosis  of,  267 
sequels  of,  265 
s\Tnptoms  of,  261 
blood  in,  264 
bones  and  joints,  265 
cardiac,  263 
digestive,  264 
eruption,  262 
fever,  262 
kidney,  264 
IjTnphatic  glands,  265 
respiratory,  263 
special  senses,  265 
stages,  261 
throat,  263 
tongue,  264 
treatment  of,  267 
Scarlet-red  ointment,  57 
Schistosoma  hematobium,  316 
Schlesmger's  sign,  716 
Schott's  treatment  of  heart  disease,  323 
Schroth  treatment  of  pleurisy,  466 
Sciatic  neuritis,  903 
Sciatica,  903 

diagnosis  of,  904 
etiologj'  of,  903 
pathology'  of,  903 
prognosis  of,  904 
sjTiiptoms  of,  903 
treatment  of,  904 
Scleredema,  541 
Sclerema  adiposxmi,  541 
Sclerodactylia,  947 
Scleroderma,  946 
Sclerose  en  plaques,  843 
Sclerosis,  amj'trophic  lateral,  858 
diagnosis  of,  860 
etiology  of,  859 
pathology  of,  859 
prognosis  of,  860 
sjTnptoms  of,  859 
treatment  of,  861 
disseminated,  843 
insular,  843 
multiple,  843 

course  of,  845 

diagnosis  of,  845 

differentiation  of.  796,  807,  845, 

846,  856 
etiologj^  of,  843 
pathology  of,  843 
prognosis  of,  845 


INDEX 


loi: 


Sclerosis,  multiple,  S3Tnptoms  of,  843 
treatment  of,  847 
scorbutic,  696 
Scotoma,  845,  875 
Scorbutus,  695 
Scrofula,  168,  169,  182,  183 
Scrofuloderma,  183 
Scurvy,  695 

coiu-se  of,  696 
diagnosis  of,  696 
etiology  of,  695 

infantile.     See  Barlow's  disease,  697 
prognosis  of,  696 
symptoms  of,  695 
treatment  of,  696 
Secretin,  536 
Secretion,  internal,  701 
Semilunar  space,  456 
Senega,  422 
Semia,  562 
Sensation,  cortical  representation,  753 

spinal  localization,  823,  824 
Sensory  crossway,  757 
Sepsis.     See  Septic  infections,  17 
Septic  infections,  17 
atrium,  18 

colon  bacillus,  sepsis,  21 
diagnosis  of,  23 

differentiation  of,  23,  46,  47,  266 
from  malaria,  46,  47 
from  meningitis,  46,  47 
from  Alalta  fever,  126 
from    miliary    tuberculosis, 

46,  47 
from  rheumatism,  23 
from  typhoid,  46,  47 
from  syphilis,  206 
endocarditis,  ulcerative,  20,  46, 

47,  346 
etiologj'  of,  18 
gonococcic  infection,  21,  137 
groups  of,  17 
osteom3'elitis,  21,  22 
otogenous  sepsis,  22 
pathology  of,  18 
peritonitis,  22 
pneumococcic  infection,  21 
prognosis  of,  23 
puerperal  fever,  22 
pyocyaneus  infection,  22 
sore  thi'oat,  286 
staphylococcic  infection,  21 
streptococcic  infection,  21,  486 
sjTnptoms  of,  18 
general,  18 
special,  21 
treatment,  23 
tj^phoid  infection,  20 
diphtheria,  81 
Septicemia,  17 
Septicopyemia,  17 

gonorrheal,  137 
Serotherapy^,  in  diphtheria,  87 
in  dj'sentery,  123 
in  erj'sipelas,  62 
in  meningitis,  95 
in  plague,  118 
in  scarlatina,  270 


Serotherapy  in  sepsis,  23 

in  tetanus,  136 
Serous  membranes,  tuberculosis  of,  171 
Serum  disease,  88 
Flexner's,  95 
normal,  56,  189,  699 
Shaking  palsy,  934 
Sheep-stools,  561 
Shick's  test,  88 
Shiga's  bacillarj'  dysentery.     See  D_vsen- 

tery,  Shiga's. 
Sialodochitis  fibrinosa,  482 
Sialolithiasis,  482 

pancreatica,  604 
Sialorrhea,  481 
!  Side-chain  theory,  87,  134 
i  Siderosis  of  lungs,  440 
1  Silver,  106,  125,  .502,  518,  529 
Singultus,  897 
Sinus  ^regularity  of  heart,  339 

thrombosis,  783 
!  of  cavernous  sinus,  785 

diagnosis  of,  785 
differentiation,  786 
etiologj-  of,  669,  783 
of  lateral  sinus,  785 
pathology  of,  783 
prognosis  of,  786 
of    superior    longitudinal    sinus, 

785 
symptoms  of,  785 
treatment  of,  786 
Sitotoxismus,  970 
Situs  viscerum  inversus,  380,  584 
Skin,  bronzing  of,  701,  702 
diphtheria  of,  82 
tuberculosis  of,  183 
Skoda's  note  in  pleurisy,  456 

resonance  in  pneumonia,  68 
Sleeping  sickness,  246 
Smallpox,  247 
black,  252 

complications  and  sequelae  of,  253 
diagnosis  of,  254 
differentiation  of,  254,  278 
etiology  of,  248 
prognosis  of,  255 
symptoms  of,  249 

purpura  variolosa,  252 
variola  confluens,  251 

pustulosa      hemmorrhagica, 

252 
discreta,  249 
varioloid,  252 
treatment  of,  256 

prophylactic,  256,  258 
symptomatic,  258 
vaccination  256 
Smegma  bacillus,  140 
Smell,  centre  for,  754 
Sodium  benzoate,  110,  376 

bicarbonate,  110,  516,  562,  735 
borate,  52 

bromide,  110,  338,  925 
chloride,  635 

sahcylate,  287,  741,  932,  939 
sulphate,  124,  562 
Sokudu,  301 


1014 


INDEX 


Soor,  479 

Spartein,  188,  376,  400 
Spasm,  cardio-,  492,  531 
of  facial  nerve,  887 
of  fifth  nerve,  882 

habit,  930  1 

masticatory,  882  j 

mobile,  772  ; 

ocular,  880 
phrenic,  897 

of  spinal  accessory  nerve,  895,  896 
of  vagus,  891,  892 
of  vocal  cords,  892 
Spasmophilia,  716 
Speech,  centres  for,  754 
disturbances  of,  754 
scanning,  844 
Spina  ventosa,  syphilitic,  217 

tuberculous,  182 
Spinal  atrophy,  progressive  muscular,  860 
cord,  abscess  of,  840 
anatomy  of,  819 
anemia  of,  833 
compression  of,  831 
degeneration  of,  ascending,  825 
descending,  822 
in  pernicious  anemia,  675 
embolism,  833 
functions  of,  819 
hemorrhage  of,  833 
inflammation  of,  836 
localization  of,  819,  824 
physiology  of,  819 
reflexes  of,  824,  826 
segments,  824 
symptomatology  of,  819 
syphilis  of,  213 
tracts  of,  motor,  819-823 

sensory,  823 
thrombosis,  833 
transverse  lesion  of,  835 
trauma  of,  835 
tumors  of,  830 

diagnosis,  832 
localization,  831 
pathology,  830,  831 
prognosis,  832 
symptoms,  831 
treatment,  833 
irritation,  914 
meninges,  diseases  of,  829 
paraplegia,  spastic,  857 
Spinalgia,  170 

Spirals,  Leyden-Curschmann,  429 
Spirillum  Obermeyeri,  243 
Spirochete  darticola,  485 
pallida,  198 
refringens,  198 
Splanchnomegalj',  721 
Splanchnoptosis,  555 
Spleen,  abscess  of,  705 

amyloid,  168,  204,  706 

cysts  of,  707 

diseases  of,  705 

embolism  of,  705 

endothelioma  of,  707 

enlargement  of,  differentiation  of,  657 

in  erj^thremia,  691 


Spleen,  extirpation  of,  707 
floating,  706 
in  ictero-anemia,  590 
movable,  706 
neoplasms  of,  707 
rupture  of,  706 
syphilis  of,  205 
tuberculosis  of,  177 
tumor,  acute,  705 

chronic,  705,  707 
Splenectomy,  691,  706,  707 
Splenitis,  acute,  705 
chronic,  705 
suppurative,  706 
Splenomegaly,  707 
infantile,  245 
Leishman's,  245 

with  potycythemia  and  c3'anosis,  691 
primary,  707 
Splenopexy,  707 
Spondylitis,  ankylosing,  953 

luetic,  217 
Spondylose  rhizomyelique ,  953 
Sporotrichosis,  196 
Spotted  fever,  93 
Sputum,  disinfection  of,  183 
Squills,  376,  422 

Staphylococcus.    See  Septic  infections,  21 
endocarditis,  347 
spray,  86 
Status  lymphaticus,  719 

thymicus,  719 
Steatorrhea,  589,  606 
Stegomyia,  291 
Stellwag's  sign,  710 
Stenocardia,  333 

Stenosis.     See  Aorta,  Bi'onchi,  etc. 
Stereognostic  sense,  753 
Still's  disease,  953 
Stokes- Adams's  syndrome,  342 
Stomach,  abscess  of,  497 
amyloid,  168 
analysis  of  contents,  499,   500,  503, 

506,  513,  522 
anomalies  of,  508 
arteriosclerosis  of,  398 
atony  of,  505 
atrophy  of,  503 
cancer  of,  519 

complications  of,  520 

diagnosis  of,  524 

differentiation  of,  517,  524,  525, 

532 
etiology  of,  514,  519 
histology  of,  520 
localization  of,  520 
pathologj'  of,  519 
prognosis  of,  525 
symptoms  of,  521 
anemia,  523 
ascites,  524 
cachexia,  523 
digestive,  521,  522 
general,  521 

hematemesis,  517,  521,  526 
metastases,  524 
pain,  521 
toxemia,  523 


INDEX 


1015 


Stomach,  cancer  of.  symptoms  of,  tumor, 
522 
urine,  523 
vomiting,  521 
treatment  of,  medical,  525 
sui'gical,  526 
cardia  of,  cancer  of,  524 
catarrh  of.     See  Gastritis, 
cirrhosis  of,  503,  509 
congestion  of,  369 
dilatation  of,  acute,  71,  504 
etiology  of,  504 
prognosis  of,  504 
S3'mptoms  of,  504 
treatment  of,  504 
chronic,  504 

complications  of,  507 
diagnosis  of,  507,  532 
etiology  of,  504 
signs  of,  506 
s3"mptoms  of,  505 
treatment  of,  507 
dimensions  of,  506 
diseases  of,  496 
form,  changes  in,  508 
hemorrhage  from.      See   Hemateme- 

sis,  526 
hemorrhagic  erosions  of,  515 
hour-glass,  50S 

inflammation  of.     See  Gastritis, 
inflation  of,  506 
insufiiciencv  of,  motor,  504 
lavage  of,  497,  501,  508 
location  of,  508 
motility  of,  tests,  506 
neuroses  of,  527 
mixed,  533 
motor,  531 
secretory,  528 
sensory,  532 
pain  in,  496,  499,  511,  514,  515,  517, 
521,  528,  529,  532 
'  perforation  of,  in  cancer,  520 
in  ulcer,  514 
prolapse  of,  556 
romid  ulcer  of.  509 

complications  of,  514 
course  of,  513 
diagnosis  of,  514 
differentiation  of,  515,  517, 

532 
etiology  of,  510 
frequency  of,  510 
localization  of,  490,  514 
pathology  of,  510 
prognosis  of,  516 
sjTnptoms  of,  510 
general,  510 
hematemesis,  512 
h3-perchlorhydria,  513 
pain,  511 
vomiting,  513 
treatment  of,  diet,  518 
gastric  rest,  516 
hyperacidity',  516 
medicinal,  518 
pain,  516 
rest,  516 


Stomach,   round    ulcer  of,    treatment    of, 
surgical,  519 
symptomatic,  518 
types  of,  513 
size  of,  506,  508 
sj'philis  of,  204 
tuberculosis  of,  167,  175 
tumors  of,  519.  525 
ulcer.     See  Stomach,  Round  ulcer, 
ulceration  of,  s^-philitic,  204 

t^'phoid,  34,  35 
volvulus  of,  507 
Stomatitis,  aphthous,  478 
catarrhal,  477 
epidemic,  301 
gangrenous,  479 
parasitic,  479 
ulcerative,  477 
Stomatomycosis  o'idica,  479 
Stones,  fecal,  551,  552,  596 

of  kidneys,  q.  v. 
Strabismus,  878 
Stramonium,  430 

Strawberry  tongue,  scarlatinal,  264 
Streptococcus.     See  Septic  infections,  21 
in  diphtheria,  79,  81 
endocarditis,  347 
in  erysipelas,  58 
in  rheumatism,  281 
in  scarlatina,  261 
sore  throat,  486 
Streptothricosis,  165 
Streptothrix,  pseudotuberculosis,  165 
Strongyloides  intestinalis,  316 
Strophanthus,  76,  336,  375 
Struma  lipomatodes  aberrans  renis,  663 
Strumitis,  708 

Strychnine  poisoning,  diagnosis  of,  135 
'  therapeutics,  56,  58,  76,  188,  269,  376, 
562 
Subphrenic  abscess,  611 

differentiation      from     pneumo- 
thorax, 472 
from  pleiu-isy,  465 
pyopneumothorax,  611 
Subsultus  tendinum  in  tj'phoid  fever,  33 
Succussio  Hippocratis,  471 
Sudor  anglicus,  299 
Sugar,  therapeutics,  56 
Sulphonal,  377,  917 
Sulphuric  acid,  124 
Summer  catarrh,  412 
Sunstroke,  diagnosis  of,  976 
etiology  of,  975 
sj-mptoms  of,  975 
treatment  of,  976 
Suprarenal  glands,  degenerations  of,  704 
diseases  of,  701 
physiology  of,  702 
tuberculosis  of,  701 
tumors  of,  704 
Suralimentation,  186 
Sweats,  therap3'  of,  636 
Sympathetic  nerves,  irritation  of,  944 

paralysis  of,  944 
Synechia  pericardii,  389 
Synovitis,  syphilitic,  218 
Syphilis,  197" 


1016 


INDEX 


Syphilis,  accidental,  199 
acquired,  198 

associated  conditions,  221 
bacteriology,  198 
course  of,  abnormal,  220 
etiology  of,  198 

accidental,  199 
sexual  intercourse,  198 
life  assxarance  in,  221 
symptoms  of,  201 
aorta,  208,  401 
blood,  208,  219 
bloodvessels,  209 
bone,  217 
brain,  211,  790 

arterial  disease,  211 

differentiation,  211,  212, 
790,  796 

gumma,  213,  790 

meningitis,  212 

nerves,  cerebral,  212 
chancre,  199 

characteristics,  199 

course  of,  200 

differentiation  of,  200 

extragenital,  199 

female,  199 

histology  of,  200 

male,  199 

perigenital,  199 
circulatory,  207,  401 
ear,  216 
eruptions,  201 
eye,  214 

choroid,  215 

conjunctiva,  214 

cornea,  214 

iris,  214 

muscles,  215 

orbit,  216 

retina,  215 
fever,  201,  206 
gastro-intestinal,  203 

esophagus,  204 

intestine,  204 

mouth,  203 

pancreas,  205 

rectum,  204 

stomach,  204 
genitalia,  216 

cervix,  217 

ovaries,  217 

penis,  216 

testes,  216 

tubes,  217 

vagina,  216 

vas  deferens,  216 

vulva,  216 
gummata  of  aorta,  208,  401 

of  bones,  217 

of  brain,  213,  790 

of  bronchi,  210 

of  ear,  216 

of  esophagus,  204 

of  eye,  214 

of  heart,  207 

of  intestines,  204 

of  joints,  218 


Syphilis,  acquired,  symptoms  of,  gummata 
of  kidney,  207 
of  larynx,  209 
of  liver,  206 
of  lungs,  210 
of  mammae,  218 
of  meninges,  212 
of  mouth,  203 
of  muscles,  216 
of  nose,  209 
of  ovary,  217 
of  penis,  216 
of  peritoneum,  205 
of  pharynx,  204 
of  rectum,  204 
of  skin,  202 
of  spleen,  205 
of  stomach,  204 
of  tendons,  218 
of  testis,  216 
of  trachea,  209 
of  tubes,  217 
of  uterus,  217 
of  vagina,  216 
of  vessels,  208,  211 
of  vulva,  216 

heart,  207 

immimity,  220 

joints,  217,  743,  954 

kidney,  207 

liver,  205 

lymphadenitis,  200 

lymphangitis,  200 

mammae,  218 

muscles,  216 

nervous,  210 

onychia,  203 

primary  lesion,  199 

respiratory,  209 
bronchi,  210 
larynx,  180,  209 
lungs,  210 
nose,  209 
trachea,  209 

secondary,  201 

enanthem,  201 
exanthem,  201 
lymphadenitis,  200 

skin,  201 

spleen,  205  ' 

syphilides,  201 

tertiary,  198,  201 
treatment  of,  224 

initial  stage,  224 

local,  224 

prophylactic,  224 

secondary,  224 

tertiary,  227 
of  bones,  differentiation  of,  745 
of  brain,  211,  213,  790,  796,  803,  846 
of  bronchi,  210 
cachexia,  221 
congenital,  221 
diabetes  insipidus  in,  212 

mellitus  in,  212 
diagnosis,  219 

ex  juvantibus,  227 
luetin  test,  219 


INDEX 


lor 


Syphilis,  diagnosis,  treponema,  219 

Wassermann,  219,  229 
hemorrhagica  neonatorum,  223,  694 
liereditary,  221 

diagnosis  of,  223 

influence  on  child,  221,  222 

parental,  221 

symptoms  of,  222 
incubation  of,  199 
of  larynx,  ISO,  209 
leukoderma,  202 
leukoplakia,  203 
of  liver,  differentiation  of,  205,  206, 

587 
of  lungs,  210 
lymph  glands,  200,  203 
malignant,  220 
nerves,  214 
of  nose,  209 
parasyphilis,  198 
polyuria  in,  212 
primary,  198,  199 
prognosis,  221 
secondary,  198,  201 
of  spinal  cord,  213 
spirochete,  198 
stages  of,  198,  201      ' 
tertiary,  198,  201 
of  trachea,  209 
treponema,  198 
Syringomyelia,  846 
arthropathies,  847 
bulbar,  848 
diagnosis  of,  848 
differentiation  of,  848 
etiology  of,  846 
felons,  847 
pathology  of,  846 
prognosis  of,  849 
symptoms  of,  847 
treatment  of,  849 
System  diseases,  849,  857,  864 


Tabes  dorsalis,  849 

complications  of,  855 
course  of,  855 
diagnosis  of,  855 
differentiation  of,  855,  871 
etiology  of,  849 
pathology  of,  850 
prognosis  of,  855 
stages  of,  850 
symptoms  of,  850 

ataxia,  851 

crises,  854 

eyes,  853 

gait,  851 

motor,  851 

reflexes,  853 

Romberg's  sign,  851 

sensory,  852 

trophic,  854 
treatment  of,  856 
mesaraica,  171 
Tache  bleunire  in  typhoid  fever,  30 


Tache  cerebrale,  93 
Tachycardia,  340 

diagnosis  of,  341 

etiologj^  of,  340 

exophthalmic,  709 

prognosis  of,  341 

treatment  of,  341 
Taka-diastase,  502 
Talma-Drummond  operation,  573 
Tannic  acid,  55,  114,  124,  416,  484,  558 
Tannigen,  535,  543 
Tannin,  124 
Tape-worms,  302 
Taste,  nerve  of,  881,  885 
Teeth,  Hutchinson's,  222 
Telangiectases,  414,  699 
Tender  toes  of  Hanford  in  typhoid  fever, 

32,  34 
Tendons,  syphilis  of,  218 
Tenia  cucumerina,  305 

echinococcus,  etiology  of,  305 
locahzation  of,  306 
multilocular  form,  307 
pathology  of,  305 
symptoms  of,  305 

elliptica,  305 

mediocanellata,  304 

nana,  305 

saginata,  304 

solium,  302 
Terminal  infections,  18 
Terpine  hydrate,  188,  415,  422 
Test  meal,  499,  506 
Testicles,  sj^hilis  of,  216 

tuberculosis  of,  179 
Tetanus,  133 

in  children,  135 

diagnosis  of,  135 

differentiation  of,  135,  296 

etiology  of,  133,  257 

facialis,  135 

head,  135 

incubation  m,  134 

neonatorum,  135 
trismus,  135 

prognosis  of,  135 

puerperal,  136 

symptoms  of,  134 

treatment  of,  136 
Tetany,  715 

diagnosis  of,  717 

etiology  of,  715 

in  gastric  dilatation,  507,  508 

prognosis  of,  717 

symptoms  of,  716 

thyi-oid  operation  causing,  716 

treatment  of,  508,  717 
Thalamic  syndrome,  794 
Theocin,  377,  635 
Thiosinamin,  553 
Thomsen's  disease,  933 
Thoracocentesis,  388,  458,  467 
Thrombophlebitis  in  chlorosis,  669,  784 

in    septic    infections,    20.      See    also 
Phlebitis. 
Thrush,  479 
Thymol,  314 
Thymus  asthma,  718 


1018 


INDEX 


Thymus  gland,  abscess  of,  718 
cyst  of,  718 
diseases  of,  718 
functions  of,  718 
hemorrhage  of,  718 
hypertrophy  of,  718 
persistence  of,  718 
tumors  of,  718 
Thyroid  extract,  714,  715 
gland,  aberrant,  708 
accessor}',  708 
cancer  of,  708 
chondroma  of,  708 
cysts  of,  708 
diseases  of,  707 
echinococcus  of,  708 
goitre,  707 

exophthalmic,  709 
hypertrophy  of,  708 
inflammation  of,  708 
mj'xoma  of,  708 
overactivity  of,  709 
perversion  of,  709 
strumitis,  708 
tumors  of,  708 
ThjToidectomv,  708,  712 
Th>Toidism,  709 
Tic,  complex,  931 
convulsif,  887 
douloureaux,  940 
simple,  930 

with  explosive  utterances,  931 
Tinnitus  aurium,  888 
Tobacco  leukoplakia,  480 

pseudo-angina,  q.  v. 
Toe  phenomenon,  770,  858,  859 
Toes,  tender,  Hanford's,  32,  34 
Toluol,  86 

Tongue,  actinomycosis,  194 
cat's,  264 
diseases  of,  480 
eczema  of,  480 
glossitis,  480 
ichthyosis  of,  480 
keratosis  of,  480 
leukoplakia  of,  480 
psoriasis  of,  480 
scarlatinal,  264 
strawberry,  264 
syphilis  of,  203 
tuberculosis  of,  175 
in  typhoid  fever,  34 
Tonsillar  hypertrophy,  488 
Tonsillitis,  acute  follicular,  485 

complications  of,  486 
diagnosis  of,  486 
etiolog\'  of,  485 
symptoms  of,  486 
treatment  of,  487 
chronic,  488 

diagnosis  of,  489 
etiology  of,  488 
symptoms  of,  488 
treatment  of,  489 
diphtheria,  80,  85 
in  influenza,  104 
rheumatic,  282,  485 
septic,  486 


Tonsillitis,  suppurative,  etiology  of,  487 
.symptoms  of,  487 
treatment  of,  487 
Tonsils,  diseases  of,  485 
tuberculosis  of,  175 
Tophi  arthi-itici,  739,  740 
Tormina  ventriculi,  531 
Torticollis,  895 
Tourette's  dLsease,  931 
Toxemia,  17 
Trachea,  diseases  of,  418 

stenosis  of,  etiology  of,  426 

symptoms  of,  426 
sj-philis  of,  209 
tumors,  426 
Tracheal  tugging,  aneurysmal,  404 
Tracheitis  in  influenza,  104 
Tracheotomj'  in  diphtheria,  89 
Transudates,  character  of  fluid,  615 
Traube's  space,  456 

tones,  355 
Traumatic  neuroses,  918 
Trematodes,  diseases  caused  by,  316 
Trembles,  300 
Tremor,  exophthalmic,  710 
intention,  844,  845 
varieties  of,  934,  936 
Treponema  gambiense,  246 
pallidum,  198 
pertenue,  247 
Trichina  spiralis,  diagnosis  of,  46,  308,  310 
etiology  of,  308 
prognosis  of,  310 
.symptoms  of,  309 
treatment  of,  311 
Trichinosis,  308 

differentiation  of,  46,  310 
Trichocephalus  dispar,  315 
Trichomonas,  247 
Trichuris  trichura,  316 
Tricuspid  insufficiency,  363 
diagnosis  of,  363 
etiology  of,  363 
mechanism  of,  363 
signs  of,  363 
stenosis,  365 

congenital,  380 
Trismus,  134,  135,  882 
Trophedema,  hereditary,  946 
Trophic  neuroses,  744 
Trousseau's  sign,  716 
Trypanosoma  fever,  246 
TrATjanosomiasis,  246 
Tubercle  bacilli,  139 
Tubercles,  postmortem,  183 
Tuberculin  injections,  163,  164 

ophthalmo-reaction,  164 
Pii-quet's,  164 
Tuberculosis,  139 

of  alimentary  tract,  143,  175 
of  aorta,  181 

arthritis,  differentiation,  182,  954 
atrium  of,  142 

by  digestive  tract,  143 
by  direct  inoculation,  143 
by  respiratory  tract,  142 
bacillus,  139 

chemistry,  140 


INDEX 


1019 


Tuberculosis,  bacillus,  cultures,  140 
morphology.  139 
staining,  140 
of  bladder,  179 
of  bloodvessels,  180 
of  bones,  181,  182 
of  brain,  175,  789,  796 
of  bronchial  glands,  109,  169 
choroidal,  150,  152 
congenital,  143 
of  ear,  180 
of  esophagus,  175 
etiology  of,  139 
extension  of,  mode  of,  146 
of  eye,  175 

of  Fallopian  tubes,  180 
of  genitaha,  179,  180 
of  genito-m'inarj'  tract,  177 
of  gums,  175 
of  heart,  181 
herpes  in,  150 

histopathology  of  tubercle,  145 
influenza,  as  cause  of,  104 
of  intestines,  176 
of  joints,  181,  182,  954 
of  kidney,  177 

etiology  of,  177 
pathology  of,  178 
symptoms  of,  178 
general,  179 
local,  178 
urinary,  178 
of  laryrix,  180 

etiology  of,  180 
forms  of,  181 
pathology  of,  181 
symptoms  of,  ISO 
treatment  of,  181 
latent,  141 
of  lips,  175 
of  liver,  167,  177 
of  lungs,  152 
in  aged,  163 
in  children,  162 
complications  of,  165 

amyloid  degeneration,  168 
cii'culatory,  166 
digestive,  167 
genito-urinarj^,  168 
muscular,  167 
nervous,  167 
respiratory,  165 
skin,  168 
course  of,  160 
in  diabetes,  731,  736 
diagnosis  of,  126,  163,  206,  423, 

425 
extension  of,  152 
forms  of,  acute,  160 

disseminated,  161 
galloping,  160 
miliary,  162,  146 
pneumonic,  74,  160 
ulcerative,  162 
chronic,  162 

fibrous  phthisis,  162 
pleuritic,  162 
ulcerative,  162 


Tuberculosis  of  lungs,  pathology  of,  152 
prognosis  of,  165 
stages  of,  confirmed,  160 
consummated,  160 
incipient,  160 
symptoms  of,  153 
general,  155 
physical  signs,  156,  159 
respiratory,  local,  153 
treatment,  183 
lymphadenitis,    differentiation    from 

pseudoleukemia,  171,  689 
of  lymph  glands,  168 

bronchial  adenitis  of,  169 

diagnosis  of,    109,    170, 

689 
issues  of,  170 
signs  of,  170 
symptoms  of,  170 
cervical  adenitis,  169 

atrium  of,  169 
pathology  of,  169 
symptoms  of,  169 
characteristics,  169 
etiology  of,  168 
generalized  adenitis,  171 
mesenteric  adenitis,  170 
pathology  of,  169 
treatment  of,  171 
of  mammae,  180 
of  meninges,  149,  150,  175 
meningitis.      See    Meningitis,    tuber- 
culous, 149,  150 
of  mesenteric  glands,  170 
miliary,  acute,  146 

diagnosis  of,  46,  47 
etiology  of,  146 
prognosis  of,  150 
remissions  of,  150 
symptoms  of,  147 

choroidal    tubercles, 

150,  152 
cii'culatory,  149 
digestive,  149 
fever,  148 
nervous,  149 
respirator}^  149 
types,  147 
chronic,  150 

differentiation    of,    46,    47,    104, 
148,  149 
mixed  infection,  141 
of  muscles,  183 
of  nasopharynx,  175,  180 
of  nose,  180 
of  palate,  175 
of  pericardium,  171,  387 
of  peritoneum,  172 
course  of,  174 
diagnosis  of,  174 
differentiation  of,  172,  173,  174, 

616 
etiology  of,  172 
symptoms  of,  173 
adhesions,  173 
ascites,  173 
exudation,  173 
fever,  172 


1020 


INDEX 


Tuberculosis  of  peritoneum,  symptoms  of, 
friction,  174 
gastro-intestinal,  174 
meteorism,  173 
pain,  172,  174 
pehac  effusion,  174 
retraction,  173 
treatment  of,  174 
tj^pes  of,  172 
of  pharjTix,  175 
of  placenta,  143 

of  pleura,  171,  453,  454,  460,  461 
prevalence  of,  in  animals,  141 

in  man,  141 
prognosis  of,  165 
of  prostate,  179 
pseudotuberculosis,  141,  165 
quiescent,  141 
roseolse  in,  150 
of  salivarj'  glands,  175 
of  serous  membranes,  171 
of  skin,  150,  183 
of  spleen,  177 
of  stomach,  175 
of  suprarenal  glands,  701 
of  testicle,  179 
of  tongue,  175 
of  tonsils,  175 
treatment  of,  183 
expectant,  187 
cough,  187 

digestive  disorders,  189 
dyspnea,  189 
fever,  187 
hemoptysis,  188 
insomnia,  189 
pain,  189 

sexual  sjTnptoms,  190 
sweats,  188 
hvgienic,  184 
food,  186 
fresh  air,  184 
rest,  186 
prophylactic,  183 

antibacillary,  183 
governmental,  184 
iadividual,  184 
specific,  186 
tuberculin,  186 
in  tj^phoid  fever,  40 
of  ureter,  179 

vaccination  as  cause  of,  257 
Tuffnell  treatment,  408 
Tumor  albus.  s^TDhilitic,  218 
Tm-pentine,  55,"'  188_,  189,  416,  422 
Tussis  hepatica,  57/ 
Tympanites,  treatment  of,  55 
Typhhtis,  tuberculous,  176 
Typhoid  fever,  24 
ia  aged,  43 

anomalous  courses  of,  41 
bacillus,  25 
carriers,  25,  49 
in  children,  42 
chills  in,  28,  44 
cUnical  types  of,  26,  41 
convalescence  of,  27,  44 
diagnosis  of,  44 


Typhoid   fever,    differentiation   of,    from 
anthrax,  45 

from    endocarditis,    46,    47, 
345 

from  enteritLs,  45 

from  gastritis,  45 

from  influenza,  105 

from  malaria,  46,  47,  239 

from  meningitis,  46,  47 

from    miliary    tuberculosis, 
46,  47,  147 

from  paratj-phoid,  45 

from  pneumonia,  44 

from  sepsis,  46,  47 

from  sj-philis,  206 

from  trichinosis,  46 

from  t}T3hus  fever,  278,  279 
etiology-  of,  25 

baciUus  t3-phosus,  25 

predisposing,  26 
exacerbations  of,  43 
gall-stones  in,  relation  of,  38 
hemorrhage,  36 
immunity  from,  26 
incubation  of,  26 
onset  of,  26 
parat>'phoid,  26 
perforation.  37 
prognosis  of,  47 
recrudescences  of,  43 
relapses  of,  43 
"scarlet-tj-phoid."  264 
second  attacks  of.  26 
spine  in,  41 
state,  33,  44 
sudoral  tj-pe  of,  28,  30 
symptoms  of,  26 

bone,  41 

cardinal,  44 

circulatory,  30 

contra-indicating,  44 

dermal,  29 

digestive  tract,  34 

fever,  27 

genito-urinar}',  40 

joint,  41 

muscle,  41 

nervous,  33 

pulse,  30 

respirator^-,  39 

secondary,  44 

special  senses,  41 

splenic  tumor,  28 

thjToid  gland,  41 
treatment  of,  48 

antip^Tesis,  50 

antiseptic,  50 

of  bacihuria,  57 

of  bed-sores,  57 

caloric  feeding,  53 

care  of  skin,  57 

of  circulatory  symptoms,  56 

of  convalescence,  57 

of  diarrhea,  55 

diet,  52 

of  epistaxis,  57 

expectant,  54 

of  hemorrhage,  55 


INDEX 


1021 


Typhoid  fever,  treatment  of,  hygienic,  50 
of  nervous  symptoms,  57 
of  perforation,  56 
prophylactic,  48 
of  respiratory  symptoms,  57 
specific,  50 
symptomatic,  54 
of  thrombophlebitis,  57 
of  tympany,  55 
vaccines,  50. 
vomiting,  54 
types,  26,  41 
Typhoidette,  42 
Typhus  fever,  276 

differentiation  of,  274,  278,  279 
etiology  of,  276 
exanthematous,  276 
prognosis  of,  279 
symptoms  of,  276 
treatment  of,  279 
icteroides,  293 

recurrens.    See  Recurrent  fever. 
Tyrotoxismus,  970 


Ulcus  perforans  of  stomach,  509 

rotundum  of  stomach,  509 
Uncinaria  duodenaUs,  311 
Uncinariasis,  311 
Urates  in  urine,  650 
Uremia,  630 

coma  from,  631,  772 

convulsions  from,  630 

diagnosis  of,  632 

differentiation  of,  632 

etiology  of,  630 

latent,  659 

scarlatinal,  265 

symptoms  of,  630 
cardiac,  631 
digestive,  631 
nervous,  630 
respiratory,  631 

treatment  of,  633-638 
Ureter,  calculus  of,  660,  661 

tuberculosis  of,  179 

tumor  of,  662 
Uric  acid  in  urine,  650,  738 
Urine,  albumin  in,  644 

alkaptone  in,  651 

bile  in,  589 

blood  in,  647 

casts  in,  620,  625,  629 

chyle  in,  649 

fat  in,  650 

febrile,  40 

hematoporphyrin  in,  651 

hydrochinon  in,  651 

indican  in,  651 

melanin  in,  579 

in  nephritis,  620,  625,  628 

oxalates  in,  651 

phosphates  in,  650; 

pus  in,  649 

tests  of,  elimination,  635 

urates  in,  650,  738 


Urine,  uric  acid  in,  650 
Urobilin,  icterus,  588,  590 
Urobilinuria,  589 
Urostealiths,  658 

Urotropin.    See  Hexamethylenamina. 
Urticaria,  visceral  crises  in,  693 
Uterus,  syphilis  of,  217,  222 
tuberculosis  of,  180 


Vaccination,  256,  257 
Vaccine  therapy,  23,  24 
in  gonorrhea,  139 
in  typhoid,  50 
Vaccinia,  256 
Vagina,  syphilis  of,  216 
Vagus.     See  Nerves,  vagus. 
Valerian,  336,  338 
Valleix's  points,  940 
Valsalva's  experiment,  386 
Valvular    disease,    chronic.      See    Aortic 
insufficiency,  etc. 
combined  lesions,  365 
etiology,  350 

general  symptoms  of,  366 
insufficiency,  351 
pathology,  350 
prognosis,  370 
stenosis,  351 
treatment,  371 
heart    disease.       See    Aortic    insuffi- 
ciency, etc. 
Vaquez's  disease,  691 
Varicella.     See  Chicken-pox. 
Variola.     See  Smallpox. 
Varioloid,  252 

Vas  deferens,  syphilis  of,  216 
Vasomotor  neuroses,  744 
Veins,  syphilis  of,  209 
Venesection.     See  Phlebotomy. 
Veratrum,  therapeutics  of,  338,  637 
Veronal,  therapeutics  of,  57 
Vertigo,  auditory,  888 
cerebellar,  762 
e  stomacho  laeso,  500 
ocular,  889 
Vincent's  angina,  485,  484 
Visceroptosis,  555 
Vision,  centre  for,  753,  874 

fields  of,  875,  907 
Vocal  cords,  paralysis  of,  891-893 

spasm  of,  982 
Volvulus,  550 

diagnosis  of,  552 
differentiation  of,  552 
etiology  of,  550 
gastric,  507 
pathology  of,  550 
symptoms  of,  550 
treatment  of,  553 
Vomiting  in  brain  tumor,  792,  795 
cyclic,  531 

differentiation'  of,  532 
in  gastric  cancer,  517,  521 
dilatation,  505 
ulcer,  512,  513,  517 


1022 


INDEX 


Vomiting  in  gastritis,  496,  499 
in  meningitis,  91 
nervous,  531 

causes  of,  531 
differentiation  of,  532 
in  pneumonia,  69 
in  tuberculosis,  167 
in  typhoid  fever,  35 

treatment  of,  54,  55 
Vomitus,  cofTee-grounds,    512,    517,    521, 
526 
cruentus,  527 
V.  Eiselberg's  sign,  in  hour-glass  stomach, 

509 
V.  Graefe's  sign,  710 
V.  Pirquet's  test,  164 
Voussure,  pericarditic,  383 
Vulva,  syphilis  of,  216 
Vulvovaginitis,  diphtheritic,  82 


W 


Wassermaxx  reaction,  219,  229 
Water,  635 
Weil's  disease,  299 

diagnosis  of,  300 

etiology  of,  299 

prognosis  of,  300 

sj'mptoms  of,  299 

treatment  of,  300 
Werlhof's  disease,  693 
Westphal's  sign,  853 
Whip-worm,  315 
Whooping-cough,  106 

"  af  tei'-pertussis, "  109 

complications  of,  108 

bronchopneumonia,  108 
con\ailsions,  108 
glottis,  spasm  of,  108 
hemorrhages,  108 

course  of,  107 

diagnosis  of,  109 

differentiation  of,  108 

etiology  of,  107 

prognosis  of,  109 

sequels  of,  108 

symptoms  of,  107 

convulsive  stage,  107 

treatment  of,  109 
Widal  test,  32 
Widal's  sj'ndrome,  590 
Winckel's  disease,  694 


Wintrich  change  of  note,  159 

Wolff-Eisner  reaction,  164 

Wolfler's  sign  in  hour-glass  stomach,  509 

Wooden-tongue,  194 

Woolsorters'  disease,  130 

Word-blindness,  753 

Wound  diphtheria,  82 

Writers'  cramp,  932 

diagnosis  of,  933 

etiology  of,  932 

symptoms  of,  933 

treatment  of,  933 
Wryneck,  895 


Xanthelasma  in  icterus,  590 
Xanthopsia  in  icterus,  590 
Xerostomia,  481 
X-rays,  458,  515,  524,  596,  660 


Yaws,  247 

Yeast,  pseudotuberculosis,  165 

Yellow  fever,  291 

complications  of,  293 

diagnosis  of,  293 

etiology  of,  291 

prognosis  of,  294 

sequels  of,  293 

symptoms  of,  general,  292 
stages  of,  292 
special,  292 

black  vomit,  293 
circulatory,  293 
digestive,  293 
fever,  292 
hemorrhages,  293 
icterus,  293 
liver,  293 
nervous,  292 
urine,  293 

treatment  of,  294 


Zinc  oxide,  502 
Zomotherapy,  186 
Zoonoses,  127 
Zuckergussleber,  612,  616 


'^i^S^Si 


